Closure Grading and Visual Outcome in Patients with Large Idiopathic Macular Holes: A Spectral-Domain Optical Coherence Tomography Observation.

INTRODUCTION: So far, there has been no closure grade system synthesizing morphological and microstructural features for large idiopathic macular holes (IMHs) treated by vitrectomy and internal limiting membrane (ILM) peeling. This study aimed to propose a concise one and explore its relevance with visual acuity and the related preoperative factors. METHODS: Consecutive patients with large IMHs (minimum diameter >400 µm), undergoing vitrectomy and ILM peeling, obtaining primary closure and regularly followed-up were enrolled. Preoperative clinical charts and spectral-domain optical coherence tomography (SD-OCT) parameters were reviewed. SD-OCT images and best corrected visual acuity (BCVA) were assessed at 1, 4, and 10 months postoperatively. SD-OCT features at last visit were categorized by BCVA significance, and preoperative risk factors were analyzed. RESULTS: Sixty-eight eyes from 64 patients were enrolled. The 10-month postoperative SD-OCT images were categorized into closure grade 1, 2, and 3 with successively decreased BCVA (p < 0.001). During early follow-up, part of grades 2 and 3 could evolve into the upper grade, respectively, but grade 3 could never evolve into grade 1 and exhibited the least satisfactory long-term BCVA. Binary logistic regression showed that large minimum linear diameter (MLD) was a risk factor for grade 3 occurrence (p < 0.001), with a cutoff value of 625.5 µm from the receiver operating characteristic curve for MLD predicting grade 3 occurrence (p = 0.001). CONCLUSION: Long-term closure status of large IMHs could be categorized into three grades with BCVA significance. Large horizontal MLD is a risk factor for occurrence of grade 3 closure with unsatisfactory visual recovery.

Foveal Microstructure and Visual Outcomes after Pars Plana Vitrectomy in Patients with Different Types of Epiretinal Membrane Foveoschisis.

INTRODUCTION: The aim of this study was to evaluate the clinical characteristics and surgical outcomes of the epiretinal membrane foveoschisis (ERM-FS) with different morphological types. METHODS: This retrospective observational study reviewed 44 consecutive ERM-FS patients who underwent ERM surgery. According to the optical coherence tomography images, ERM-FS was classified into three groups: group A, FS crossed the fovea with the foveola elevated; group B, FS located at the foveal edges with a near-normal central foveal point thickness; and group C, FS with undermined foveal edges with a near-normal central foveal point thickness. RESULTS: There were 10 eyes in group A, 20 eyes in group B, and 14 eyes in group C. Preoperatively, eyes in group A had the best best-corrected visual acuity (BCVA), the thickest central foveal point thickness, and the highest ellipsoid zone (EZ) intact rate among the three groups. After surgery, a resolution of foveoschisis was observed in 40.0%, 45.0%, and 50.0% of the eyes in group A, group B, and group C (p = 0.928), respectively. BCVA was significantly improved postoperatively. Although there was no significant difference in BCVA among the three groups at 1 month postoperatively, BCVA of group A was the best at 4 and 10 months. Correlation analysis indicated that the type of ERM-FS, baseline BCVA, central foveal point thickness, and postoperative EZ continuity (all p < 0.05) were important factors for the final BCVA. CONCLUSIONS: The damage to the retinal structure and visual function was milder in group A ERM-FS. Our study emphasized the necessity of OCT-based subtyping in patients with ERM-FS.

PREDICTIVE FACTORS ASSOCIATED WITH THE VISUAL PROGNOSIS AFTER SURGERY FOR IDIOPATHIC VITREOMACULAR TRACTION.

