INTERNAL LIMITING MEMBRANE PEELING AND AIR TAMPONADE FOR STAGE III AND STAGE IV IDIOPATHIC MACULAR HOLE.

PURPOSE: To evaluate the effect of internal limiting membrane peeling and air tamponade for idiopathic macular hole, and explore reasons and interventions for persistent holes. METHODS: One hundred and thirty-five eyes with Stage III and IV idiopathic macular hole that underwent 23-gauge vitrectomy, internal limiting membrane peeling, and air tamponade were reviewed. Eyes with persistent holes underwent a second surgery. Outcome-related factors and interventions treating persistent holes were discussed. RESULTS: The initial closure (Type I) rate was 89.63% (121/135). Eyes that underwent the second surgery all obtained final closure (Type I). Diameter of macular hole was significantly smaller (P < 0.001) and duration of symptoms was significantly shorter (P = 0.017) in initially closed cases than in unclosed ones. Binary logistic regression indicated large diameter of macular hole as a risk factor for initial closure (P = 0.004). A cutoff value of 677 µm was provided by receiver operating characteristic curve to predict initial closure (P < 0.001). Best-corrected visual acuity of all individuals improved significantly (P < 0.001) from 20/154 to 20/40 (mean follow-up: 4.5 months). CONCLUSION: Internal limiting membrane peeling and air tamponade for idiopathic macular hole provide satisfactory morphologic and functional outcomes. Large diameter of macular hole and long duration of symptoms are risk factors for initial closure. Proper second surgery can obtain satisfactory outcomes for persistent holes.

CLOSING MACULAR HOLES WITH "MACULAR PLUG" WITHOUT GAS TAMPONADE AND POSTOPERATIVE POSTURING.

PURPOSE: To investigate the surgical results of macular hole surgery without gas tamponade or postoperative posturing in patients with Stage 3 and Stage 4 macular holes with ≥500 µm mean base diameter. DESIGN: Retrospective interventional case series. PARTICIPANTS: Twenty-six patients with Stage 3 and Stage 4 macular holes. METHODS: Twenty-six eyes of 26 patients with Stage 3 and Stage 4 macular holes and a mean base diameter of 892.8 ± 349 µm underwent pars plana 23-gauge vitrectomy with broad internal limiting membrane peel (ILM peel), inverted ILM flap repositioning (ILMR), and use of autologous gluconated blood clumps as a macular plug to close the macular hole. No fluid-air exchange, endotamponade, or postoperative posturing was used. The subjects were followed up for 12 months. The anatomical outcome of the procedure was evaluated by fundus examination and optical coherence tomography. Spectral domain optical coherence tomography was used to study the restoration of the outer retinal layer integrity in the postoperative period. The preoperative and postoperative best-corrected visual acuities in logMAR units were compared to evaluate functional outcome. MAIN OUTCOME MEASURE: Macular hole closure and best-corrected visual acuity before and after surgery. RESULTS: Twenty-six patients with mean age 62.8 ± 7.3 years, preoperative median best-corrected visual acuity 6/60 (1.0 logMAR units), and a mean base diameter of 892.8 ± 349 µm underwent surgery to close macular holes without gas tamponade or postoperative posturing. Twenty patients (76.9%) were phakic. Twenty eyes (76.92%) had Stage 3 macular holes and 6 eyes (23.10%) had Stage 4 macular holes. After a single surgery, hole closure was achieved in 100% of eyes. The median best-corrected visual acuity improved from 6/60 (1.0 logMAR units) to 6/18 (0.50 logMAR units) (P < 0.001). Three patients needed cataract surgery at 12-month follow-up. No major intraoperative or postoperative complications were observed. CONCLUSION: Twenty-three-gauge pars plana vitrectomy combined with broad ILM peeling, use of ILMR and autologous gluconated blood clumps as a macular plug is effective in achieving satisfactory hole closure with statically significant functional improvement for large Stage 3 and Stage 4 macular holes.

Epiretinal proliferation in lamellar macular holes and full-thickness macular holes: clinical and surgical findings.

