Pre- and postoperative OCT features and surgical outcomes of advanced retinitis pigmentosa with macular hole: case series and literature review.

BACKGROUND: Macular hole (MH) is a rare complication of retinitis pigmentosa (RP) and has an adverse impact on residual visual function. At present, the underlying mechanisms are not fully understood and surgical experience is limited. METHODS: We reviewed the medical records and optical coherence tomography (OCT) scans in a cohort of eight eyes of seven RP patients with MH in order to report their OCT features and vitreoretinal surgical prognosis. RESULTS: This study includes four lamellar macular holes (LMHs) and four full-thickness macular holes (FTMHs). Pre-operative OCT revealed other macular abnormalities in all eyes, such as epiretinal membrane (ERM), cystoid macular edema (CME), lamellar hole-associated epiretinal proliferation (LHEP) and vitreoretinal traction. MH progression and subjective vision worsening were noted in one LMH eye during a seven-month follow-up. All holes closed after vitrectomy with internal limiting membrane (ILM) peeling. At final follow-up, one eye had improved vision and seven eyes remained stable compared to baseline. CONCLUSIONS: The occurrence of MH in RP is accompanied by various imaging characteristics, such as ERM, CME and LHEP, suggesting a multifactorial pathogenesis. Considering poor vision in most RP patients with potentially progressive MH, surgery appears to be effective in maintaining or improving the central vision in a period of time. Thus, vitrectomy should be performed as soon as possible and flap-assisted techniques or episcleral surgeries are needed for some special cases.

Intraoperative challenges and management of fibrovascular membrane with tractional retinoschisis in proliferative diabetic retinopathy.

BACKGROUND: In severe Proliferative Diabetic Retinopathy (PDR), fibrovascular membrane (FVM) causes macular tractional retinal detachment (MTRD) which threatens vision and eventually leads to blindness. Here we present a case of separation between the inner and outer retina in tractional retinoschisis, induced during intraoperative FVM delamination. CASE PRESENTATION: A 68-year-old woman presented with PDR in the right eye, characterized by a combined FVM and retinal detachment, for which a vitrectomy was performed. Multiple holes, large retinal detachment extending to all quadrants, and white-lined blood vessels with FVM were found during the procedure. When membrane delamination was performed, it strayed into the space between the inner and outer retinal layers without being noticed due to retinoschisis and multiple retinal holes. After removing the FVM and detaching the separated inner retina, fluid-gas and photocoagulation were performed. Retinal reattachment was successfully achieved after surgery, and the postoperative visual acuity was improved and maintained for 26 months postoperatively. CONCLUSIONS: When tractional retinoschisis due to FVM is combined with retinal holes in tractional retinal detachment (TRD), care must be taken to prevent delamination from straying into retinoschisis during separation.

Comparison of the therapeutic effects of lens capsular flap transplantation and autologous retinal transplantation in the management of refractory macular holes.

PURPOSE: To report the comparison of the therapeutic effects of lens capsular flap transplantation (LCT) and autologous retinal transplantation (ART) in refractory macular hole (MH) treatment. METHODS: Thirty-one patients (31 eyes) with refractory MH were retrospectively reviewed. The patients were divided into two groups based on the surgical procedures: the LCT group (13 eyes) and the ART group (18 eyes). Patients were monitored for a minimum of 6 months. Best corrected visual acuity (BCVA), hole closure rate, postoperative central foveolar thickness (CFT), and some complications (e.g. graft loss or dislocation, postoperative retinal detachment, or postoperatively elevated intraocular pressure) were the primary outcome measures. RESULTS: The mean preoperative MH diameter was 1104 ± 287 µm in the LCT group and 1066 ± 297 µm in the ART group (t = 0.353, P = 0.727). The MH was closed in 12 patients (92.3%) of the LCT group and 17 patients (94.4%) of the ART group (χ2 = 0.057, P = 0.811); the MHs of 10 patients (76.9%) in the LCT group and 11 patients (61.1%) in the ART group were completely closed (χ2 = 0.864, P = 0.353). The BCVA improved from 2.3 ± 1.0 logMAR preoperatively to 1.3 ± 0.9 logMAR postoperatively in the LCT group and 2.3 ± 0.9 logMAR preoperatively to 1.0 ± 0.6 logMAR postoperatively in the ART group (postoperative BCVA vs preoperative BCVA in the LCT group: t = 4.374, P = 0.001; postoperative BCVA vs preoperative BCVA in the ART group: t = 5.899, P = 0.000018). The visual improvement was 1.3 ± 0.9 logMAR in the ART group and 1.0 ± 0.8 logMAR in the LCT group (t = - 1.033, P = 0.310). The postoperative CFT was 139.7 ± 48.3 µm in the LCT and 199.2 ± 25.1 µm in the ART group (t = - 4.062, P = 0.001). Graft dislocation emerged in 2 patients (15.4%) in the LCT group and 1 patient (5.6%) in the ART group. CONCLUSIONS: Applications of LCT and ART may both enhance anatomical and visual outcomes in refractory MH cases. The ART group exhibited a more optimal postoperative CFT than the LCT group one.