PURPOSE: To investigate the predictive factors for postsurgical visual prognosis in patients with vitreomacular traction (VMT). METHODS: This retrospective study enrolled 31 eyes from 29 patients who underwent vitrectomy for idiopathic VMT with a follow-up period of ≥3 months. The VMT was divided into three grades based on optical coherence tomography images: Grade 1 denoted partial vitreomacular separation with foveal attachment; Grade 2 exhibited intraretinal cysts or cleft with grade 1 findings; and Grade 3 was Grade 2 plus the subretinal fluid. RESULTS: Three eyes developed a full-thickness macular hole after surgery, all of which were Grade 3 patients. In the rest 28 eyes, the mean postoperative follow-up period was 23.3 ± 25.8 months. The postoperative central foveal thickness ( P = 0.001) and final best-corrected visual acuity (BCVA; P < 0.001) were both significantly improved from baseline. Fifteen eyes (53.8%) gained ≥ two Snellen lines. Multilinear regression analysis showed that the worse the baseline BCVA ( P = 0.004), or the more advanced the VMT grade ( P = 0.049), the worse the final BCVA. Baseline BCVA was negatively associated with the postoperative visual improvement ( P < 0.001). Those Grade 3 patients with baseline Snellen BCVA of ≥20/40 were more likely to achieve a final Snellen BCVA of ≥20/25 ( P = 0.035). CONCLUSION: The VMT grade is an important predictive factor for the postsurgical visual prognosis. Surgical intervention should be performed as early as possible for Grade 3 patients to prevent further disease progression and maximize the postsurgical visual benefit.

Photoreceptor Outer Segment Loss at the Macular Hole Border: Clinical Characteristics and Surgical Prognosis.

INTRODUCTION: During macular hole (MH) formation, the vitreofoveal traction may lead to foveal neural tissue avulsion and consequent photoreceptor loss. However, the clinical significance of the photoreceptor outer segment disruption at the MH border remains unclear. This study aims to investigate the clinical features and surgical outcomes of MHs with photoreceptor outer segment disruption at the MH border. METHODS: This study retrospectively reviewed 86 eyes from 85 patients who underwent vitrectomy combined with internal limiting membrane peeling for idiopathic MHs. Baseline and postoperative best-corrected visual acuity (BCVA) and foveal microstructure on optical coherence tomography images were compared between eyes with smooth and bumpy morphology, the latter of which was defined as those with an uneven and irregular surface with evident lumps and indentations at the MH border. RESULTS: The bumpy morphology was identified in 59 of 86 eyes (68.9%). At baseline, eyes with a bumpy MH morphology had a significantly larger minimum linear diameter (p = 0.043), a longer external limiting membrane defect (p = 0.013), and a worse baseline BCVA (p = 0.017) than those with a smooth morphology. Postoperatively, in a multivariate regression model adjusting preoperative confounding effects, eyes with bumpy borders were associated with a longer ellipsoid zone defect (p = 0.006) and a thinner central fovea (p = 0.002) at 1 month, and a thinner central fovea (p = 0.005) and a worse BCVA (p = 0.015) at 10 months. CONCLUSION: A severe photoreceptor outer segment loss is common at the MH border, which represents a chronic pathogenic process and may be an independent predictor for an incomplete photoreceptor recovery and worse long-term visual outcomes after surgery.

The Evolution and Visual Prognosis of Glial Proliferation with Different Grades after Macular Hole Surgery: An Optical Coherence Tomography-Based Study.

INTRODUCTION: The glial proliferation after macular hole (MH) surgery was divided into two types previously: those replacing the entire intraretinal layer and those involving only the inner foveal layers. The evolution and prognosis of the former type were elaborated on in previous studies, but the latter one has received limited attention. Therefore, this study aims to investigate the evolution of glial proliferation with varying grades after MH surgery and its effects on foveal microstructure and best-corrected visual acuity (BCVA). METHODS: In this retrospective research, we reviewed 202 eyes from 196 consecutive patients who underwent a successful idiopathic MHs repair. Based on optical coherence tomography images, glial proliferation was classified into three types: A-type, which replaced the entire intraretinal layer; B-type, located at the level of and above the external limiting membrane (ELM); and C-type, situated above the ELM. RESULTS: Of the 67 eyes that attended the 1-, 4-, and 10-month follow-up, A-type, B-type, C-type, and no glial proliferation were identified in 27 (40.3%), 17 (25.4%), 20 (29.8%), and 3 eyes (4.5%), respectively, at 1 month. Within 10 months, the prevalence of A-type glial proliferation significantly decreased (p < 0.001), but the changes in B-type (p = 0.261), C-type (p = 0.151), and no glial proliferation (p = 0.492) were not significant. In 32 of the 67 eyes, the grade of glial proliferation gradually improved, with A-type transforming into B- or C-type in 19 of 27 eyes (70.4%), B-type into C-type or no glial proliferation in 11 out of 17 eyes (64.7%), and C-type gradually disappearing in 2 out of 20 eyes (10.0%). Among the eyes that attended at least one follow-up (1 M, 202 eyes; 4 M, 161 eyes; 10 M, 97 eyes), those with A-type glial proliferation showed the most defective outer retinal layers, worst BCVA, and thinnest central fovea compared with the other two types at all follow-up time points (p < 0.001). Eyes with C-type glial proliferation exhibited significantly better photoreceptor layer status and BCVA compared with those with B-type glial proliferation. A-type glial proliferation at 1 month, which showed significant association with BCVA at 10 months, could be accurately predicted by the minimum linear diameter with a cut-off >547.5 µm (p < 0.001). CONCLUSION: Within 10 months, A-type glial proliferation substantially resolves but the prevalence of B- and C-type remains unchanged. B-type glial proliferation hinders the restoration of photoreceptors and impairs visual recovery despite being located within the inner retina.

