Effects of a human amniotic membrane extract on ARPE-19 cells.

BACKGROUND: Human Amniotic Membrane (hAM) is endowed with several biological activities and might be considered an optimal tool in surgical treatment for different ophthalmic pathologies. We pioneered the surgical use of hAM to treat retinal pathologies such as macular holes, tears, and retinal detachments, and to overcome photoreceptor damage in age-related macular degeneration. Although hAM contributed to improved outcomes, the mechanisms of its effects are not yet fully understood. The characterization and explanation of the effects of hAM would allow the adoption of this new natural product in different retinal pathologies, operative contexts, and hAM formulations. At this end, we studied the properties of a hAM extract (hAME) on the ARPE-19 cells. METHODS AND RESULTS: A non-denaturing sonication-based technique was developed to obtain a suitable hAME. Viability, proliferation, apoptosis, oxidative stress, and epithelial-mesenchymal transition (EMT) were studied in hAME-treated ARPE-19 cells. The hAME was able to increase ARPE-19 cell viability even in the presence of oxidative stress (H2O2, TBHP). Moreover, hAME prevented the expression of EMT features, such as EMT-related proteins, fibrotic foci formation, and migration induced by different cytokines. CONCLUSIONS: Our results demonstrate that the hAME retains most of the properties observed in the whole tissue by others. The hAME, other than providing a manageable research tool, could represent a cost-effective and abundant drug to treat retinal pathologies in the future.

Smartphone Augmented En-Face Guided Epiretinal Membrane Peeling: A 3D Ngenuity Tool For Customized Treatment.

PURPOSE: We aimed to introduce a novel visualization technique of en-face scans during epiretinal membrane (ERM) peeling, by using the in-built picture-in-picture (PIP) modality of the Alcon Ngenuity 3D System, connected to a smartphone. METHODS: Prospective mono-centric interventional analysis on 20 patients undergoing vitrectomy and peeling for idiopathic ERMs. RTVue XR Avanti device was used perform a 6 × 6 mm optical coherence tomography angiography (OCTA). En-face image from a custom slab from 9 µm upon the internal limiting membrane (ILM) to 30 µm below the ILM was taken and 180° flipped. The smartphone was connected to the Alcon 3D Ngenuity display using an HDMI-to-USB cable and the picture-in-picture modality of the display was chosen in the software menu. ERM peeling was performed without dye stain starting from black linear structures on the en-face, indicating area of weaker adhesion to the ERM and could be used as cleavage point for membrane removal using vitreal forceps. RESULTS: We reported successful peeling initiation and flap lift at the first forceps' grasp in all cases (100%). After ERM peeling, dual blue staining highlighted ILM remnants in 15 cases (75%) and peeling was completed. Total surgical time, including cable connections and projection to the display, was 41.6±9.2 minutes. Intraoperative total peeling time was 11.1±2.6 minutes. Central macular thickness significantly reduced 1 month after surgery (p=0.01). CONCLUSION: In summary, this is a cheap and easily reproducible surgical technique to optimize ERM management, offering an intraoperative guide for peeling initiation and minimizing un-necessary surgical maneuvers.

Evaluation of ocular surface following PreserFlo Microshunt implantation: Functional outcomes and quality of life.