PEDICLE TRANSPOSITION FLAP, INVERTED FLAP, FREE FLAP, AND STANDARD PEEL FOR LARGE FULL-THICKNESS MACULAR HOLES: A Comparative Study.

PURPOSE: To compare anatomical and functional outcomes of four different techniques for the treatment of large idiopathic full-thickness macular holes. METHODS: This single-center retrospective study included 129 eyes of 126 patients with large (>500 µ m) full-thickness macular holes who presented between January 2018 and October 2022. All patients underwent 23/25 G vitrectomy and gas with standard internal limiting membrane (ILM) peel, pedicle transposition, inverted, or free flap technique. Postoperative optical coherence tomography images were assessed by two independent masked graders. RESULTS: Mean age was 73.2 years (SD 8.4) with a median F/U of 5 months (IQR 8). The overall anatomical success rate was 81%; it was significantly lower (59%) for the standard ILM peel ( P < 0.0001). The pedicle transposition flap showed superior visual recovery compared with the free flap (+27 vs. +12 ETDRS letters, P = 0.02). At 3 months, restoration of the external limiting membrane was significantly better for the pedicle transposition flap compared with free flap and standard ILM peel ( P = 0.008 and P = 0.03) and superior to all the other techniques at 6 months ( P = 0.02, P = 0.04, and P = 0.006). CONCLUSION: Standard ILM peel alone offers inferior outcomes for the management of large full-thickness macular holes. Of the alternative ILM techniques, despite similar closure rates, foveal microstructural recovery is most complete following the pedicle transposition flap and least complete following the free flap.

[Macular hole: Differential diagnosis, treatment options and new guideline recommendations]. / Makulaforamen: Differenzialdiagnose, Behandlungsoptionen und neue Leitlinienempfehlungen.

Full-thickness macular holes (FTMH) usually result in a pronounced reduction of visual acuity and represent one of the most frequent indications for retinal surgery. If diagnosed and treatment is initiated at an early stage, surgery has a high success rate with respect to both hole closure and improvement of visual acuity. Optical coherence tomography (OCT)-based staging and sizing enables an estimation of the surgical outcome. The differential diagnostic distinction from clinically similar disorders, such as lamellar macular holes, macular pseudoholes, and foveoschisis is clinically relevant as the pathogenesis, prognosis and treatment are significantly different. While vitrectomy with peeling of the inner limiting membrane (ILM) and gas tamponade is established as the standard treatment for FTMH, some aspects of treatment are handled differently between surgeons, such as the timing of surgery, the choice of endotamponade and the type and duration of postoperative positioning. For FTMH associated with vitreomacular traction, alternative treatment options in addition to vitrectomy include intravitreal ocriplasmin injection and pneumatic vitreolysis. The current clinical guidelines of the German ophthalmological societies summarize the evidence-based recommendations for diagnosis and treatment of FTMH.

Vision-Language Models for Feature Detection of Macular Diseases on Optical Coherence Tomography.

