Spontaneous Closure of Full-Thickness Macular Holes.

PURPOSE: To describe retinal morphology and vision recovery after spontaneous closure of full-thickness macular hole (FTMH). MATERIALS AND METHODS: Retrospective, observational study. From a database containing 750 FTMH, we included 23 cases. All patients had a complete ophthalmic examination. Swept-source optical coherence tomography angiography was performed. RESULTS: Prior to spontaneous closure in 11 women and 12 men (mean age 67 years), the mean minimum FTMH diameter was 201 µm, and mean base FTMH diameter was 638 µm. Visual acuity improved from 0.29 Snellen to 0.47 Snellen (p = 0.001) after 6 months and showed no further improvement. Spontaneous closure of FTMH was associated with vitreous detachment in less than half of the cases. Irregularities in the deep vascular layer and hyporeflective areas in the choriocapillaris were noted. DISCUSSION: Equal sex distribution of spontaneous closures (1:1) differs from the high prevalence of females seen in the literature. Complete visual recovery is uncommon in cases of spontaneous closure of FTMH. It might be explained by prolonged defects of the choriocapillaris layer. These findings, along with the evolution of the various morphologies reported in the study, could possibly suggest that delaying vitrectomy while hoping for spontaneous closure might not be justified.

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

Surgical treatment is generally necessary to repair full-thickness macular holes (FTMH). Although vitrectomy with or without internal limiting membrane (ILM) peeling remains the standard surgical technique, the inverted ILM flap procedure has increasingly assumed a role in the primary surgical repair of FTMHs. Some vitreoretinal surgeons reserve this technique to treat large or myopic holes, whereas others use it routinely in all cases. This paper is a comprehensive review of the current scientific evidence on the anatomical and functional outcomes of the inverted ILM flap technique in the repair of macular holes, following the International Vitreomacular Traction Study (IVTS) group classification.

Fovea Morphology After Vitrectomy in Eyes With Full-Thickness Macular Hole Coexisting With Diabetic Retinopathy.

Purpose: This work presents the effects of vitrectomy with an inverted internal limiting membrane flap in full-thickness macular holes (FTMHs) in eyes with diabetic retinopathy (DR). Methods: Vitrectomy with the inverted and temporal inverted internal limiting membrane flap technique was performed in all cases. Inclusion criteria were FTMH, diabetes treated with oral drugs or with insulin for at least 5 years, spectral-domain or swept-source optical coherence tomography performed before surgery then 1 week, 1, 3, 6, 12, and 18 to 36 months after surgery. Results: FTMH with nonproliferative DR (NPDR) was noted in 20 eyes and with proliferative DR (PDR) in 5 eyes. In PDR the margins of the macular holes (MHs) were always detached, and the MHs tended to be larger than in NPDR. The minimum diameter-to-base diameter ratio was 1:2 in NPDR and 1:10 in PDR. Postoperatively central retinal thickness and visual acuity (VA) were significantly lower for PDR. Twenty-one of 25 FTMHs were closed after the first surgery, and all were closed after the second surgery. VA improved, final results did not depend on FTMH diameter. Photoreceptor defects decreased in size but were present in all cases 12 months after surgery. Conclusions: Morphology of MHs in NPDR and PDR was varied. FTMH in NPDR resembled idiopathic cases; morphology of FTMH with PDR was different. In PDR, FTMHs were larger and the fovea was usually detached; retina thinning was also observed. Final VA depended on initial VA and the severity of the disease (NPDR vs PDR).

Vitrectomy with the inverted internal limiting membrane flap technique in eyes with full-thickness macular hole and dry age-related macular degeneration.