BACKGROUND: This study aimed to evaluate the impact of PreserFlo Microshunt on the ocular surface, focusing on both objective and subjective parameters. METHODS: Prospective-observational study on 48 eyes undergoing PreserFlo Microshunt implantation, standalone or combined with phacoemulsification. At baseline, 1-month, 6-months and 12-months post-operative follow-ups, we performed Ocular Surface Disease Index (OSDI) questionnaire, Schirmer's test (ST), Tear-film break-up time (TBUT), fluoresceine staining (FS), tear osmolarity and minimum corneal epithelial thickness (Epi-ThkMIN. ) measurements. RESULTS: OSDI score improved from 37.43 ± 17.49 at baseline, to 24.13 ± 12.55 at 1-month (p = 0.003) and to 12.89 ± 8.54 and 13.09 ± 10.22 at 6-months and 12-months (p < 0.0001). TBUT and ST, in a similar way, non-significantly increased at 1-month, but then improved at 6-months and 12-months (p < 0.05 for both). Tear osmolarity significantly decreased from 308.2 ± 7.3 mOsm/L at baseline, to 303.3 ± 8.2 mOsm/L, 295.6.2 ± 7.0 mOsm/L and 297.6 ± 6.8 mOsm/L at 1-month, 6-months and 12-months (p < 0.05 for all). Epi-ThkMIN was stable when comparing baseline (44.9 ± 5.7 µm) and 1-month (p = 0.28), and successively increased in 6-months (47.8 ± 5.5 µm, p = 0.02) and 12-months (48.0 ± 3.6 µm, p = 0.01). In subgroup analysis, OSDI score and tear osmolarity were significantly higher at 1-month in combined group compared to standalone group (p = 0.03 and p = 0.02, respectively), but reaching comparable values in successive follow-ups. Further, Oxford scale grades for FS were significantly improved when comparing baseline-6-months and baseline-12-months. CONCLUSION: PreserFlo implantation improved ocular surface subjective symptoms, increased TBUT and ST, and reduced FS, highlighting the potential benefits of this surgical intervention. Moreover, we reported significant improvements of tear osmolarity and corneal epithelium.

Scleral Buckling Using Chandelier and Releasable Suture: A Useful Surgical Variant.

PURPOSE: To describe a surgical variant for scleral buckling technique using a chandelier and scleral releasable suture. METHODS: We collected retrospectively 20 eyes of 20 patients who underwent to scleral buckling for retinal detachment. In all cases, the surgeons performed the surgical variant of scleral buckling using a 27-gauge (G) chandelier as endoillumination and releasable 7.0 vicryl scleral suture. RESULTS: None of the operated eyes developed lens opacity or lens marks at the entrance site of the chandelier used during the surgery, and no cataract development was observed as well, during the follow-up. Retinal reattachment was achieved in 19 out of 20 eyes at the first surgery in the follow-up time of 6 months. CONCLUSION: The association of chandelier and releasable suture was a useful surgical variant when performing scleral buckling technique for retinal detachment. Complications like lens opacity or lens marks at the entrance site of the chandelier due to the use of chandelier itself can be greatly reduced, as well as complications due to vitreous prolapse from the sclerotomy by using releasable scleral suture.

Wedge-Shaped Pars Plana Sclerotomies: Is It Still an Actuality in the Era of Microincision Vitrectomy?

PURPOSE: To describe and evaluate the effectiveness of wedge-shaped sclerotomies to close 25-gauge and 23-gauge transconjunctival pars plana vitrectomies. MATERIALS AND METHODS: This prospective, consecutive, interventional study examined 50 eyes of 50 patients who underwent 25-gauge and 23-gauge vitrectomy with wedge-shaped sclerotomies. RESULTS: The number of eyes requiring a wedge shape for sclerotomy closure and sclerotomies requiring sutures was collected. Three eyes had hypotony on Day 1. No statistically significant difference was observed between preoperative intraocular pressure and postoperative intraocular pressure on Days 15 and 30. No postoperative complications were observed during the follow-up period. CONCLUSION: The wedge-shaped sclerotomy is a simple, fast, and effective technique that does not require extra surgical materials and could be applied to microincision vitrectomy.

Management of Optic Disk Pit-associated Macular Detachment with Human Amniotic Membrane Patch.

PURPOSE: To report a new surgical technique involving a human amniotic membrane patch (hAM) to solve a serous macular detachment associated with optic nerve head pit. METHODS: Three eyes of three patients affected by macular detachment associated with optic nerve head pit were enrolled. A 23-gauge pars plana vitrectomy were performed. hAM patch was implanted inside the optic nerve pit; air was used as endotamponade. The patients were instructed to maintain face-down position for the first days after surgery. RESULTS: The subretinal fluid gradually resolved during 6 months of follow-up, and visual acuity improved to 20/25 at the sixth month after surgery. We did not observe a recurrence of subretinal fluid during the 6 months of follow-up. No postoperative complications were reported during the follow-up. CONCLUSION: Implant of the hAM may be effective to repair optic disk pit maculopathy. All the cases were successful with encouraging visual acuity recovery.