Importance: Vision-language models (VLMs) are a novel artificial intelligence technology capable of processing image and text inputs. While demonstrating strong generalist capabilities, their performance in ophthalmology has not been extensively studied. Objective: To assess the performance of the Gemini Pro VLM in expert-level tasks for macular diseases from optical coherence tomography (OCT) scans. Design, Setting, and Participants: This was a cross-sectional diagnostic accuracy study evaluating a generalist VLM on ophthalmology-specific tasks using the open-source Optical Coherence Tomography Image Database. The dataset included OCT B-scans from 50 unique patients: healthy individuals and those with macular hole, diabetic macular edema, central serous chorioretinopathy, and age-related macular degeneration. Each OCT scan was labeled for 10 key pathological features, referral recommendations, and treatments. The images were captured using a Cirrus high definition OCT machine (Carl Zeiss Meditec) at Sankara Nethralaya Eye Hospital, Chennai, India, and the dataset was published in December 2018. Image acquisition dates were not specified. Exposures: Gemini Pro, using a standard prompt to extract structured responses on December 15, 2023. Main Outcomes and Measures: The primary outcome was model responses compared against expert labels, calculating F1 scores for each pathological feature. Secondary outcomes included accuracy in diagnosis, referral urgency, and treatment recommendation. The model's internal concordance was evaluated by measuring the alignment between referral and treatment recommendations, independent of diagnostic accuracy. Results: The mean F1 score was 10.7% (95% CI, 2.4-19.2). Measurable F1 scores were obtained for macular hole (36.4%; 95% CI, 0-71.4), pigment epithelial detachment (26.1%; 95% CI, 0-46.2), subretinal hyperreflective material (24.0%; 95% CI, 0-45.2), and subretinal fluid (20.0%; 95% CI, 0-45.5). A correct diagnosis was achieved in 17 of 50 cases (34%; 95% CI, 22-48). Referral recommendations varied: 28 of 50 were correct (56%; 95% CI, 42-70), 10 of 50 were overcautious (20%; 95% CI, 10-32), and 12 of 50 were undercautious (24%; 95% CI, 12-36). Referral and treatment concordance were very high, with 48 of 50 (96%; 95 % CI, 90-100) and 48 of 49 (98%; 95% CI, 94-100) correct answers, respectively. Conclusions and Relevance: In this study, a generalist VLM demonstrated limited vision capabilities for feature detection and management of macular disease. However, it showed low self-contradiction, suggesting strong language capabilities. As VLMs continue to improve, validating their performance on large benchmarking datasets will help ascertain their potential in ophthalmology.

Staircase Lamellar Macular Hole in a Male Patient Aged 54 Years.

This case report discusses a diagnosis of X-linked Alport syndrome in a 54-year-old male patient who presented with a lamellar macular hole in his left eye.

Pediatric and Adolescent Traumatic Macular Hole: A Systematic Review.

PURPOSE: The optimal management of pediatric traumatic macular holes (TMH) is unclear from lack of prospective randomized trials. The literature is divided into early (≤1month post-trauma), delayed (>1 month) pars plana vitrectomy (PPV), and observation. Our aim is to find which group can achieve best-superior spectacle corrected visual acuity (VA), visual gain, and time for hole closure. DESIGN: Systematic review. METHODS: This systematic review was registered with PROSPERO (ID:CRD42022383134). The databases searched from inception until July 31, 2023, were MEDLINE OVID, Scopus, Web of Science, Embase, and Google Scholar. The articles were screened for title and abstract then for full text. Risk of bias was also assessed. Three outcome measures were analyzed: final VA, visual gain, and time to closure of macular hole (MH). MH size was divided into small (≤250 µm), medium (>250-500 µm), and large (>500 µm). RESULTS: Ninety eight (98) studies with 234 patients in the PPV group and 87 patients in the observation group were included in the review. Final VA (logarithm of the minimum angle of resolution) and visual gain were respectively in PPV vs observation groups: (1) small MH 0.37 ± 0.52 vs 0.42 ± 0.56 (P = .484) and -0.96 ± 0.83 vs -0.49 ± 0.40 (P = .005); (2) medium MH 0.58 ± 0.39 vs 0.34 ± 0.34 (P = .06) and -0.36 ± 0.42 vs -0.74 ± 0.44 (P < .001); (3) large MH 0.62 ± 0.42 vs 0.59 ± 0.35 (P = .337) and -0.31 ± 0.48 vs -0.62 ± 0.37 (P = .11). Small TMH had comparable closure time: 3.21 ± 2.52 months vs 3.49 ± 4.43 (P = .954) in the PPV and observation groups. Early and late PPV yielded comparable final VA 0.67 ± 0.66 vs 0.54 ± 0.35 (P = .576) and visual gain -0.58 ± 0.69 vs -0.49 ± 0.48 (P = .242) in the PPV and observation groups. CONCLUSIONS: PPV was very effective in closing TMH and VA gain in children throughout a wide range of hole size. Early and delayed PPV yielded similar anatomic and visual results. Observation and PPV yielded comparable final VA and closure time. Clinicians can choose either early PPV or delayed PPV when healing biomarkers are absent on periodic optical coherence tomography.