Comparison of Different Internal Limiting Membrane Peeling Sizes for Idiopathic Macular Holes: A Systematic Review and Meta-Analysis.

BACKGROUND: Although internal limiting membrane (ILM) peeling facilitates macular hole (MH) closure and reduces late hole reopening, it brings some detrimental consequences to the retinal microstructure and functional outcomes. So far, previous studies have not reached a consensus on the optimal ILM peeling size. OBJECTIVES: The objective of this study was to evaluate the outcomes of different ILM peeling sizes for idiopathic MHs. METHODS: PubMed, Embase, Cochrane Library, Web of Science, CNKI, and WANFANG were searched until April 10, 2022. Studies in English or Chinese that compare the effects of two ILM peeling sizes (>2 disk diameters [DDs] vs. ≤2DD) for idiopathic MHs were included. The overall closure rate, postoperative best-corrected visual acuity (BCVA), type 1 closure, and adverse events were extracted. BCVA was converted to logarithm of the minimum angle of resolution (LogMAR). RESULTS: Seven eligible studies (560 eyes) including 3 randomized clinical trials, 3 prospective trials, and one retrospective cohort were included. Pooled results showed a significantly better postoperative BCVA (mean difference = -0.16; 95% confidence interval [CI]: -0.27 to -0.04; LogMAR) and higher type 1 closure rate (risk ratio [RR] = 1.24; 95% CI: 1.08-1.43) in eyes with ILM peeling >2DD than those with peeling ≤2DD. No significant difference was found in overall closure rate and adverse events between the two groups. Subgroup analysis indicated that in MHs >400 µm, peeling >2DD helped obtain a better postoperative BCVA (mean difference = -0.17; 95% CI: -0.29 to -0.04; LogMAR) and higher frequency of type 1 closure (RR = 1.25; 95% CI: 1.03-1.51). CONCLUSIONS: Peeling >2DD shares similar safety level with peeling ≤2DD and has a superiority of facilitating visual recovery. Larger ILM peeling may be more beneficial for large MHs.

Microstructural and microperimetric comparison of internal limiting membrane peeling and insertion in large idiopathic macular hole.

BACKGROUND: The internal limiting membrane (ILM) insertion technique was widely used to treat large macular hole (MH) for the high closure rate. However, the prognosis of closed MH after ILM insertion compared to ILM peeling remains controversial. This study aimed to compare foveal microstructure and microperimeter in large idiopathic MH surgically closed by ILM peeling and ILM insertion. METHODS: This retrospective, non-randomized, comparative study included patients with idiopathic MH (minimum diameter ≥ 650 µm) who underwent primary pars plana vitrectomy (PPV) with ILM peeling or ILM insertion. The initial closure rate was recorded. Patients with initially closed MHs were divided into two groups according to the surgery methods. The best-corrected visual acuity (BCVA), optical coherence tomography (OCT) and microperimeter-3 (MP-3) outcomes of two groups were compared at baseline, 1 and 4 months postoperatively. RESULTS: For idiopathic MH (minimum diameter ≥ 650 µm), ILM insertion had a significantly higher initial closure rate than ILM peeling (71.19% vs. 97.62%, P = 0.001). Among 39 patients with initially closed MHs who were on regular follow-up, twenty-one were assigned to the ILM peeling group and 18 to the ILM insertion group. Postoperative BCVA improved significantly in both groups. The final BCVA (logMAR) (0.40 vs. 0.88, P < 0.001), macular hole sensitivity (19.66 dB vs. 14.14 dB, P < 0.001), peripheral sensitivity of macular hole (24.63 dB vs. 21.95 dB, P = 0.005), and fixation stability (FS) within 2 degrees (82.42% vs. 70.57%, P = 0.031) were significantly better and external limiting membrane (ELM) defect (330.14 µm vs. 788.28 µm, P < 0.001) and ellipsoid zone (EZ) defect (746.95 µm vs. 1105.11 µm, P = 0.010) were significantly smaller in the ILM peeling group than in the ILM insertion group. CONCLUSION: For initially closed MHs (minimum diameter ≥ 650 µm), both ILM peeling and ILM insertion significantly improved the microstructure and microperimeter in the fovea. However, ILM insertion was less efficient at microstructural and functional recovery after surgery.