PURPOSE: To present effects of the inverted internal limiting membrane flap technique in full-thickness macular holes coexisting with dry age-related macular degeneration. METHODS: Our database was retrospectively reviewed in order to spot patients with the simultaneous diagnosis of dry age-related macular degeneration and full-thickness macular hole. Vitrectomy with the inverted internal limiting membrane flap technique was performed. Inclusion criteria were full-thickness macular hole, drusen, vitrectomy performed, and spectral domain optical coherence tomography (Copernicus HR, Optopol, Poland) or swept source optical coherence tomography (Triton, Topcon, Japan) before surgery, then 1 week (±3 days), 1 month (±1 week), 3 months (±1 month), 6 months (±1 month), 12 months (±2 months), and 18 months to 12 years after surgery. MAIN OUTCOME MEASURES: Closure of macular hole and visual acuity at the final control. RESULTS: A total of 18 eyes of 12 patients (mean age: 68 years) were included. Mean minimum macular hole diameter was 493 µm. Mean maximum macular hole diameter was 1072 µm. Macular hole was closed in 16 eyes after first surgery and in all eyes after second surgery. Improvement of visual acuity was statistically significant (P = 0.05), but there was no statistical significant correlation observed between initial macular hole diameters and final visual acuity (P > 0.1). CONCLUSION: The inverted internal limiting membrane flap technique improves anatomical and functional results in eyes with coexisting dry age-related macular degeneration and full-thickness macular holes. Final development of choroidal neovascularization or geographic atrophy is possible in rare cases.

Swept-Source OCT and Swept-Source OCT Angiography before and after Vitrectomy with Stuffing of the Optic Pit.

PURPOSE: To identify swept-source (SS) OCT and SS OCT angiography (OCTA) patterns predicting outcome in patients with optic disc pit-associated maculopathy and to present the results of a novel surgical technique, stuffing of the optic disc pit. DESIGN: Prospective, interventional study. PARTICIPANTS: Fifteen eyes. METHODS: Swept-source OCT before surgery and then 1 week and 1, 3, and 6 months after surgery, then up to 4 years later. Swept-source OCTA was performed from 2015 (9 patients). After core vitrectomy, internal limiting membrane (ILM) was peeled between the optic nerve and fovea and stuffed into the optic disc pit. Laser photocoagulation was performed at the temporal side of the optic disc pit. Fluid-air exchange followed. The following data were noted: visual acuity, central retinal thickness, distribution of fluid on SS OCT, and diameters and circuit of the foveal avascular zone on OCTA. MAIN OUTCOME MEASURES: Normalization of the fovea contour and visual acuity. RESULTS: We subdivided patients into 2 groups. On SS OCT, we observed subretinal fluid with elevation of the fovea (group 1) in 8 eyes. Group 2 comprised 7 eyes without subretinal fluid, but with intraretinal fluid. Five of these eyes additionally showed an outer lamellar macular hole. Anatomic success was achieved in all eyes. The decrease of central retinal thickness 1 week after surgery was more marked in group 1 (P = 0.002). The area of the foveal avascular zone in the superficial retinal vessel layer increased significantly after surgery for group 2 (P = 0.04), but not for group 1 (P = 0.4). Visual acuity improved without statistically significant differences between groups. CONCLUSIONS: Stuffing of the optic disc pit with the ILM results in improvement of anatomic and functional results. Prognosis depends on initial morphologic features. Central retinal thickness normalizes faster after surgery in eyes with subretinal fluid when compared with eyes with intraretinal fluid. Faster anatomic improvement does not correlate with improvement of vision. Postoperative increase in the size of the foveal avascular zone in the superficial retinal vessel layer, more pronounced in group 2, may be associated with the prolonged postoperative anatomic recovery in those eyes.

An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study.