PURPOSE: To report the clinical findings and surgical outcomes of lamellar macular holes (LMH) with or without lamellar hole-associated epiretinal proliferation (LHEP), and those of full-thickness macular holes (FTMH) presenting with LHEP. METHODS: From 2009 to 2013, consecutive cases of surgically treated LMH, and all FTMH cases with LHEP were reviewed, given a follow-up time over 1 year. RESULTS: In the LMH group (43 cases), those with LHEP (19 cases) had significantly thinner bases and larger openings than those without (24 cases). The rate of disrupted IS/OS line was higher in the LHEP subgroup preoperatively (68.4 % vs 37.5 %), but similar between subgroups postoperatively (36.8 % and 33.3 %). The preoperative and postoperative visual acuity showed no significant difference between two subgroups. In the FTMH group (13 cases), the average hole size was 219.2 ± 92.1 µm. Permanent or transient spontaneous hole closure was noted in 69.2 % of cases. An intact IS-OS line was found in only 23 % of cases at the final follow-up. CONCLUSION: In the LMH group, LHEP was associated with a more severe defect but didn't affect surgical outcomes. In the FTMH group, spontaneous hole closure was frequently noted. Despite small holes, disruption of IS-OS line was common after hole closure.

TEMPORAL INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS CLASSIC INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE: A Comparative Study.

PURPOSE: To determine if reducing the area of internal limiting membrane (ILM) peeling in the inverted ILM flap technique results in satisfactory outcomes for the repair of large Stage IV idiopathic macular holes. METHODS: Prospective comparative interventional study of 87 consecutive eyes. Participants were randomized into two treatment groups. In Group A, the classic inverted ILM flap technique was performed. In Group B, a modification of this procedure, the temporal inverted ILM flap technique, was performed. In the modified inverted ILM flap technique, peeling of the ILM was restricted to the temporal side of the fovea only--the macular hole was then covered with the temporal ILM flap. RESULTS: There was no significant difference in initial and final visual acuities between Groups A and B. In both groups, defects in photoreceptors and the external limiting membrane decreased with time. Successive postoperative examinations revealed an increasing number of patients with the dissociated optic nerve fiber layer appearance, although this was less frequent in Group B (modified ILM flap) than in Group A. CONCLUSION: The study results indicate that the temporal inverted ILM flap technique is as effective as the classic inverted ILM flap technique for the repair of large Stage IV macular holes.

Foveola nonpeeling internal limiting membrane surgery to prevent inner retinal damages in early stage 2 idiopathic macula hole.

PURPOSE: The purpose of this study was to investigate and present the results of a new vitrectomy technique to preserve the foveolar internal limiting membrane (ILM) during ILM peeling in early stage 2 macular holes (MH). METHODS: The medical records of 28 consecutive patients (28 eyes) with early stage 2 MH were retrospectively reviewed and randomly divided into two groups by the extent of ILM peeing. Group 1: foveolar ILM nonpeeling group (14 eyes), and group 2: total peeling of foveal ILM group (14 eyes). A donut-shaped ILM was peeled off, leaving a 400-µm-diameter ILM over foveola in group 1. RESULTS: Smooth and symmetric umbo foveolar contour was restored without inner retinal dimpling in all eyes in group 1, but not in group 2. The final vision was better in group 1 (P = 0.011). All eyes in group 1 (100 %) and seven of 14 eyes in group 2 (50 %)regained the inner segment/outer segment (IS/OS) line. Restoration of the umbo light reflex was found in 12 of 14 eyes in group 1 (86 %) but none in group 2 (0 %). CONCLUSIONS: Nonpeeling of the foveolar ILM in early stage 2 idiopathic MH surgery prevented inner retinal damages, restored umbo light reflex, achieved better foveolar microstructures, and led to better final visual acuity.

Idiopathic macular hole: analysis of visual outcomes and the use of indocyanine green or brilliant blue for internal limiting membrane peel.