Clinical features of idiopathic epiretinal membrane in children and the factors influencing postoperative visual acuity.

PURPOSE: To describe the characteristics and surgical outcomes of idiopathic epiretinal membrane (iERM) in children and to determine the factors associated with postoperative visual acuity (VA). METHODS: We retrospectively reviewed the medical records of 17 patients with iERM (age, < 18 years) who had undergone ERM surgery from 2009 to 2021. Spectral-domain optical coherence tomography features were documented. The eyes with iERMs involving the fovea were assigned to the localized and diffused groups depending on the morphological description of the membrane. Multiple linear regression analysis was used to explore the factors associated with the final VA. RESULTS: The mean age was 9.2 ± 3.8 years. The mean follow-up period was 38.9 ± 45.4 months. After surgery, the central foveal thickness and the best-corrected VA (BCVA) improved significantly (all, P < 0.05). Fourteen eyes with iERMs showed involvement of the foveal area (localized group, six eyes; diffused group, eight eyes). There were no significant differences in the preoperative BCVA between the two groups (P = 0.064). However, the final BCVA was better in the diffused group than in the localized group (P = 0.043). Multiple regression analysis indicated that the localized membrane (P = 0.042) and lower preoperative BCVA (P = 0.043) were factors associated with a worse final VA in pediatric iERMs. CONCLUSIONS: Surgical removal of ERM showed a high anatomical and functional success rate in children. In pediatric patients with iERMs involving the fovea, a good VA was more common when the membrane was diffused than when it was localized.

Stage or size? The identity of anatomical and visual outcomes in stage 3 and stage 4 idiopathic macular holes after vitrectomy.

BACKGROUND: Several previous reports suggested that stage 4 idiopathic macular holes (IMHs) may exhibit lower rate of anatomical success and poorer functional results comparing with stage 3 IMHs, while some others showed no differences. Actually, few studies focused on comparison of prognosis between stage 3 and stage 4 IMHs. Our previous study found that IMHs of these two stages demonstrate similar preoperative characteristics, and this study aims to compare anatomical and visual outcomes of IMHs between stage 3 and stage 4, and tries to figure out the outcome-associated factors. METHODS: This retrospective consecutive case series reviewed 317 eyes with IMHs of stage 3 and stage 4 from 296 patients who underwent vitrectomy with internal limiting membrane peeling. Preoperative characteristics like age, gender, and hole size, and intraoperative interventions such as combined cataract surgery were evaluated. Outcome measures included the primary closure rate (type 1), best-corrected visual acuity (BCVA), foveal retinal thickness (FRT) and prevalence of outer retinal defect (ORD) at the last visit. The pre-, intra-, and post-operative information were respectively compared between stage 3 and stage 4. RESULTS: The preoperative characteristics and intraoperative interventions exhibited no significant differences between stages. With comparable follow-up durations (6.6 vs. 6.7 months, P = 0.79), IMHs of the two stages exhibited similar primary closure rate (91.2% vs. 91.8%, P = 0.85), BCVA (0.51 ± 0.12 vs. 0.53 ± 0.11, P = 0.78), FRT (134.8 ± 55.5 µm vs. 138.8 ± 60.7 µm, P = 0.58), and prevalence of ORD (55.1% vs. 52.6%, P = 0.39). IMHs, either < 650 µm or larger, exhibited no significant difference in outcomes between the two stages. However, smaller IMHs (< 650 µm) demonstrated higher rate of primary closure (97.6% vs. 80.8%, P < 0.001), better postoperative BCVA (0.58 ± 0.26 vs. 0.37 ± 0.24, P < 0.001), and thicker postoperative FRT (150.2 ± 54.0 vs. 104.3 ± 52.0, P < 0.001) comparing with larger ones regardless of stage. CONCLUSION: IMHs of stage 3 and stage 4 exhibited considerable identity of anatomical and visual outcomes. In large IMHs, the hole size, instead of stage, may be more important for prediction of surgical outcomes and choice of surgical techniques.