[THE CHALLENGE OF DIAGNOSIS AND TREATMENT IN PEDIATRIC RETINAL DETACHMENT].

INTRODUCTION: Retinal detachment is visually impairing in children and adults. The treatment for retinal detachment is challenging, especially in children. There are many etiologies for retinal detachment such as retinal detachment due to retinal tear (rhegmatogenous), tractional retinal detachment and exudative detachment. It is crucial to understand retinal detachment etiology in the pediatric population as it affects treatment decisions. After the diagnosis of retinal detachment in a child, and its etiology, a long process of surgical treatment and recovery begins. The process may include more than one surgery, and therefore close follow-up is very important. Even with anatomic success, functional results are worse with children. The purpose of this article is to review the common etiologies for retinal detachment in children and present case studies that were treated in our department.

[Multimodal topographically oriented approach to the study of full-thickness macular holes]. / Mul'timodal'nyi topograficheski orientirovannyi podkhod k izucheniyu skvoznykh makulyarnykh razryvov.

PURPOSE: This article studies the relationship between structural changes according to the findings of optical coherence tomography (OCT) and OCT angiography (OCTA), microperimetry (MP), multifocal electroretinography (mfERG) parameters in topographically corresponding areas of the macular region in idiopathic full-thickness macular holes (FTMH). MATERIAL AND METHODS: OCT, OCTA, MP and mfERG were performed in 14 eyes with FTMH stages I-IV according to Gass. In 13 points at a distance of 0-2.5°, 2.5-5.0°, and 5.0-10.0° from the fixation point, the light sensitivity (LS), amplitude and latency of the P1 component were compared with the size of the hole, the area of cystic changes (CC) at the level of the inner nuclear layer (INL) and the outer plexiform layer and Henle fiber layer complex (OPL+HFL), vessel density in the superficial and deep capillary plexus (SCP and DCP). RESULTS: LS and P1 component amplitude were significantly reduced at a distance of up to 5.0° from the fixation point. LS correlates with the apical and basal diameter of the hole (R> -0.53), the area of CC in the INL (R> -0.62) and the OPL+HFL complex (R> -0.55), the density of vessels in the SCP at a distance of up to 2.5° from the fixation point (R>0.51) and in the DCP at a distance of up to 5° from the fixation point (R>0.49). The P1 amplitude correlates with the basal diameter of the hole (R= -0.38), the area of CC in the INL and the OPL+HFL complex (R> -0.33) and vessel density in the SCP (R=0.37) at a distance of up to 2.5° from the fixation point, as well as vessel density in the DCP at a distance of up to 5° from the fixation point (R=0.47). Vessel density in the DCP is significantly lower in the presence of CC in the retina (p<0.001). CONCLUSION: In FTMH, there is a relationship between bioelectrical activity and LS, and structural disorders, capillary perfusion in different layers of the retina. A multimodal topographically oriented approach allows studying the relationship between structural and functional parameters in individual points of the retina and can be used in monitoring of FTMH after surgical treatment.

The time course of spontaneous closure of idiopathic full-thickness macular holes.