New Releasable Nonabsorbable Polypropylene 8.0 Suturing Technique for Sclerotomy Sealing in 23-Gauge Vitrectomy.

PURPOSE: We propose a new releasable 8.0 polypropylene suture for leaking sclerotomies at the end of vitrectomy. Characteristic of this suture is that it can be easily removed the day after surgery at the slit-lamp examination. METHODS: Patients undergoing 23-gauge pars plana vitrectomy with the need for at least 2 sclerotomy sutures and having a preoperative Ocular Surface Disease Index score <12 were consecutively allocated to sealing with either polyglactin 910 absorbable suture (VY GROUP) or nonabsorbable 8.0 polypropylene releasable suture (PR GROUP). Evaluation of adverse events, Ocular Surface Disease Index score, and conjunctival hyperemia (through the Efron scale) was performed at 1, 7, and 30 days postoperatively. RESULTS: Both methods effectively sealed sclerotomies. PR GROUP showed a significantly lower Ocular Surface Disease Index score and lower degree of conjunctival hyperemia at both 7 and 30 days follow-up. The Ocular Surface Disease Index score decreased significantly after 7 days in PR GROUP while in VY GROUP improved at 30 days postoperatively. PR GROUP showed a lower degree of conjunctival hyperemia both at 7 and 30 days follow-up. CONCLUSION: Polypropylene 8-0 releasable sutures proved to be effective in 23-gauge pars plana vitrectomy wound sealing while inducing less ocular surface inflammation and patient discomfort compared with the standard polyglactin 910 suture.

Stripping of the Posterior Hyaloid for the Treatment of Vitreomacular Traction.

PURPOSE: To describe and evaluate the effectiveness of stripping the posterior hyaloid as vitreomacular traction treatment. METHODS: This prospective, consecutive, interventional study examined 10 eyes of 10 patients who underwent vitrectomy for vitreomacular traction. RESULTS: The best-corrected visual acuity improved from 20/63 (0.5 ± 0.18 logMAR) preoperatively to 20/36 (0.25 ± 0.15 logMAR) 3 months after the surgeries. Optical coherence tomography analysis showed a reduction of the mean foveal thickness from 462 ± 82 µ to 372 ± 28 µ at 3-month follow-up in all the eyes. No postoperative complications were reported. CONCLUSION: Stripping of the posterior hyaloid for the treatment of vitreomacular traction could improve the symptoms and visual acuity of patients, alleviating the traction on the macula and avoiding secondary retinal damage as macular hole formation.

Modified Carlevale Intraocular Lens Fixation Technique: Two Vitrectomy Ports As Lens Plug Fixation Sites.

PURPOSE: To describe and evaluate the effectiveness of the modified Carlevale intraocular lens (IOL) fixation technique, using two vitrectomy ports as lens plug fixation sites. MATERIALS AND METHODS: This prospective, consecutive, interventional study examined 60 eyes in 60 patients, who underwent 25- or 23-gauge vitrectomy for an IOL subluxation/luxation, lens dislocation, or aphakia, with Carlevale IOL implantation. RESULTS: Postoperatively, transient ocular hypotension was observed in four eyes. The mean refractive prediction error was -0.27 ± 0.78 diopters. No postoperative complications, such as retinal detachment, endophthalmitis, or IOL dislocation, were observed in the 4-month follow-up. CONCLUSION: This new technique may be simple, fast, and effective because of fewer scleral wounds and fewer postoperative complications.

NEW ARTIFICIAL INTELLIGENCE ANALYSIS FOR PREDICTION OF LONG-TERM VISUAL IMPROVEMENT AFTER EPIRETINAL MEMBRANE SURGERY.