PURPOSE: To study and compare the efficacy of different therapeutic options for the treatment of central serous chorioretinopathy (CSCR). METHODS: This is a nonrandomized, international multicentre study on 1719 patients (1861 eyes) diagnosed with CSCR, from 63 centres (24 countries). Reported data included different methods of treatment and both results of diagnostic examinations [fluorescein angiography and/or optical coherent tomography (OCT)] and best-corrected visual acuity (BCVA) before and after therapy. The duration of observation had a mean of 11 months but was extended in a minority of cases up to 7 years. The aim of this study is to evaluate the efficacy of the different therapeutic options of CSCR in terms of both visual (BCVA) and anatomic (OCT) improvement. RESULTS: One thousand seven hundred nineteen patients (1861 eyes) diagnosed with CSCR were included. Treatments performed were nonsteroidal anti-inflammatory eye drops, laser photocoagulation, micropulse diode laser photocoagulation, photodynamic therapy (PDT; Standard PDT, Reduced-dose PDT, Reduced-fluence PDT), intravitreal (IVT) antivascular endothelial growth factor injection (VEGF), observation and other treatments. The list of the OTHERS included both combinations of the main proposed treatments or a variety of other treatments such as eplerenone, spironolactone, acetazolamide, beta-blockers, anti-anxiety drugs, aspirin, folic acid, methotrexate, statins, vitis vinifera extract medication and pars plana vitrectomy. The majority of the patients were men with a prevalence of 77%. The odds ratio (OR) showed a partial or complete resolution of fluid on OCT with any treatment as compared with observation. In univariate analysis, the anatomical result (improvement in subretinal fluid using OCT at 1 month) was favoured by age <60 years (p < 0.005), no previous observation (p < 0.0002), duration less than 3 months (p < 0.0001), absence of CSCR in the fellow eye (p = 0.04), leakage outside of the arcade (p = 0.05) and fluid height >500 µm (p = 0.03). The OR for obtaining partial or complete resolution showed that anti-VEGF and eyedrops were not statistically significant; whereas PDT (8.5), thermal laser (11.3) and micropulse laser (8.9) lead to better anatomical results with less variability. In univariate analysis, the functional result at 1 month was favoured by first episode (p = 0.04), height of subretinal fluid >500 µm (p < 0.0001) and short duration of observation (p = 0.02). Finally, there was no statistically significant difference among the treatments at 12 months. CONCLUSION: Spontaneous resolution has been described in a high percentage of patients. Laser (micropulse and thermal) and PDT seem to lead to significant early anatomical improvement; however, there is little change beyond the first month of treatment. The real visual benefit needs further clarification.

Antivascular Endothelial Growth Factor Treatment Might Be Continued Even After Vitrectomy for Endophthalmitis in Neovascular Age-Related Macular Degeneration.

Purpose: This article studies visual outcome and frequency of antivascular endothelial growth factor (anti-VEGF) injections continued in patients with neovascular age-related macular degeneration (AMD) who had an earlier vitrectomy for postinjection endophthalmitis. Methods: A retrospective interventional study was conducted reviewing our database for patients with a diagnosis of endophthalmitis in the course of anti-VEGF injections. Endophthalmitis diagnosis was made on clinical examination of pain, rapid decrease in visual acuity (VA), conjunctival hyperemia, hypopyon, and vitritis. In all eyes, core vitrectomy with intravitreal antibiotics was performed. Spectral-domain optical coherence tomography was performed monthly before and after surgery during follow-up. Anti-VEGF injections were continued after surgery in all cases. Results: Eight eyes with postinjection endophthalmitis were included. Mean VA immediately before endophthalmitis was 20/50 Snellen with a mean of 19 intravitreal anti-VEGF injections (P = .45). At time of endophthalmitis diagnosis, mean VA was 20/1000 (range, 20/2000-20/200). Mean time from injection to when the patient noted first symptoms was 4.3 days (range, 1-8 days). Mean time from first symptoms to surgery was 12 hours (range, 2.5-26 hours). Final mean VA at the end of follow-up (range, 12-84 months) did not statistically differ from VA at the visit immediately before endophthalmitis diagnosis (P = .69). Mean frequency of injections after vitrectomy did not significantly differ from the presurgical course of treatment (P =.97). Conclusions: Anti-VEGF treatment might be continued after vitrectomy for endophthalmitis and results in satisfactory anatomical and visual outcome. Surgery did not influence the frequency of anti-VEGF injections for neovascular AMD.

International Practice Patterns for the Management of Acute Postsurgical and Postintravitreal Injection Endophthalmitis: European Vitreo-Retinal Society Endophthalmitis Study Report 1.