BACKGROUND: Our aim was to analyze outcomes of idiopathic macular hole surgeries in relation to staging and the use of indocyanine green (ICG) or brilliant blue (BB) for internal limiting membrane (ILM) peel. METHODS: Baseline, surgical, and outcome data for 351 consecutive primary macular hole surgeries was prospectively collected using electronic medical record software between 2001 and 2011. The outcomes for these cases were analysed in relation to staging and the use of ICG (0.5 mg/ml) or BB for ILM peel. RESULTS: Mean age was 68.9 years (range 39-87) with 66.4 % females and 54.1 % right eyes. Follow-up duration was median 0.55 years. Vision was significantly improved from logMAR 0.97 (SD 0.45) (Snellen equivalent 20/185) preoperatively to 0.65 (SD 0.51) (20/90) at final follow-up. One hundred and eighteen patients had stage 2 macular holes, 185 stage 3, and 48 stage 4. Mean duration of symptoms varied with stage of hole: stage 2 0.53 years (SD 0.43), stage 3 0.79 years (SD 0.68), and stage 4 1.20 years (SD 1.26), p = 0.0002. Closure rates of the holes were significantly different, with stage 2 closing in 95.8 %, stage 3 in 73.0 %, and stage 4 in 56.3 %, p < 0.0001. At final follow-up, mean visual acuity (VA) was 0.42 (SD 0.33) (20/50) for stage 2, 0.75 (SD 0.53) (20/110) for stage 3, and 0.87 (SD 0.60) (20/145) for stage 4 holes, p < 0.0001. Postoperative VA was 0.71 (SD 0.53) (20/100) for patients in whom ICG was used, and 0.52 (SD 0.43) (20/70) for BB, p = 0.003. The proportion of patients who achieved a closed hole was less for ICG (73.2 %) than BB (89.9 %), p = 0.0005. For those patients with stage 2 hole who achieved hole closure, mean improvement in VA was significantly better for BB (0.47, SD 0.36) than for ICG (0.30, SD 0.31), p = 0.01. CONCLUSIONS: Macular hole stage is a useful measure to help predict the chance of postoperative hole closure and visual outcome. The relationship between duration of symptoms and increasing stage suggests macula hole patients require prompt referral for consideration of early surgery. Better visual outcomes were achieved with BB for ILM peel than with ICG.

Quantification of retinal pigment epithelium tear area in age-related macular degeneration.

PURPOSE: To compare different quantification tools based on confocal scanning laser ophthalmoscopy for assessment of retinal pigment epithelium (RPE) tear area size. METHODS: Confocal scanning laser ophthalmoscopy fundus autofluorescence (FAF) and near-infrared reflectance (IR) images were retrospectively evaluated in 23 patients with RPE tear after intravitreal injection for pigment epithelium detachment due to exudative age-related macular degeneration at baseline and additionally in 11 patients after 5.1 ± 1.8 months of follow-up. Retinal pigment epithelium tear area was measured by three independent readers using three methods: manually on confocal scanning laser ophthalmoscopy FAF images, manually on confocal scanning laser ophthalmoscopy IR images, and using an FAF-based semiautomated software. RESULTS: Confidence intervals were 0.08 and 0.12 for FAF, 0.11 and 0.09 for FAF-based semiautomated software, and 0.25 and 0.27 for IR for intraobserver (Reader 1) and interobserver agreements (Readers 1 and 2), respectively. The average values of the square errors of the quantification methods were 0.040 ± 0.033 mm (FAF), 0.035 ± 0.060 mm (software), and 0.187 ± 0.219 mm (IR). Mean area of RPE tears at baseline given as the average measurement of all 3 readers using FAF-based semiautomated software was 5.77 ± 4.62 mm (range, 0.13-14.74 mm). Follow-up measurements of unilobular RPE tears (8 patients) showed no change in lesion area size (0.14 ± 0.33 mm); in contrast, multilobular RPE tears (3 patients) showed a progression in lesion area size of 1.80 ± 0.74 mm. CONCLUSION: Manual FAF-based and semiautomated FAF-based quantifications of RPE tear area are accurate and reproducible and superior to manual IR-based measurement. Retinal pigment epithelium tear area quantification is clinically relevant regarding further intravitreal treatment, particularly in multilobular RPE tears.

The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole.