PURPOSE: To predict improvement of best-corrected visual acuity (BCVA) 1 year after pars plana vitrectomy for epiretinal membrane (ERM) using artificial intelligence methods on optical coherence tomography B-scan images. METHODS: Four hundred and eleven (411) patients with Stage II ERM were divided in a group improvement (IM) (≥15 ETDRS letters of VA recovery) and a group no improvement (N-IM) (<15 letters) according to 1-year VA improvement after 25-G pars plana vitrectomy with internal limiting membrane peeling. Primary outcome was the creation of a deep learning classifier (DLC) based on optical coherence tomography B-scan images for prediction. Secondary outcome was assessment of the influence of various clinical and imaging predictors on BCVA improvement. Inception-ResNet-V2 was trained using standard augmentation techniques. Testing was performed on an external data set. For secondary outcome, B-scan acquisitions were analyzed by graders both before and after fibrillary change processing enhancement. RESULTS: The overall performance of the DLC showed a sensitivity of 87.3% and a specificity of 86.2%. Regression analysis showed a difference in preoperative images prevalence of ectopic inner foveal layer, foveal detachment, ellipsoid zone interruption, cotton wool sign, unprocessed fibrillary changes (odds ratio = 2.75 [confidence interval: 2.49-2.96]), and processed fibrillary changes (odds ratio = 5.42 [confidence interval: 4.81-6.08]), whereas preoperative BCVA and central macular thickness did not differ between groups. CONCLUSION: The DLC showed high performances in predicting 1-year visual outcome in ERM surgery patients. Fibrillary changes should also be considered as relevant predictors.

Kaminari Kagura: the "lightning bolt shape" technique for posterior vitreous detachment induction.

PURPOSE: To describe and evaluate the effectiveness of the Kaminari Kagura technique as a posterior hyaloid detachment treatment. STUDY DESIGN: This was a prospective, consecutive, randomized interventional study. METHODS: This study examined 30 eyes from 30 patients divided into two groups: (1) a Kaminari Kagura group (15 eyes) and (2) a control group (15 eyes) scheduled for vitrectomy with an optical coherence tomography (OCT)-based diagnosis of adherent posterior hyaloid. RESULTS: The mean time for posterior vitreous detachment (PVD) induction in the Kaminari Kagura group was 58 ± 6.6 s, and that in the control group was 69 ± 9 s (p < 0.005). No intra- or post-operative complications were reported. CONCLUSIONS: The Kaminari Kagura technique results in effective posterior hyaloid detachment in less time than that required for posterior vitreous cortex engagement.

Sutureless scleral fixation Carlevale IOL: a review on the novel designed lens.

BACKGROUND:  Complicated cataract surgery is the main cause of secondary lens implantation surgery. Several approaches have been introduced to face those circumstances. As it concerns scleral-fixated IOLs for the posterior chamber, many types of IOL can be implanted. The aim of article is to review the single piece sutureless scleral fixation Carlevale lens; Methods: Narrative review; Results: Several works described as safe the IOL implantation utilizing the handshake approach, without tactile manipulation, which allows for self-centration and lens firm fixation in uncomplicated surgery. This allows to reduce high order aberration such as astigmatism and coma, with a very good postoperative BCVA Conclusions: Carlevale lens is one of the best option to manage insufficient capsular support.

Early evaluation of optic nerve head morphology and choroidal thickness after PreserFlo MicroShunt implantation.

PURPOSE: The aim of this study is to investigate changes in choroidal and optic nerve morphological parameters following MicroShunt PreserFlo implantation. The secondary aim is to investigate how the structural changes relate to the decrease in intraocular pressure (IOP). METHODS: Prospective observational study on 15 eyes with glaucoma requiring MicroShunt implantation. Optical coherence tomography was used to measure macular choroidal thickness (MCT), peripapillary choroidal thickness (PCT), lamina cribrosa depth (LCD), cup depth and prelaminar tissue thickness (PLT), before and one day after surgery. Results were expressed in median and interquartile range (IQR) and correlated with IOP results. RESULTS: The IOP decreased from a median of 25 (IQR = 11) mmHg to 8 (IQR = 2) mmHg the day after surgery. Median MCT increased after MicroShunt implantation from 252.1 (IQR = 156.4) µm to a postoperative value of 318.1 (IQR = 166.6) µm (p < 0.001), with a median increase of + 87.7 µm (+ 26.4%). PCT increased from 157.2 (IQR = 109.1) µm before surgery to 206.0 (IQR = 136.1) µm after surgery (p < 0.001). Moreover, we found a significant post-operative decrease in cup depth (median reduction of - 29.3 µm, p < 0.001) and an increase in PLT (median increase of 27.3 µm, p = 0.028). On the other side, LCD reduction 24 h after surgery didn't reach any statistical significance. CONCLUSION: PreserFlo implantation determines retinal structural changes which appear similar to those caused by traditional filtering surgery, confirming the effectiveness of this device, meantime carrying a much smaller complications rate when compared to trabeculectomy.

