Immunocytochemical characterization of macular hole opercula.

OBJECTIVES: To immunocytochemically characterize the neural and glial elements of idiopathic full-thickness macular hole (FTMH) opercula excised during vitrectomy, and to correlate them with the outcome of surgery. METHODS: Opercula were collected from eyes undergoing vitrectomy for stage 3 FTMH and processed for transmission electron microscopy, light epifluorescence, and laser scanning confocal microscopy. Glia were identified using anti-glial fibrillary acid protein (GFAP), antivimentin, and anti-cellular retinaldehyde binding protein antibodies. Anti-phosphodiesterase gamma and antirhodopsin were used for cone and rod photoreceptors, and anticytokeratin was used for retinal pigment epithelium. The findings were correlated with the clinical data before and after surgery. For statistical analysis, data were combined with those of a previous study by the authors of 18 opercula. RESULTS: Opercula from 12 consecutive eyes of 12 patients were studied. In all opercula, GFAP, vimentin, and cellular retinaldehyde binding protein-positive glia were present. Six (50%) of 12 opercula contained more than 5 photoreceptors with somata and internal photoreceptor fibres, but lacking outer segments, demonstrating strong immunoreactivity to anti-phosphodiesterase gamma without antirhodopsin reactivity consistent with cones. Further, 2 (17%) of 12 opercula showed few cones (1-5 cones), and 4 (33%) of 12 contained only glia. Clinicopathologic correlation of the 30 opercula from the 2 studies showed that eyes with opercula containing more than 5 photoreceptors were associated with a worse anatomical closure rate after initial surgery, compared with those with fewer than 5 photoreceptors (P =.004). Once closure had been achieved with reoperation, median postoperative vision was similar in both groups (20/40 and 20/60, respectively). CONCLUSIONS: A spectrum of opercula occur in FTMH ranging from those containing only glia to those containing numerous cones. The extent of foveal neuroretinal tissue loss may affect the outcome of surgery.

Macular hole opercula. Ultrastructural features and clinicopathological correlation.

OBJECTIVE: To investigate the ultrastructural features of idiopathic full-thickness macular hole (FTMH) opercula excised during vitrectomy and to correlate them with the outcome of surgery. METHODS: Opercula were collected from eyes undergoing vitrectomy for stage 3 FTMH using noncrushing, cupped foreign body forceps. Following immediate fixation, specimens were processed for transmission electron microscopy. The ultrastructural features were correlated with the clinical data recorded for each patient before and after surgery. RESULTS: Eighteen specimens were studied. Native vitreous collagen was identified on the surface of all 18, while fragments of internal limiting membrane were present in 11 (61%). Eleven (61%) were found to contain only glia, comprising fibrous astrocytes and Müller cells in variable proportions. The remaining 7 (39%) were found to contain, in addition to glia, neurites and synaptic complexes, of which some were typical of cone photoreceptors. The initial surgical closure rate was significantly better in eyes in which only glia were present (9/11 [82%]), compared with those with neurites (1/7 [14%]) (P = .01). Once closure had been achieved with reoperation, the median final visual acuity was 20/60 in both groups (P = .26), although the likelihood of achieving an acuity of 20/40 or better was greater in the former (50%) than the latter group (17%). CONCLUSIONS: Two distinct types of opercula occur in association with stage 3 FTMH--those containing only glia (pseudo-opercula), which are probably associated with a foveal dehiscence and little or no loss of foveal tissue, and those containing both glia and a significant number of avulsed foveal cones (true opercula), which arise from a full-thickness foveal tear. Although the loss of foveal tissue in true opercula would seem to explain the worse initial anatomical and more modest visual results in some eyes, significant visual improvement may still be achieved after successful closure. The presence of neurites in true opercula suggests that, in at least some cases, direct traction on the foveal retina leads to macular hole formation.

Membranectomy and autologous serum for the retreatment of full-thickness macular holes.

OBJECTIVE: To determine the efficacy of reoperation with rigorous epiretinal membrane dissection and autologous serum for full-thickness macular holes remaining open after initial surgery. METHODS: Forty-six consecutive eyes that had previously undergone unsuccessful macular hole surgery were re-treated with epiretinal membrane dissection, adjunctive autologous serum, and 16% perfluoropropane (C3F8) gas tamponade. Anatomical closure and improvement of best-corrected Snellen visual acuity were used as outcome measures, and nuclear sclerosis was graded clinically before and after reoperation. RESULTS: Epiretinal membrane was identified and dissected in 29 (63%) of the 46 eyes and anatomical closure was achieved in 37 (80%) of the 46 eyes. Of these, 23 (62%) of 37 improved by at least 2 Snellen lines, 12 (35%) of 37 by at least 3 Snellen lines, and 6 (16%) of 37 by at least 4 Snellen lines. Increase in nuclear sclerosis occurred in 30 (65%) of the 46 eyes postoperatively, leading to cataract extraction in 12 (26%) of the eyes at last follow-up (mean, 10.3 months). A longer total duration (P<.001) and a worse preoperative visual acuity (P=.001), prior to reoperation, were associated with a worse final visual acuity after surgery. CONCLUSIONS: Retreatment with rigorous membranectomy and autologous serum seems to be beneficial in most eyes in which initial macular hole surgery has failed. Although the anatomical closure rate is similar to that reported after primary surgery, final visual acuity improvement seems to be less than after successful primary closure, owing to the longer mean duration of holes in which initial surgery has failed.

Cataract extraction following vitrectomy and silicone oil tamponade.

Surgery for cataract resulting from pars plana vitrectomy combined with fluid/silicone oil exchange is often rewarding in terms of visual acuity improvement. Careful choice of surgical method and suitable modifications of standard technique reduce the incidence of serious complications. Per-operative posterior capsulotomy is a safe method of maintaining a clear visual axis after ECCE.