OBJECTIVE: The International Vitreomacular Traction Study (IVTS) Group was convened to develop an optical coherence tomography (OCT)-based anatomic classification system for diseases of the vitreomacular interface (VMI). DESIGN: The IVTS applied their clinical experience, after reviewing the relevant literature, to support the development of a strictly anatomic OCT-based classification system. PARTICIPANTS: A panel of vitreoretinal disease experts was the foundation of the International Classification System. METHODS: Before the meeting, panel participants were asked to review 11 articles and to complete 3 questionnaires. The articles were preselected based on searches for comprehensive reviews covering diseases of the VMI. Responses to questionnaires and the group's opinions on definitions specified in the literature were used to guide the discussion. MAIN OUTCOME MEASURES: Optical coherence tomography-based anatomic definitions and classification of vitreomacular adhesion, vitreomacular traction (VMT), and macular hole. RESULTS: Vitreomacular adhesion is defined as perifoveal vitreous separation with remaining vitreomacular attachment and unperturbed foveal morphologic features. It is an OCT finding that is almost always the result of normal vitreous aging, which may lead to pathologic conditions. Vitreomacular traction is characterized by anomalous posterior vitreous detachment accompanied by anatomic distortion of the fovea, which may include pseudocysts, macular schisis, cystoid macular edema, and subretinal fluid. Vitreomacular traction can be subclassified by the diameter of vitreous attachment to the macular surface as measured by OCT, with attachment of 1500 µm or less defined as focal and attachment of more than 1500 µm as broad. When associated with other macular disease, VMT is classified as concurrent. Full-thickness macular hole (FTMH) is defined as a foveal lesion with interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium. Full-thickness macular hole is primary if caused by vitreous traction or secondary if directly the result of pathologic characteristics other than VMT. Full-thickness macular hole is subclassified by size of the hole as determined by OCT and the presence or absence of VMT. CONCLUSIONS: This classification system will support systematic diagnosis and management by creating a clinically applicable system that is predictive of therapeutic outcomes and is useful for the execution and analysis of clinical studies.

Incidence, morphology, and classification of epimacular membrane rip.

PURPOSE: To describe the incidence, associated factors, morphology, and visual characteristics of a series of patients with tears within an epimacular membrane (EMM). METHODS: Consecutive, prospective, observational case series of patients with EMM rip. Patients were evaluated with spectral domain optical coherence tomography, infrared photography, and fundus autofluorescence. Symptomatic patients were treated with pars plana vitrectomy and EMM removal. Follow-up imaging evaluation was performed at 3-month intervals. RESULTS: A total of 761 patients presented with EMM. Thirty-four eyes of 34 patients (4.5%) developed EMM rip. Frequent associated features included history of cataract extraction, diabetes mellitus, and retinal tear treated with photocoagulation. Morphologic characteristics included a scrolled torn edge of internal limiting membrane/EMM. Rip patterns include horseshoe shapes and patchy confluent striae and appeared as dark lines on infrared or fundus autofluorescence imaging. The EMM rips were classified as Type 1 if the rip occurred within 500 µm of the foveola on spectral domain optical coherence tomography and Type 2 if extrafoveal. Foveal involvement was associated with worse presenting vision (P = 0.002) and visual outcome after EMM removal (P = 0.012). Previous retinal tear was associated with worse visual outcome. CONCLUSION: The EMM rip occurs in a small but significant minority of patients with EMM. Foveal involvement leads to increased visual deficit and may indicate a worse visual outcome at presentation and after intervention. Fundus autofluorescence and infrared imaging are useful in identifying EMM rip patterns.

Modified technique for inducing posterior vitreous detachment through the posterior precortical vitreous pocket during microincision vitreous surgery with a wide-angle viewing system.

PURPOSE: To introduce a simple technique to create a posterior vitreous detachment (PVD) through the posterior precortical vitreous pocket (PPVP) during microincision vitreous surgery using a wide-angle viewing system (WAVS). METHODS: This study included 20 eyes of 20 consecutive patients (mean age, 65.6 years; range, 56-76) with a stage 2 or 3 idiopathic macular hole who underwent 25-gauge microincision vitreous surgery using a WAVS and phacoemulsification surgery. A triamcinolone suspension was injected into the vitreous cavity. The triamcinolone facilitated visualization of the posterior wall of the PPVP. Using a vitreous cutter, we suctioned the outer margin of the PPVP. After a resultant small break of the posterior hyaloid membrane developed and enlarged rapidly, a PVD easily expanded at the periphery. RESULTS: Using this technique, we induced a PVD without close proximity to the optic disk and macula. CONCLUSION: This technique is an easy and safe method for creating a PVD during microincision vitreous surgery using a WAVS.