CLINICAL CHARACTERISTICS AND SURGICAL PROGNOSIS OF IDIOPATHIC MACULAR HOLES WITH EPIRETINAL PROLIFERATION.

PURPOSE: To investigate the clinical features and surgical outcomes of idiopathic macular holes with epiretinal proliferation (EP). METHODS: This retrospective study included 282 eyes of 269 consecutive patients who underwent vitrectomy for idiopathic macular holes. Clinical demographic data, baseline and postoperative retinal microstructure features on optical coherence tomography images, best-corrected visual acuity, and postoperative closure rate were compared between eyes with and without EP. RESULTS: EP was identified in 38 of 282 eyes (13.5%). Eyes with EP had a significantly longer symptom duration ( P = 0.019), higher frequency of pseudophakic conditions ( P = 0.034), presence of epiretinal membrane ( P < 0.001), and a larger base diameter ( P = 0.014) than those without EP. In addition, compared with eyes without EP, those with EP had a higher percentage of U-type closure ( P = 0.047) and a thicker central fovea ( P = 0.012) at 1 month postoperatively and a significantly lower frequency of ellipsoid zone disruption ( P = 0.033) and outer foveolar lucency ( P = 0.021) and a thicker central fovea ( P = 0.004) at 10 months postoperatively. CONCLUSION: The presence of EP represents a more chronic pathogenic process but has no negative effect on postoperative outcomes and can even facilitate anatomical recovery after surgery.

Internal Limiting Membrane Peeling or Inverted Flap Technique Combined with Air Tamponade in the Treatment of Macular Holes in High Myopia.

PURPOSE: The aim of this study was to analyze the anatomical and visual outcomes after internal limiting membrane (ILM) peeling or ILM flap insertion in highly myopic macular holes (HMMHs) and try to compare these two surgical techniques in large HMMHs. METHODS: This is a retrospective, consecutive series study of patients with HMMH undergone vitrectomy from September 2016 to January 2021. We observed the outcomes of the HMMHs with ILM peeling and ILM flap insertion, respectively. Binary logistic regression and receiver operating characteristic (ROC) curve were used to analyze the relationship between the minimum linear diameter (MLD) of macular hole and the initial closure rate in ILM peeling group. Finally, we compared the surgical outcomes between these two surgical techniques in large HMMHs. RESULTS: There were 69 HMMHs using ILM peeling with a mean MLD of 423.55 ± 190.99 µm and 33 HMMHs using ILM flap insertion with a mean MLD of 600.79 ± 187.85 µm. The initial type I closure rate was 86.9% (60/69) and 81.8% (27/33), respectively. MLD had a good correlation with the initial closure rate in HMMHs with ILM peeling (p = 0.046). The large HMMH (MLD >461.5 µm obtained by ROC curve) was present in 26 eyes with each surgical technique, and there was no significant difference of baseline characteristics between them. In large HMMHs, the initial closure rate of ILM peeling was 73.0% and that of ILM flap insertion was 84.6% (p = 0.499). Postoperative best-corrected visual acuity (BCVA) improved significantly in both groups (p < 0.001), and the BCVA at last follow-up was better in closed large HMMHs with ILM peeling (p = 0.034). CONCLUSION: In HMMHs with ILM peeling, the initial closure rate was decreased when MLD >461.5 µm. ILM peeling may obtain better functional prognosis in eyes with closed large macular holes compared with ILM flap insertion.

DIFFERENCES IN ANATOMICAL AND VISUAL OUTCOMES AMONG THREE INTERNAL LIMITING MEMBRANE TECHNIQUES TREATING EXTRA-LARGE IDIOPATHIC MACULAR HOLES.