PURPOSE: To study the practice patterns for the management of acute postoperative and postinjection endophthalmitis. DESIGN: Retrospective, interventional, nonrandomized, multicenter study. PARTICIPANTS: Data on 237 eyes diagnosed with acute endophthalmitis occurring after intraocular surgery or procedures provided by 57 retina specialists from 28 countries. MAIN OUTCOME MEASURES: Rates of pars plana vitrectomy (PPV), repeat intravitreal injection, and adjunctive therapeutic regimens (local and systemic antibiotics and steroids). RESULTS: Of 237 analyzed eyes, acute endophthalmitis secondary to cataract surgery or secondary lens implantation represented 64.6% of cases (153 eyes), whereas the remaining were secondary to intravitreal injections (35 eyes [14.8%]), PPV (29 eyes [12.2%]), and other intraocular surgeries (20 eyes [8.4%]). All eyes received intravitreal antibiotics on the same day of diagnosis. Overall, early PPV was used within the first week of presentation in 176 eyes (74.3%). There was no statistical difference in the proportion of eyes requiring a second intravitreal injection of antibiotics whether the eye was managed primarily with intravitreal antibiotics alone versus early PPV plus intravitreal antibiotics (29.5% [18 eyes] vs. 25.0% [44 eyes], respectively). Adjunctive therapies in the form of intravitreal steroids, systemic steroids, and systemic antibiotics were used in 25.3%, 21.9%, and 66.6% of eyes, respectively. The absence of disc or macular view and absence of endophthalmitis after cataract surgery were associated with an increased likelihood for early PPV (odds ratios 4.1 and 5.1, respectively). CONCLUSIONS: Pars plana vitrectomy was frequently performed regardless of the presenting vision in eyes with endophthalmitis after cataract surgery and intravitreal injections. Increased vitreous opacification was associated with a higher probability for performing PPV.

UNDERDIAGNOSED OPTIC DISK PIT MACULOPATHY: Spectral Domain Optical Coherence Tomography Features For Accurate Diagnosis.

PURPOSE: To report a cohort with optic disk pit maculopathy (ODPM) presenting with neurosensory macular detachment that were initially misdiagnosed and mistreated; and to describe structural features on spectral domain optical coherence tomography in misdiagnosed and all other consecutive cases of ODPM. METHODS: Multicenter international retrospective cohort study. PARTICIPANTS: 59 eyes from 59 patients with ODPM. MAIN OUTCOME MEASURES: 1) Proportion of patients with ODPM initially misdiagnosed, inaccurate diagnosis and treatment. 2) Morphologic features on spectral domain optical coherence tomography: other causes of subretinal and/or intraretinal fluid, inner/outer retinoschisis, communication with optic disk pit, and retinal pigment epithelium alterations. 3) Visual and anatomical outcomes 6 months after proper treatment. RESULTS: Fifteen patients (25.4%) with ODPM were correctly diagnosed initially and those were significantly younger than misdiagnosed cases (age 33.8 ± 15.2 vs. 58.7 ± 15.8 years, P < 0.0001). Forty of forty-four misdiagnosed eyes (90.9%) were treated for their presumed diagnosis before referral. Eyes with initial misdiagnosis had significantly more outer retinoschisis at baseline (88.4 vs. 40.0%, P = 0.0002) and more retinal pigment epithelium alterations (90.0 vs. 27.3%, P < 0.0001) 6 months after proper treatment. CONCLUSION: Optic disk pit maculopathy is an underdiagnosed entity and can mimic other causes for subretinal fluid. Awareness and identification of pertinent spectral domain optical coherence tomography features can help avoid inappropriate and delayed treatment.

Repeat Surgery in Failed Primary Vitrectomy for Macular Holes Operated With the Inverted ILM Flap Technique.

BACKGROUND AND OBJECTIVE: Effects of repeat surgery in failed primary full-thickness macular hole (FTMH) closure with the inverted internal limiting membrane (ILM) flap technique. PATIENTS AND METHODS: Retrospective analysis of patients operated with the inverted ILM flap technique. Optical coherence tomography was performed before initial and secondary surgeries and then at up to 12 months post-surgery. RESULTS: During the second surgery, the inverted ILM flap created at the first attempt had returned to its original position, instead of covering the FTMH. FTMH was closed in 29 eyes after second surgery (89%) and in all eyes after third surgery. Visual acuity improved in 28 of 32 cases (87.5%). The tamponade used (either silicone oil or air) did not influence final visual results (P = .06). CONCLUSIONS: Repeat surgery with the inverted ILM flap technique is an effective method of treatment. Silicone oil improved anatomical outcome after second surgery but did not influence visual results. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:611-618.].