PURPOSE: Spontaneous closure of idiopathic full-thickness macular holes (iFTMH) has been reported regularly. However, little is known about its probability and timeline. METHODS: In this retrospective study all consecutive patients who presented between August 2008 and August 2019 were screened for the presence of a macular hole and only iFTMHs were included. The primary outcome measure was the spontaneous closure of the iFTMH. RESULTS: Of 1256 eyes with macular holes, 338 fulfilled the inclusion criteria. Spontaneous closure of the iFTMH was detected in 31 eyes (9.2%) with a median time of 44 days after diagnosis. Eyes exhibiting spontaneous closure demonstrated a higher baseline best-corrected visual-acuity (BCVA) and smaller iFTMH diameter (p < 0.0001 and p < 0.0001, respectively). The mean BCVA improved from 0.4 logMAR (SD ± 0.21) to 0.29 logMAR (SD ± 0.20) after spontaneous closure (p = 0.031). The iFTMH diameter was positively correlated with the time to spontaneous closure (Pearson-r = 0.37, p = 0.0377). Spontaneously closed iFTMHs reopened in 16% (n = 5) of cases, with a median of 136 days after closure. A logistic regression model showed the hole diameter was associated with spontaneous closure (odds-Ratio 0.97, 95%CI [0.96, 0.98]). The Kaplan-Meier-Curve revealed that approximately 25% of small-iFTMH (n = 124) and 55% of iFTMH with a diameter < 150µm (n = 48) closed spontaneously within two months. CONCLUSION: The established gold-standard for the treatment of iFTMHs is macular surgery. However, the potential for spontaneous closure of small iFTMHs must be acknowledged. Therefore, if surgical treatment is delayed in individual cases, close observation is recommended.

Scoping review of nonsurgical treatment options for macular holes.

Macular holes (MH) are full-thickness retinal defects affecting central vision. While vitrectomy with inner limiting membrane (ILM) peel is the conventional MH treatment, non-surgical alternatives are gaining interest to mitigate surgical risks. This study conducted a comprehensive literature review and analysis of nonsurgical MH management. A systematic literature search was conducted on PubMed, Embase, Scopus, and the Cochrane Library from January 1, 1973, to September 13, 2023. Treatments included laser therapy, carbonic anhydrase inhibitors (CAIs), nonsteroidal antiinflammatory drugs (NSAIDs), steroids (topical, subtenons, peribulbar, intravitreal), intravitreal gas, anti-vascular endothelial growth factors and ocriplasmin injections. Data extraction covered study details, patient characteristics, MH features, treatment outcomes, and recurrence rates. The initial search yielded 3352 articles, refined to 83 articles that met inclusion criteria following screening. Overall reported anatomical closure rates were 36% with laser photocoagulation, 37% with intravitreal ocriplasmin, 55% with intravitreal gas. Closures were more frequently observed with topical NSAIDs (79%), steroids (84%) and CAIs (73%). Closures were more often observed in patients with smaller MH and in the presence of cystic macular oedema. Although non-surgical MH management approaches show potential for conservative therapy, evidence is limited to support routine use. Stage 1 and traumatic MH may benefit from a short period of observation, but the gold standard approach for full-thickness MH remains to be vitrectomy with ILM peel.

Macular hole surgery follow-up with spectral domain-optical coherence tomography-guided facedown posturing.

PURPOSE: The main treatment for macular hole (MH) is pars plana vitrectomy, with or without internal limiting membrane (ILM) peeling, followed by gas tamponade and face-down positioning (FDP). This study aims to present the anatomical and visual outcomes following MH repair with optical coherence tomography (OCT)-guided FDP. METHODS: Thirty-two patients who underwent surgery for idiopathic MH were enrolled. The requirement for the prone position was lifted for those with MH closure observed under gas on postoperative day one OCT. Patients with unclosed MHs were instructed to maintain FDP until the 3rd day. Best-corrected visual acuity at preoperative, postoperative 1st month, and the last visit, closure time post-surgery, duration of prone position, and surgical success rate were recorded. RESULTS: Among the patients, 21 underwent phacovitrectomy + ILM peeling + gas tamponade, while 11 had vitrectomy + ILM peeling + gas tamponade. On postoperative day one, 28 out of 32 MHs closed, with 3 closures on day 3 and one on day 5. There were 18 stage two (56.3%), 13 stage three (40.6%) and 1 stage four (3.1%) MHs. The mean minimum MH diameter was 381.75 ± 68.07 (min 260-max 517) microns. All patients with MH closure time over postoperative day one had non-combined vitrectomy instead of phacovitrectomy. No late complications were observed. CONCLUSIONS: OCT-guided FDP approach yields excellent closure rates with no late complications and ensures good patient comfort.