Intravitreal expansile gas in the treatment of early macular hole: reappraisal.

PURPOSE: To study the effects of intravitreal injection (IVI) of expansile gas for early macular holes (EMH). METHODS: Prospective interventional case series. Twelve eyes of 12 patients with EMH (stage 2) underwent IVI of perfluoropropane 0.2 ml followed by 5 days' facedown positioning. RESULTS: Six cases (50%) achieved vitreous-macula separation. Three cases (25%) had hole closure with vision improvement; one of them developed rhegmatogenous retinal detachment (RRD) and hole re-opening. Another case with persistent hole also developed RRD. Seven of the 9 cases without hole closure and the one where the hole re-opened had vitrectomy, all resulting in hole closure and vision improvement. Duration of symptoms had borderline significance for hole closure (p = 0.11) and subsequent visual improvement (p = 0.03). CONCLUSION: With its low success rate, IVI of gas may not be a good option for EMH. Complications include retinal detachment. The procedure seems to not affect hole closure with subsequent vitrectomy.

[Study on the time course of macular pigment density measurement in patients with a macular hole--clinical course and impact of surgery]. / Untersuchungen zum zeitlichen Verlauf der Makulapigmentdichte bei Patienten mit idiopathischem Makulaforamen--klinischer Verlauf und Einfluss der Operation.

BACKGROUND: In a prospective clinical study we examined the course of the optical density of the macular pigment (MPOD) in patients with idiopathic macular holes before and after pars-plana vitrectomy. PATIENTS AND METHODS: Of the 26 patients four had macular holes stage 1, six patients had stage 2 or stage 4 holes and ten people had a macular hole stage 3. The surgical procedure consisted always of a standard 3-port pars plana vitrectomy (PPV) with colouring assisted peeling of the internal limiting membrane. The optical density of macular pigment was determined by the 1-wavelength reflection method before pars plana vitrectomy and after macular hole closure. RESULTS: The macular hole was completely closed in 25 of 26 eyes (96.15 %). This anatomical success is also the basis for a postoperative improvement in the retinal function. In the case of macular holes from stages 3 and 4 the surgery achieved an increase in visual acuity and an increase of the optical density of the the macular pigment. In patients with macular holes stage 2 the visual acuity and the optical density of the macular pigment were reduced after vitrectomy. In the case of stage 1 holes the visual acuity and the volume of macular pigment also were reduced after the operation. DISCUSSION: In the group of stage 4 macular holes there was a significant increase in maximum optical density and volume of macular pigment after successful surgical hole closure, so the functional profit of PPV is very high in these patients. Even in the case of macular holes of stage 3 the PPV effected a functional improvement in the sense of an increase of the optical density of macular pigment. The increase in volume proved to be significant. For macular holes stage 2 the vitrectomy as a therapy option is generally recognised but PPV does not effect positively the height of the optical density of macular pigment. In these patients both the maximum optical density as well as the volume of macular pigment were reduced in the therapeutic course. Whether surgical intervention is indicated in stage 1 is still controversial. Taking into account the development of MPOD the profit from surgery for the patients is very low. This led to a decrease in volume of macular pigment and only a slight increase in maximum optical density after pars plana vitrectomy.

Intraoperative iatrogenic retinal breaks in 23-gauge vitrectomy for stage 3 and stage 4 idiopathic macular holes.