Early post-operative anterior segment parameters modifications induced by PreserFlo MicroShunt in primary open-angle glaucoma.

PURPOSE: The aim this study is to determine anterior chamber parameters variations induced by PreserFlo MicroShunt implantation, in the early post-operative days. METHODS: This is a prospective observational study on 48 eyes undergoing PreserFlo MicroShunt implantation alone (n = 30) or combined with phacoemulsification (n = 18). Anterior chamber depth (ACD) and volume (ACV), central corneal thickness (CCT) and total corneal astigmatism (TCA) were evaluated pre-operatively, post-operatively at day-1 and at 1 week with the Pentacam tomography. RESULTS: Intraocular pressure decreased significantly from 20.9 ± 4.0 to 8.0 ± 2.8 mmHg (p < 0.0001) and to 10.8 ± 3.7 mmHg (p = 0.0001) at day-1 and week-1, respectively. TCA varied significantly from baseline (1.5 ± 1.2 D) to both day 1 follow up (2.7 ± 1.9 D, p = 0.0003) and week 1 follow up (2.2 ± 1.6 D, p = 0.02). Nevertheless, only K1 showed a transient flattening at day 1, while K2 value didn't show any statistical variation in the early post-operative period. CCT value rose significantly at day 1 (547 ± 49 vs. 529 ± 32 µm at baseline, p = 0.04), but then returned toward pre-operative values at week 1 (537 ± 39 µm, p = 0.57). In contrast, ACD values changed insignificantly from 3.3 ± 0.9 to 3.7 ± 1.0 mm at day 1 (p = 0.21), and then stabilized at 3.4 ± 0.9 mm (p = 0.82) at week 1 follow up. ACV changed from 150.0 ± 36.2 to 159.5 ± 42.1 mm3 at day 1 (p = 0.58), and successively to 153.9 ± 37.9 mm3 at week 1 follow up (p = 0.96). The subgroup analysis in eyes undergoing standalone PreserFlo implantation didn't show significant changes in both ACD and ACV. CONCLUSION: PreserFlo implantation minimizes the anterior chamber modifications generated by traditional filtering surgery, inducing low and transient corneal and biometric changes only in the very early postoperative period and insignificant changes to ACD and ACV, label of its safety and minimal invasiveness.

Intrascleral hydration for 23-Gauge Pars Plana Vitrectomy Sclerotomy Closure.

PURPOSE: To describe and evaluate the effectiveness of a new technique to close 23-gauge sclerotomies in transconjunctival pars plana vitrectomy. MATERIALS AND METHODS: A prospective, consecutive, interventional study of 90 eyes of 90 patients who underwent 23-gauge pars plana vitrectomy with the introduction of the new sealing technique was conducted. The 23-gauge sclerotomies were hydrated with a 30-gauge needle inserted in the scleral stroma near the scleral opening. RESULTS: A total of 90 eyes of 90 patients were recruited in the study. The number of the eyes requiring suture for sclerotomy closure was 3.3% (3 of 90), and the sclerotomies requiring suture were 1.4% (4 of 270). Three eyes had hypotony on Day 1. No statistically significant difference was registered between preoperative intraocular pressure and postoperative intraocular pressure on Days 15 and 30. No leaking of endotamponade bubble filling was noticed on Day 1. No postoperative complications were registered during the follow-up period. CONCLUSION: The intrascleral stroma hydration is a simple and fast technique that does not require extra surgical materials.

Evaluation of intraoperative slow-release dexamethasone implant combined with idiopathic epiretinal membrane removal.