PURPOSE: To compare the anatomical and visual outcomes of extra-large idiopathic macular holes treated with internal limiting membrane peeling and two inverted internal limiting membrane flap techniques, namely insertion and cover technique. METHODS: Patients with idiopathic macular holes (minimum linear diameter ≥ 650 µm) were divided into peeling group, insertion group, and cover group. The initial closure rate, final length of external limiting membrane and ellipsoid zone recovery, and best-corrected visual acuity were evaluated. RESULTS: A total of 124 eyes were included, and the average follow-up was 7.2 months. All the baseline characteristics were comparable among the three groups. Initial closure rate of the peeling group, the insertion group, and the cover group was 65.0% (26/40), 97.6% (41/42), and 90.5% (38/42), respectively (P < 0.001). In closed idiopathic macular holes, the peeling group and the cover group exhibited significantly longer length of external limiting membrane recovery than the insertion group (P < 0.001), and the peeling group exhibited significantly longer length of ellipsoid zone recovery than the other two groups (P = 0.021). The peeling group and the cover group exhibited significantly better best-corrected visual acuity improvement than the insertion group (P = 0.009). CONCLUSION: For extra-large idiopathic macular holes, cover technique surpasses internal limiting membrane peeling technique in closure rate and outperforms insertion technique in anatomical and functional recovery, whereas insertion technique may adversely affect the recovery of foveal microstructure and best-corrected visual acuity.

Morphological Characteristics of Foveal Pit Base and Its Impact on Visual Acuity in Macular Pseudoholes.

INTRODUCTION: To investigate the characteristics of macular pseudoholes (MPHs) with different foveal profiles and their impact on preoperative and postoperative visual acuity (VA). METHODS: A retrospective review of 47 eyes from 46 consecutive patients with MPH who had undergone vitrectomy was conducted. The MPHs were classified into u-shape and v-shape according to the morphological description of the foveola base. The best-corrected visual acuity (BCVA), central foveal point thickness, parafoveal thickness, parafoveal inner and outer retinal thickness, stretched lamellar cleavage, microcystic macular edema (MME), disorganization of retinal inner layers (DRIL), and the integrity of outer retinal layers were recorded. RESULTS: The eyes in the v-shaped group (n = 31) had lower BCVA, thicker retinal thickness, more intraretinal cleavage, MME, and DRIL than the u-shaped (n = 16) group (all p < 0.05). Multiple regression analysis revealed that the morphology of the foveola base was significantly related to the preoperative BCVA (p = 0.025). The VA was significantly improved in both groups, and the improvement was greater in the v-shaped group (p = 0.024). No significant difference was found in the postoperative BCVA between the two groups (all p > 0.05). CONCLUSION: The v-shape, reflecting the stretch in the foveola, had a significant impact on preoperative BCVA. However, the VA was improved after surgery whatever their initial foveal profile.

COMPARISON OF AIR VERSUS PERFLUOROPROPANE INTRAOCULAR TAMPONADE COMBINED WITH VITRECTOMY FOR THE TREATMENT OF MACULAR HOLE IN HIGH MYOPIA.

PURPOSE: To compare the efficacy of air and perfluoropropane (C3F8) with pars plana vitrectomy (PPV) in highly myopic macular holes (HMMHs) and explore the factors related to surgical prognosis. METHODS: A retrospective comparison of a consecutive series of HMMHs undergone vitrectomy and internal limiting membrane peeling. According to tamponade type, they were divided into air group and C3F8 group, which were further divided into subgroups based on hole diameter or axial length (AXL). Anatomical and functional outcomes were compared between tamponades. Related factors of initial closure rate and postoperative best-corrected visual acuity (BCVA) were analyzed by logistic regression. RESULTS: The baseline characteristics in air group (n = 63) and C3F8 group (n = 37) were similar except the age of air was older ( P = 0.019). The mean follow-up period was 17.16 ± 17.97 months. After surgery, the initial closure rate of air group was 85.7% and that of C3F8 group was 83.7% ( P = 0.780). And the initial closure rate showed no difference between tamponades in the same subgroup classified by hole diameter or AXL (all P > 0.05). Postoperative BCVA improved significantly in both groups ( P < 0.001), but no difference between them ( P = 0.793). Logistic regression showed that age, minimum linear diameter, and AXL were risk factors of initial closure rate, and preoperative BCVA was the only factor associated with postoperative BCVA (all P < 0.05). CONCLUSION: With a long-term follow-up of HMMH, we found air had a similar tamponade effect anatomically and functionally compared with C3F8. Air may also be a good choice for patients with HMMH.