Short-term results of surgical treatment in large idiopathic macular hole cases.

PURPOSE: To evaluate results of the surgical treatment for large stage (Stage 3 and 4) idiopathic macular hole cases with and without ILM flap technique. METHODS: Sixty eyes of 60 patients diagnosed with idiopathic macular hole (MH) were included in the study. Complete ophthalmologic examination and SD-OCT examination were performed in all eyes. MH stages, MH base diameter, height and closest distance were measured quantitatively. Postoperative and 3 months visits were evaluated. RESULTS: The mean age of the cases was 65.0 ± 8.0 (range 30-84) years, there were 31 (51.7%) female and 29 (48.3%) male patients with a mean follow-up period of 18.1 ± 16.7 (range 3-63) months. The mean best corrected visual acuity recorded at preoperative and third month control visits were 0.89 ± 0.40(preoperative) logMAR, 0.82 ± 0.60(3 month) logMAR (p < 0.05). The mean MH index was 0.48 ± 0.16, the closest hole distance was 517.86 ± 210.89 µm and mean basal diameter of holes was 947.78 ± 361.90 µm and the average height was 448.93 ± 79.80 microns. There was no statistically significant difference between anatomic results of macular hole surgery with (n = 22) and without (n = 38) flap in terms of hole closure (86.4% vs. 92.1% p > 0.05). In 90% (54 cases) of the cases, closure was observed after the first surgery. Two eyes that failed macular hole surgery were reoperated. In one of these eyes, anatomical success was obtained with macular hole massage and mechanical cytumulation. However, anatomical success could not be achieved in the other eye. CONCLUSiON: In the treatment of large macular holes, pars plana vitrectomy, internal limiting membrane peeling with/without flap and gas tamponade demonstrated high anatomical and functional success.

Relationship between lymphocytes and idiopathic macular hole.

BACKGROUND: An idiopathic macular hole (IMH) is a full-thickness anatomic defect extending from the internal limiting membrane to the photoreceptor layer of the macula without any known cause. Recently, clinical laboratory markers of systemic inflammatory status derived from complete blood counts have been evaluated in ocular diseases. This study aimed to explore whether they could predict the development and progression of IMHs. METHODS: A retrospective review of 36 patients with IMH and 36 sex-and-age-matched patients with cataracts was conducted. We collected complete blood counts of all participating individuals and calculated systemic immunoinflammatory indicators. The maximum base diameter of the IMH (BD), minimum diameter of the IMH (MIN), height of the IMH (H), area of the intraretinal cyst (IRC), and curve lengths of the detached photoreceptor arms were measured on optical coherence tomography (OCT) images. We used these values to calculate the macular hole index (MHI), tractional hole index (THI), diameter hole index (DHI), hole form factor (HFF), and macular hole closure index (MHCI). We performed a receiver operating characteristic (ROC) curve analysis of 30 patients with IMH who were followed up 1 month after surgery. RESULTS: Lymphocyte counts were significantly higher in the IMH group. No other significant differences were observed between the IMH and control groups. Lymphocyte counts in the IMH group were significantly negatively correlated with MIN and BD and were significantly positively correlated with MHI, THI, and MHCI. However, lymphocyte counts were not significantly correlated with H, IRC, DHI, and HFF. In the ROC analysis, BD, MIN, MHI, THI, and MHCI were significant predictors of anatomical outcomes. According to the cut-off points of the ROC analysis, lymphocyte counts were compared between the above-cut-off and below-cut-off groups. Lymphocyte counts were significantly higher in the MIN ≤ 499.61 µm, MHI ≥ 0.47, THI ≥ 1.2, and MHCI ≥ 0.81 groups. There were no significant differences between the above-cut-off and below-cut-off BD groups. CONCLUSIONS: Although inflammation may not be an initiating factor, it may be involved in IMH formation. Lymphocytes may play a relatively important role in tissue repair during the developmental and postoperative recovery phases of IMH.