PURPOSE: To evaluate the efficacy of intraoperative slow-release dexamethasone implant (DEX) combined with removal of idiopathic epiretinal membrane (ERM). METHODS: In this observational retrospective study, data of 40 patients with phakic eyes affected by idiopathic ERM were analysed. All patients underwent cataract phacoemulsification, 25-gauge (G) pars plana vitrectomy (PPV), ERM removal with DEX implant ("DEX YES" group, #20) or without DEX implant ("DEX NO" group, #20). We collected data on best-corrected visual acuity (BCVA) < 20/40 Snellen charts, central macular thickness (CMT) ≤ 400 µm (measured by SD-OCT) and integrity of sub-foveal ellipsoid/myoid zone. BCVA, CMT and intraocular pressure (IOP) were evaluated at baseline as well as 15, 30 and 90 days after surgery. RESULTS: In the "DEX YES" group, statistically significant BCVA improvement was observed at 15, 30 and 90 days (p < 0.001), while in the "DEX NO" group, improvements were observed only at 30 and 90 days (p < 0.001). In both groups, CMT significantly decreased at each follow-up visit (p < 0.001), and no statistically significant increase of IOP was detected at each follow-up visit. CONCLUSIONS: In this study, DEX accelerated the improvement of BCVA at 15 days after surgery. However, no evidence of further anatomical (CMT) and functional (BCVA) DEX effectiveness combined with removal of idiopathic ERM by 25-G PPV at 30 and 90 days follow-up was observed.

HUMAN AMNIOTIC MEMBRANE TO TREAT MACULAR HOLES THAT FAILED TO CLOSE, SULFUR HEXAFLUORIDE ENDOTAMPONADE VERSUS AIR ENDOTAMPONADE: A Prospective Comparative Study.

BACKGROUND/PURPOSE: To determinate the efficacy of the human amniotic membrane plugs with sulfur hexafluoride versus human amniotic membrane plug with air as endotamponade to treat macular holes that failed to close after vitrectomy plus internal limiting membrane peeling. Multimodal imaging was focused to evaluate preoperative features and postoperative changes. METHODS: Prospective interventional comparative study. Twenty eyes of 20 patients affected with macular hole that failed to close were divided into 2 groups: 10 eyes received an amniotic membrane plug with 20% sulfur hexafluoride tamponade and 10 eyes received an amniotic membrane plug with air tamponade. All eyes were studied using multimodal advanced diagnostic tools, such as spectral-domain optical coherence tomography, optical coherence tomography angiography, microperimetry, and adaptive optics to investigate the postoperative results. RESULTS: In both groups, all macular holes were found successfully closed after 12 months. Mean preoperative best-corrected visual acuity was 20/400 in the SF6 group and 20/250 in air group. Final mean best-corrected visual acuity was 20/63 in both groups. The superficial capillary plexus, studied using optical coherence tomography angiography, showed a statistically significant difference between the treated and the fellow eyes. Adaptive optics images revealed the presence of a photoreceptor cell mosaic in the area of the amniotic membrane plug. CONCLUSION: The human amniotic membrane combined with air endotamponade demonstrated its effectiveness to seal macular holes that failed to close after vitrectomy plus internal limiting membrane peeling. Advanced multimodal diagnostic imaging helped us to better understand the modifications associated with the use of the amniotic membrane in these cases.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FINDINGS BEFORE AND AFTER VITRECTOMY FOR MACULAR HOLES: Useful or Useless?

PURPOSE: To investigate the vascular remodeling of optical coherence tomography angiography in full-thickness macular hole surgery. METHODS: This retrospective, observational case series included 33 eyes of 33 patients with a full-thickness macular hole who underwent epiretinal membrane removal. Data were collected on best-corrected visual acuity, structural B-scan optical coherence tomography, and optical coherence tomography angiography preoperatively and at 1, 3, and 6 months postoperatively. Optical coherence tomography angiography was used to assess the retinal vascular density (VD) of the superficial vascular plexus and deep vascular plexus (DVP). Vascular density was assessed using the Early Treatment Diabetic Retinopathy Study grid for the whole, inner, and outer grids. RESULTS: A statistically significant correlation was found between the VD (whole, inner, and outer grids) of the superficial vascular plexus alone from baseline to 1-month postoperatively (P < 0.001). Similarly, VD was correlated from baseline to 1, 3, and 6 months postoperatively to the whole (P < 0.0005, F = 23.22), inner (P < 0.0005, F = 28.23), and outer Early Treatment Diabetic Retinopathy Study grids of DVP (P = 0.033, F = 3.49). The best-corrected visual acuity and VD were significantly correlated with the superficial vascular plexus and DVP at baseline and 6 months (P < 0.05, all correlations). The most significant correlation was observed at 6 months between best-corrected visual acuity and DVP in the whole, inner, and outer Early Treatment Diabetic Retinopathy Study grids (P < 0.001). CONCLUSION: Superficial vascular plexus and DVP are affected by full-thickness macular holes, with the most significant effects being on the DVP. Full-thickness macular hole surgery leads to an improvement in the best-corrected visual acuity in many eyes and the restoration of the VD, especially of the DVP.