Observation of macular hole associated with retinoschisis in patients with high myopia.

PURPOSE: To observe the characteristics of highly myopic macular holes (HMMHs) with macular retinoschisis (MRS) by optical coherence tomography (OCT) and explore the possible relationship between HMMHs and different types of MRS. METHODS: We consecutively reviewed the clinical data and OCT images of the patients with HMMHs from June 2015 to February 2021. Then we picked eyes with MRS from these HMMHs for analysis. The minimum linear diameter (MLD), basal diameter (BD), and height (H) of HMMHs were measured. HMMHs were grouped according to the extent or layer involvement of the concomitant MRS and the characteristics were compared among groups. The impact of MRS on the MLD of macular hole was analyzed with multivariable linear regression. RESULTS: We included 127 patients with MRS from 168 HMMHs (75.5%) for analysis. According to the different classification systems, the most frequent type of MRS in HMMHs was S3 (foveal but not entire macular area MRS) (62.2%) and both inner- and outer- (I/O-MRS) involved types. In our study, HMMHs with more extensive MRS had larger MLD, larger BD, larger H, and poorer best-corrected visual acuity (BCVA). Meanwhile, HMMHs with outer layer-involved MRS (outer MRS and I/O-MRS) had larger BD than HMMH with only inner layer-involved MRS. (All P < 0.05) Multivariable linear regression further illustrated only the extent of MRS was significantly associated with the MLD of HMMH, while there was no significant correlation between the involved retinal layers and the MLD of HMMH. CONCLUSION: HMMH with MRS presented as a predominant type in HMMHs. The MRS was always with a relatively large extent and involved both inner and outer layers. MLD of HMMH was mainly affected by the extent of MRS.

Changes in foveal photoreceptor integrity after idiopathic epiretinal membrane surgery and its relationship with visual outcomes.

PURPOSE: To investigate the changes in the external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (IZ) integrity and their relationship with visual outcomes after idiopathic epiretinal membranes peeling. METHODS: Clinical records of 150 eyes from 144 consecutive patients who underwent vitrectomy were reviewed. The status of IZ, EZ, and ELM was assessed by spectral-domain optical coherence tomography at baseline and 1, 4, 10, and 24 months postoperatively. RESULTS: Sixty-one eyes presented with photoreceptor layer disruption preoperatively, and IZ disruption (40.7%) was the primary type. The best-corrected visual acuity (BCVA) in the photoreceptor disruption group was significantly lower than that in the intact group at baseline and the final follow-up. Of them, ELM + EZ + IZ disruption showed the worst BCVA (P = 0.001). After surgery, 62 eyes were observed with disruption aggravated. EZ + IZ disruption (51.0%) was the most frequent type at 1 month postoperatively. The eyes with longer symptom duration, better BCVA, earlier stage, thinner CFT at baseline, and combined cataract surgery more tended to be observed with photoreceptor damage progressed after surgery (P < 0.05). There was no significant difference in the final BCVA between the eyes with and without damage progressed (P = 0.332). Finally, 28.1% of the eyes recovered photoreceptor continuity. The eyes with foveal photoreceptor integrity restored had better BCVA than those remaining discontinuous (P < 0.001). CONCLUSION: ERM-induced photoreceptor disruption mainly manifests as IZ disruption and has a negative effect on BCVA, whereas surgery mainly causes EZ and IZ disruption, which does not have a significant impact on the final BCVA.

CLINICAL FEATURES AND PROGNOSIS IN IDIOPATHIC EPIRETINAL MEMBRANES WITH DIFFERENT TYPES OF INTRARETINAL CYSTOID SPACES.