AIMS: To investigate characteristics of intraoperative iatrogenic retinal breaks in 23-gauge vitrectomy for idiopathic macular hole and classify the breaks based on their causes to analyse the risk factors. METHODS: This retrospective study enrolled patients with stage 3 or 4 idiopathic macular hole who underwent 23-gauge vitrectomy in Beijing Tongren Hospital from July 2015 to August 2018. The intraoperative iatrogenic retinal breaks were classified into three types: by induction of posterior vitreous detachment (type 1), by peripheral vitreous cutting (type 2) and by others (type 3). The types, incidence and distribution of the breaks were analysed, and all clinical features were compared between eyes with and without the breaks. RESULTS: A total of 364 eyes from 341 patients were recruited. Twenty-five breaks from 24 eyes (6.6%) were encountered, 52% (13/25) of which distributed in the superior region. Type 1 and type 2 breaks contributed 52% (13/25) and 44% (11/25) to all, respectively. Eyes with stage 3 and stage 4 holes showed no significant differences in incidence or distribution in type 2 breaks. No breaks occurred on the surface of lattice degenerations. All clinical features showed no significant differences between eyes with and without the breaks. CONCLUSION: Distribution of intraoperative iatrogenic retinal breaks shows no preference for the superior or inferior region. Induction of posterior vitreous detachment and traction from peripheral vitreous cutting are major causes of the breaks, which classify them into two main types. The presence of lattice may not be one of the risk factors if treated properly.

Foveal anatomic changes in a progressing stage 1 macular hole documented by spectral-domain optical coherence tomography.

OBJECTIVE: To report the case of a stage 1 macular hole and the sequential intrafoveal changes with spectral-domain optical coherence tomography (SD-OCT). DESIGN: Single, observational case report. PARTICIPANT: A 51-year-old woman with a stage 1A macular hole that progressed to a stage 2 macular hole. METHODS: Clinical ophthalmologic examinations were repeated, including SD-OCT, during follow-up at intervals of several weeks. MAIN OUTCOME MEASURES: Sequential intrafoveal tomographic alterations in a patient with a stage 1 macular hole. Foveal splits in the inner retina progressed to an enlarged pseudocyst that disrupted the outer retinal layer (ORL) resulting from the vitreous traction associated with a perifoveal posterior vitreous detachment (PPVD). RESULTS: The patient was referred for decreased vision in the left eye. Her best-corrected visual acuity was 20/32 in the left eye. The SD-OCT showed intrafoveal splits of a typical stage 1A macular hole with a PPVD. Two weeks later, a small, triangularly shaped foveal detachment was detected beneath the central fovea. Four weeks after the initial visit, the splits expanded and the foveal surface was elevated anteriorly; a columnar structure between the splits beneath the central fovea was seen. Eight weeks after the initial visit, the columnar structure was pulled from the outer retina with formation of the PPVD; the structure had shortened anteriorly and formed a cone-shaped structure under the roof. Eleven weeks after the initial visit, the cone-shaped structure shortened and became smaller under the inner roof, and the ORL was separated completely. The anatomic features of the foveal pseudocyst were comparable with that of a typical stage 1B macular hole. Eighteen weeks after the initial visit, the cone-shaped structure disappeared under the inner roof. Thirty weeks after the initial visit, the roof opened with formation of the PPVD. The foveal anatomic features of the full-thickness macular hole became comparable with that of a typical stage 2 macular hole. CONCLUSIONS: These OCT findings suggested that the cone-shaped structure was pulled from the outer retina by anteroposterior vitreous traction. This may cause a progressively enlarging pseudocyst that disrupts the ORL in some cases of stage 1 macular holes. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A new grading system for retinal pigment epithelial tears.

PURPOSE: The purpose of this study was to assess the prognostic value of a new grading system for retinal pigment epithelium (RPE) tears that developed after antivascular endo-thelial growth factor (VEGF) therapy for exudative age-related macular degeneration. METHODS: The authors performed a retrospective review of consecutive eyes that developed an RPE tear after intravitreal injection of an anti-VEGF agent (pegaptanib, bevacizumab, or ranibizumab) within a 4.5-year period (January 2005 to January 2009) at a single center. Fundus photography, fluorescein angiography, and optical coherence topography were studied for each case of RPE tear, and using fluorescein angiography analysis, a measurement of greatest linear diameter (millimeter) was obtained and a grading scale devised. The grade of RPE tear was correlated with visual and anatomical outcomes and response to continued anti-VEGF therapy. RESULTS: Twenty-one eyes from 20 patients were evaluated in this study. Retinal pigment epithelium tears were graded from one to four based on the greatest length in the vector direction of the tear and involvement of the fovea. Nineteen percent (n = 4) of eyes had Grade 1 tears (diameter smaller than 200 microm), 14% (n = 3) had Grade 2 tears (diameter between 200 microm and 1-disk diameter), 19% (n = 4) had Grade 3 tears (diameter greater than 1-disk diameter), and 48% (n = 10) had Grade 4 tears (Grade 3 tears that involved the foveal center). Lower grade tears were more likely to have better visual acuity and better response to continued anti-VEGF therapy and less likely to develop a disciform scar but were at risk of progressing to a higher grade tear over time. CONCLUSION: The grading of RPE tears according to greatest linear diameter may have prognostic value in predicting visual acuity and anatomical outcome with or without continued anti-VEGF therapy. Lower grade tears have better visual acuity and response to anti-VEGF therapy. Grade 4 tears have a very poor prognosis with or without anti-VEGF therapy.