Macular hole closure patterns: an updated classification.

BACKGROUND: The classification of macular hole closure patterns (MHCPs) currently relies on time domain OCT allowing only "open" and "closed" statuses or is based on inner foveal contour shape. Both classification types give no information on retinal layer reconstitution. Novel sophisticated surgical techniques lead to previously unknown MHCPs, outdating existing classifications and urging new ones. The purpose of the present study is to introduce a new classification allowing proper description of all MHCPs resulting from newer surgeries and based on the restoration of retinal layers. METHODS: Retrospective analysis of patients undergoing MH surgery with five different surgical techniques was performed. MHCPs were classified according to spectral domain optical coherence tomography (SD-OCT). Type 0: open MH (0A: flat margin, 0B: elevated, 0C: oedematous); type 1: closed MHs (1A: reconstitution all retinal layers; 1B interruption of the external layers; 1C interruption of internal layers); type 2: MH closed with autologous or heterologous filling tissue interrupting the normal foveal layered anatomy (2A: filling tissue through all layers; 2B reconstitution of normal inner retinal layers; 2C reconstitution of normal outer retinal layers; 2D H-shaped bridging of filling tissue). RESULTS: Closure rate was 95.2% (241/253). Surgical technique and vision correlated to closure pattern (p < 0.001). Type 1 MHCPs had the best post-operative visual acuity (VA) compared with type 2 and type 0 (p < 0.001). MHCPs 1A and 1C performed better than all others. MHCP at months 1 and 3 changed in 42/254 (16.5%) and remained stable in 212/254 (83.5%). Improvement in vision was higher in eyes with shifting closure pattern (0.57 ± 0.33 vs 0.51 ± 0.48 logMAR; p 0.021). CONCLUSION: MHCP classification based on retinal layer restoration properly comprises post-operative anatomic morphologies. MHCPs correlate the surgical technique and post-operative visual outcomes.

HUMAN AMNIOTIC MEMBRANE TO CLOSE RECURRENT, HIGH MYOPIC MACULAR HOLES IN PATHOLOGIC MYOPIA WITH AXIAL LENGTH OF ≥30 mm.

PURPOSE: To assess the effectiveness of the human amniotic membrane plug for recurrent high myopic macular hole (MH) that already underwent pars plana vitrectomy with internal limiting membrane peeling and gas endotamponade. METHODS: Sixteen eyes of 16 patients with recurrent high myopic MH were enrolled. A 23-gauge pars plana vitrectomy was performed. Human amniotic membrane plugs were implanted under the neuroretina inside the MH. Twenty percent sulfur hexafluoride or air was used as endotamponades. The patients were instructed to maintain facedown position for 5 days after surgery. RESULTS: Optical coherence tomography examinations showed that the MHs closed in 15 of the 16 patients (93.75%) 2 weeks after one surgical intervention, and in 100% of patients after second intervention. Mean best-corrected visual acuity improved from 1 logarithm of the minimum angle of resolution (20/200) to 0.67 logarithm of the minimum angle of resolution (20/100) 6 months after surgery. Best-corrected visual acuity remained stable during the 12-month follow-up. One patient had human amniotic membrane plug dislocation after gas absorption that needed a second intervention with new AM plug implantation. No adverse events were reported during the 12-month follow-up. CONCLUSION: The first case series of recurrent high myopic MH was reported, assessing the effectiveness of the human amniotic membrane plug to close recurrent MHs in pathologic myopia. All the cases were successful with encouraging best-corrected visual acuity recovery.