PURPOSE: To observe the characteristics and prognosis of different types of intraretinal cystoid spaces in idiopathic epiretinal membranes (iERMs). METHODS: Two hundred and seven consecutive patients with symptomatic iERM who underwent vitrectomy between September 2016 and December 2019 were included. According to spectral-domain optical coherence tomography images, intraretinal cystoid spaces were classified into cystoid macular edema (CME) and microcystic macular edema (MME). Other optical coherence tomography characteristics, including ectopic inner foveal layers, central foveal thickness, and interdigitation zone integrity, were also evaluated. RESULTS: Intraretinal cystoid spaces were presented in 30.1% of the iERMs, 21.5% were CME-type, 66.2% were MME-type, and 12.3% were combined-type. Compared with CME, eyes with MME-type and combined-type showed a significantly lower best-corrected visual acuity (BCVA) preoperatively and postoperatively. Cystoid macular edema is always presented in earlier stages (92.9%) and has no significant effects on BCVA (PStage I = 0.927, PStage II = 0.985). Conversely, MME is the primary type in advanced stages associated with a longer duration of symptoms (P = 0.037) and lower preoperative BCVA (P = 0.008). After surgery, cystoid spaces were newly occurred in 33 eyes (21.6%), with no effects on BCVA (P = 0.668). In the multiple regression analysis, the presence of MME was a risk factor for preoperative BCVA (P = 0.001). However, it is not an independent predictor for the postoperative VA. CONCLUSION: Our research further proved that MME is an adverse factor for preoperative and postoperative VA in iERMs. Moreover, we underlined the importance of distinguishing between CME and MME, which may affect prognosis differently.

EFFECTS OF ECTOPIC INNER FOVEAL LAYERS ON FOVEAL CONFIGURATION AND VISUAL FUNCTION AFTER IDIOPATHIC EPIRETINAL MEMBRANE SURGERY.

PURPOSE: To investigate the effects of ectopic inner foveal layers (EIFLs) on foveal configuration recovery and visual acuity after idiopathic epiretinal membrane removal and analyze the relationship of foveal configuration recovery between 1-month and long-term postoperatively. METHODS: This retrospective study included 216 consecutive eyes with idiopathic epiretinal membrane that underwent vitrectomy surgery. A comprehensive ophthalmic examination was performed for all patients before and 1, 4, 10, and 24 months after surgery. We observed the postoperative anatomical and functional recovery of eyes with and without EIFLs and analyzed the association between short-term and long-term anatomical recovery. RESULTS: The presence of EIFL was associated with severe preoperative visual damage ( P < 0.001) and was considered as a negative factor for postoperative foveal depression recovery ( P < 0.001). No significant difference was found in postoperative best-corrected visual acuity between the eyes with and without EIFLs ( P = 0.442). For eyes with Stage II epiretinal membranes, 17.6% developed EIFLs postoperatively, which did not affect the final best-corrected visual acuity. Overall, 24.5% of epiretinal membranes restored the foveal configurations at 1 month postoperatively, and 14.7% continued recovering during the follow-up. Foveal structure recovery in eyes with EIFLs was associated with earlier stage, fewer microcystic macular edema, complete interdigitation zone layer, and a thinner central foveal thickness (all P < 0.05) at 1 month postoperatively. CONCLUSION: The EIFL is associated with severe preoperative visual damage and is a negative factor for postoperative anatomical recovery, but it is a minor factor for postoperative visual acuity. We also found an association of foveal configuration recovery between 1 month and long-term after surgery.

CHANGES OF FIXATION STABILITY AND LOCATION AFTER EPIRETINAL MEMBRANE SURGERY.

PURPOSE: This study aimed to evaluate fixation stability and position changes after epiretinal membrane (ERM) surgery. METHODS: This is a retrospective study that included 60 consecutive eyes with idiopathic ERM. All patients received comprehensive ophthalmic examinations preoperatively and 1, 4, and 10 months postoperatively. Main outcome measures included fixation stability and position, bivariate contour ellipse area, and preferred retinal locus. RESULTS: The number of patients with stable fixation and predominantly central fixation was increased significantly after ERM surgery (61.7 vs. 73.3%, P = 0.001; 41.7 vs. 71.7%, P = 0.037). The correlation analysis showed that the preoperative factors associated with improved postoperative fixation stability were a larger bivariate contour ellipse area value (P < 0.001), poorer visual acuity (P = 0.002), advanced stage (P = 0.002), thicker central fovea thickness (P = 0.015), and a longer preferred retinal locus-fovea distance (P = 0.025). As for the improved fixation location, the associated preoperative factors were age (P = 0.003), central fovea thickness (P = 0.044), and preferred retinal locus-fovea distance (P < 0.001). CONCLUSION: Our observations point to the changes of fixation parameters in patients after ERM surgery. We found that patients with preoperative unstable, eccentric fixation and poor BCVA can significantly benefit from the surgery. This result indicates that even in patients with severe macular damage, the ERM surgery still has great benefits in recovering visual function.

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.