Classification of full-thickness traumatic macular holes by optical coherence tomography.

PURPOSE: To describe morphologic features of traumatic macular holes on optical coherence tomography and to correlate them with clinical findings. METHODS: Seventy-three consecutive patients diagnosed with full-thickness traumatic macular holes involving the fovea underwent complete ophthalmic evaluation followed by horizontal and vertical line scans using the Stratus optical coherence tomography. Retinal thickness at the edges of the holes, apical and basal diameters, and various clinical parameters were recorded. The approximate apical and basal areas and eccentricities of the holes were calculated. Morphologic parameters were correlated with clinical findings. RESULTS: On the basis of optical coherence tomography findings, traumatic macular holes were classified into five morphologic types with varying average retinal thicknesses, apical areas, and basal areas. Patients who presented >90 days after injury had greater average retinal thickness (P = 0.03) and apex areas (P = 0.002) compared with those who presented within 90 days. Older patients developed more circular holes, i.e., less eccentricity of the apex (P = 0.04) and base (P = 0.01). Interestingly, none of the morphologic parameters investigated in the current study correlated with visual acuity. Patients who presented later in the clinical course or who had greater average retinal thicknesses tended to have better vision (P = 0.11 and P = 0.07, respectively). CONCLUSIONS: Optical coherence tomography evaluation may yield important insights into the pathogenesis and clinical findings of traumatic macular holes.

Spontaneous closure of stage III and IV idiopathic full-thickness macular holes--a two-case report.

BACKGROUND: To document and study the spontaneous closure of stage III and IV idiopathic full-thickness macular holes by using both optical coherence tomography (Stratus OCT) and spectral optical coherence tomography (SOCT). METHODS: A two-center, two-case, observational study of stage III and IV macular holes is presented. OCT and SOCT were performed. RESULTS: Macular holes spontaneously resolved after 4 to 12 weeks of observation. CONCLUSION: The spontaneous closure of large idiopathic full-thickness stage III and IV macular holes is possible. We suggest that, as long as no smooth oval shape of the macular hole edges appears on the cross-sectional OCT and SOCT scans, there is still a chance for its spontaneous closure.

The Manchester Large Macular Hole Study: Is it Time to Reclassify Large Macular Holes?

PURPOSE: To evaluate anatomic and functional outcomes of full-thickness macular holes (FTMH) larger than 400 µm following vitrectomy, internal limiting membrane peel, gas tamponade, and face-down posturing. DESIGN: A retrospective interventional case series. METHODS: A total of 258 consecutive eyes with FTMH larger than 400 µm were enrolled at the Manchester Royal Eye Hospital study over a 5-year period from 2012 to 2017. All eyes underwent pars plana vitrectomy, ILM peel, and gas tamponade. Anatomic success rates were measured. A correlation between macular hole size and closure was evaluated. RESULTS: A total of 258 eyes were analyzed. The anatomic closure rate was 89.92%. When divided into quartiles, the closure rate of FTMH was 98% (64/65) in the 400-477 µm quartile, 91% (59/65) in the 478-558 µm quartile, 94% (60/64) in the 559-649 µm quartile, and 76% (49/64) in the 650-1416 µm quartile. Using receiver operating characteristic and area under the curve analysis, the maximum sensitivity and specificity was obtained with a cutoff ≤ 630 µm (sensitivity 76.7%, specificity 69.2%) giving a Youden index (J) of 0.46. One hundred and forty-six eyes (56.6%) improved by 0.3 logMAR units from their preoperative best-corrected visual acuity at 3 months following surgery. CONCLUSION: This study shows that standard FTMH surgical repair has very high success rate up to 650 µm. It may suggest that there is a need for a reclassification of large FTMH, and new surgical techniques such as internal limiting membrane flaps should be reserved for macular holes larger than 650 µm.