Vitrectomy in the management of diabetic macular edema in treatment-naïve patients.

OBJECTIVE: To determine the efficacy of vitrectomy in eyes with treatment-naïve diabetic macular edema (DME). METHODS: Consecutive patients with treatment-naïve DME who underwent pars plana vitrectomy with internal limiting membrane peeling at a single institution were identified from the electronic medical records. Morphologic and visual acuity changes from baseline were analyzed at both the primary temporal endpoint (6 months) and the final examination with the investigators. The primary outcome measures included changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT). RESULTS: Forty-four eyes of 44 patients were included in this retrospective study. The mean BCVA improved significantly from baseline until the 6-month primary endpoint (1.35 logMAR vs 0.83 logMAR, p < 0.001) and stabilized through the final examination (0.77 logMAR). The BCVA improved by at least 0.1, 0.3, and 0.6 logMAR in 26 (60%), 24 (55%), and 14 (32%) of eyes, respectively, whereas it worsened by 0.3 logMAR in only 1 (2%) eye. Final BCVA correlated inversely with duration of diabetes (p = 0.01), presence of an epiretinal membrane (p = 0.02), and initial visual acuity (p = 0.03). Mean CRT decreased significantly from baseline through 6 months (595 µm vs 266 µm; p < 0.001), and edema recurred in only 3 eyes (6%), one of which was subsequently treated with intravitreal bevacizumab. CONCLUSIONS: Pars plana vitrectomy significantly improves macular edema and visual acuity in eyes with treatment-naïve DME. Prospective randomized trials are needed to better determine the efficacy of early vitrectomy.

SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY REVEALS INTERNAL LIMITING MEMBRANE PEELING ALTERS DEEP RETINAL VASCULATURE.

PURPOSE: To describe morphology of retinal and choroidal vessels in swept-source optical coherence tomography angiography before and after vitrectomy with the temporal inverted internal limiting membrane (ILM) flap technique for full-thickness macular holes. METHODS: Prospective, observational study of 36 eyes of 33 patients with full-thickness macular holes swept-source optical coherence tomography angiography was performed in patients before and 1 month after vitrectomy. Vitrectomy with the temporal inverted ILM flap technique was performed. In this method, ILM is peeled only at one side of the fovea. An ILM flap is created to cover the macular hole. Comparison of retina vasculature in the areas of ILM peeling vs. no ILM peeling at 1 and 3 months after successful vitrectomy was performed. RESULTS: The study demonstrated lower density of vessels in the deep retinal plexus in the area where ILM was peeled as compared to the rest of the fovea. Visual acuity and central retinal thickness 1 month after surgery correlates with fovea avascular zone diameter in deep retinal layers at the same time point (P = 0.001). CONCLUSION: This study confirmed that ILM peeling might alter blood flow in deep retinal vessels below the peeling area in the early postoperative period. The area of the fovea avascular zone corresponds to functional results at the same time point.

Swept-Source OCT Angiography of Full-Thickness Macular Holes: Appearance and Artifacts.

BACKGROUND AND OBJECTIVE: To evaluate swept-source optical coherence tomography angiography (SS-OCTA) images in full-thickness macular holes (FTMHs). PATIENTS AND METHODS: SS-OCTA of FTMHs was performed before or after surgery. Vitrectomy with the temporal inverted internal limiting membrane flap technique was used. The authors measured the diameter and area of the foveal avascular zone (FAZ) in superficial and deep retina vasculature. RESULTS: In 88 patients, two artifact types were observed. First, a hyperreflective circle in the center corresponding to a segmentation failure, as in these cases the segmentation line automatically relocated below the retinal pigment epithelium. Second, in macular holes with cystic spaces around the fovea, detection of blood flow was only partially possible, showing artifacts in the perifoveal vasculature. CONCLUSION: The authors present artifacts occurring during visualization of FTMHs with SS-OCTA and the means to correct them. Eyes with decreased postoperative central retinal thickness have an increased FAZ in the deep retinal layer plexus. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:111-121.].