Assessment of Lamellar Macular Hole and Macular Pseudohole With a Combination of En Face and Radial B-scan Optical Coherence Tomography Imaging.

PURPOSE: To investigate lamellar macular hole (LMH) and macular pseudohole (MPH) using a combination of en face and radial B-scan OCT. DESIGN: Retrospective observational case series. METHODS: Setting: Institutional study. PATIENT POPULATION: En face and radial B-scan OCT images of 63 eyes of 60 patients diagnosed with LMH or MPH based on an international classification were reviewed. OBSERVATION PROCEDURES: Cases were classified using en face images based on the presence/absence of epiretinal membrane (ERM), retinal folds, parafoveal epicenter of contractile ERM (PEC-ERM), and retinal cleavage. We compared the en face imaging-based classification system with the international classification system using radial B-scan images. We quantitatively evaluated visual function and macular morphology. MAIN OUTCOME MEASURES: Characterization of multimodal OCT-based subtypes of LMH and MPH. RESULTS: All cases showed ERM and were classified into 4 groups. In the first group, which lacked retinal folds and showed significantly lower visual acuity than the other groups, 81% of eyes had degenerative LMH. In the second group, which lacked PEC-ERM and retinal cleavage and showed significantly lower retinal fold depth, all eyes had MPH. The third group, in which 95% of eyes had symmetric tractional LMH, included eyes with retinal cleavage but without PEC-ERM, and this group showed higher circularity of the foveal aperture and cleavage area than the group with both these features, in which all eyes had asymmetric tractional LMH. CONCLUSIONS: Multimodal OCT enables classification of LMH and MPH based on pathologic conditions. Retinal traction in particular may be useful for determining treatment methods.

Treatment of stage 2 macular hole by intravitreous injection of expansile gas and induction of posterior vitreous detachment.

PURPOSE: To demonstrate the morphological and functional outcomes of intravitreous injection of an expansile gas bubble for the treatment of stage 2 macular holes. DESIGN: Prospective interventional case series. PARTICIPANTS: Twenty eyes of 20 consecutive patients with unilateral stage 2 macular holes. METHODS: The patients underwent intravitreous sulfur hexafluoride injection, followed by postoperative facedown positioning for 3 to 5 days. The patients were observed per protocol schedule with complete ophthalmological examination, including determination of corrected visual acuity (VA), slit-lamp biomicroscopic examination, funduscopic examination, and optical coherence tomography (OCT). Follow-up was greater than 12 months for all patients (mean, 19.5). MAIN OUTCOME MEASURES: Posterior vitreous detachment, anatomical closure of the hole, VA, and hole diameter as measured by OCT. RESULTS: Detachment of the posterior vitreous at the macula was achieved in 19 of 20 eyes (95%). Ten cases (50%) had anatomical closure of the hole with intravitreous gas injection alone. The remaining 10 cases (50%) achieved anatomical closure of the hole after subsequent vitreous surgery. There was a significant difference in hole diameter (P = 0.004) and in pretreatment vision (P = 4.5x10(-5)) in patients for whom gas alone resulted in hole closure and those proceeding to vitreous surgery. Hole closure by gas injection alone was achieved in 7 of 7 eyes (100%) with pretreatment vision better than 20/40 and in 6 of 7 eyes (86%) when the hole was smaller than 200 mum. There were no major complications in this series of patients. Successfully treated macular holes remained closed at all follow-up points during the study period. CONCLUSION: An intravitreous injection of an expansile concentration of the inert sulfur hexafluoride gas alone frequently induces detachment of the posterior vitreous in the aged eye. Anatomical closure of the hole without major complications is more likely in smaller holes with better pretreatment vision. This technique may have clinical application for stage 2 holes in selected cases. A number of potential advantages including decreased morbidity and a potential cost savings may result from successful utilization of this procedure.