Delayed Macular Hole Closure

Purpose

The presented case raises questions regarding the favorable scheduling of planned postoperative care and the ideal observation interval to decide for reoperations in macular hole surgery. Furthermore a discussion about the use of short- and long-acting gas tamponades in macular hole surgery is encouraged.

Methods

We present an interventional case report and a short review of the pertinent literature.

Results

We report a case of spontaneous delayed macular hole closure after vitreoretinal surgery had been performed initially without the expected success. A 73-year-old male Caucasian patient presented at our clinic with a stage 2 macular hole in his left eye. He underwent 23-gauge pars plana vitrectomy and internal limiting membrane peeling with a 20% C₂F₆-gas tamponade. Sixteen days after the procedure, an OCT scan revealed a persistent stage 2 macular hole, and the patient was scheduled for reoperation. Surprisingly, at the date of planned surgery, which was another 11 days later, the macular hole had resolved spontaneously without any further intervention.

Conclusions

So far no common opinion exists regarding the use of short- or long-acting gas in macular hole surgery. Our case of delayed macular hole closure after complete resorption of the gas tamponade raises questions about the need and duration of strict prone positioning after surgery. Furthermore short-acting gas might be as efficient as long-acting gas. We suggest to wait with a second intervention at least 4 weeks after the initial surgery, since a delayed macular hole closure is possible.Key words: Macular hole, Vitrectomy, Gas tamponade     

Retained silicone tip of diamond-dusted membrane scraper during vitrectomy in a valved cannula system

Purpose

To report a complication of retained silicone tip from a diamond-dusted membrane scraper (DDMS) that occurred while using a valved cannula vitrectomy system.

Method

Retrospective review of three cases that underwent 23 gauge (G) sutureless vitrectomy for idiopathic macular hole (cases 1 and 2) and myopic macular schisis (case 3).

Results

In all three cases following a standard vitrectomy, the internal limiting membrane (ILM) peeling was initiated by using a 23G DDMS. During the insertion of the DDMS, the flexible silicone tip of the 23G DDMS was detached from the metal shaft and was retained in the 23G valve system and in case 3, the silicone tip got dislodged from the valve onto the retina. Subsequent ILM peeling was completed by using an end-gripping forceps. All underwent intravitreal gas injection at the end. No other complications were noted.

Conclusion

These three cases demonstrate an uncommon complication of retained silicone tip within the valved cannula vitrectomy system and this complication should be considered while using flexible instruments in valved cannula systems.     

Recurrence of Macular Hole Retinal Detachment after Intravitreal Ranibizumab Injection for the Treatment of Choroidal Neovascularization from the Remaining Macular Hole Edge

Purpose

To report a case who had recurrence of macular hole retinal detachment (MHRD) after intravitreal ranibizumab injection (IVR) for the treatment of choroidal neovascularization (CNV) that arose from the damaged retinal pigment epithelium of the remaining macular hole (MH) edge, which had been successfully treated by pars plana vitrectomy (PPV) 15 years previously.

Case Report

A 67-year-old man with previous PPV for MHRD secondary to high myopia in the right eye had been under observation for 15 years after surgery. The retina had been successfully attached, but the MH remained open. He had CNV which arose from the remaining MH edge. IVR was performed for the treatment of CNV. One month after the injection, CNV was contracted but recurrence of MHRD occurred. PPV with an additional internal limiting membrane peeling, removal of the CNV membrane and 20% SF6 gas tamponade was performed. One year after the last surgery, his right retina was attached and the MH was closed successfully.

Conclusion

We propose that patients who undergo IVR should be carefully maintained and followed up for possible complications including the recurrence of MHRD.Key words: Macular hole, Retinal detachment, Intravitreal ranibizumab injection, Anti-VEGF, Lucentis, Choroidal neovascularization     

Management of Stage IV Macular Holes: When Standard Surgery Fails

Purpose

To report the surgical outcomes of reoperation of unclosed macular holes after initial vitrectomy with internal limiting membrane peeling.

Procedures

Seven eyes of 7 patients were submitted to a second procedure in which five radial retinal incisions were made, as deep as the retinal pigment epithelium, beginning one hole diameter away from its borders and extending centripetally until the hole''s margins, avoiding the papilomacular bundle. Gas tamponade was performed and face-down positioning was recommended.

Results

Anatomical closure was achieved in all cases with the second procedure. Functional success was achieved in every patient; there was no loss of best corrected visual acuity (BCVA) lines. Mean line score gain was 5.6 lines (range 1–9 lines), with a mean final BCVA of 0.42 (range 0.05–0.5).

Conclusions

Perifoveal relaxing incisions in stage IV macular holes that remained unclosed after internal limiting membrane peeling vitrectomy seem to have a positive effect on MH closure rates. Larger case series and an extended follow-up period are necessary in order to assess the efficacy and safety profile of this so far promising technique.Key Words: Macular holes, Best corrected visual acuity, Internal limiting membrane     

Intraoperative changes in idiopathic macular holes by spectral-domain optical coherence tomography

Purpose

To examine anatomical changes in idiopathic macular holes during surgery using handheld spectral-domain optical coherence tomography (SD-OCT).

Methods

Five eyes of 5 patients who underwent surgery for the repair of idiopathic macular holes were examined. The surgery included standard 25-gauge, 3-port pars plana vitrectomy, removal of the internal limiting membrane (ILM), fluid-air exchange, and 20% sulfur hexafluoride tamponade. Intraoperative SD-OCT images of the macular holes were obtained after ILM removal and under fluid-air exchange using a handheld SD-OCT. From SD-OCT images, the macular hole base diameter (MHBD) was measured and compared.

Results

All macular holes were successfully closed after the primary surgery. The mean MHBD under fluid-air exchange was significantly smaller than the mean MHBD after ILM removal and the preoperative mean MHBD. In 1 eye with a stage 3 macular hole, SD-OCT images revealed that the inner edges of the macular hole touched each other under fluid-air exchange.

Conclusion

Fluid-air exchange significantly reduced MHBD during surgery to repair macular holes. Fluid-air exchange may be an important step for macular hole closure as it reduces the base diameter of the macular hole.Key Words: Spectral-domain OCT, Macular hole, Base diameter, Intraoperative OCT     

Gas tamponade combined with laser photocoagulation therapy for congenital optic disc pit maculopathy

Purpose

To evaluate the long-term clinical efficacy and safety of gas tamponade combined with laser photocoagulation for optic disc pit maculopathy.

Methods

Seven consecutive patients with unilateral maculopathy associated with optic disc pit and one patient with bilateral optic disc pit maculopathy were given octafluoropropane (C₃F₈) tamponade combined with focal laser photocoagulation treatment. Patients were followed up for 21–62 months after treatment. Main outcomes were determined by optical coherence tomography (OCT) and best-corrected visual acuity (BCVA).

Results

Treatment with C₃F₈ tamponade followed by laser photocoagulation in ODP maculopathy patients resulted in resolution of sub-retinal and/or intra-retinal fluid in six out of eight patients. The remaining two patients had significant reduction in fluid, as determined by OCT, and funduscopy, as well as an improvement in anatomical architecture. Visual acuity improved obviously in seven eyes and remained stable in two eyes. Central visual field loss after photocoagulation was not clinically appreciable by visual field examination. No post-operative complications of maculopathy occurred during the follow-up period.

Conclusions

Although repeated treatment was needed in some patients, C₃F₈ tamponade combined with laser photocoagulation is still a simple, effective, minimally invasive, and economic therapy for optic disc pit maculopathy.     

Pilot randomised controlled trial of face-down posturing following phacovitrectomy for macular hole

Background

To gather information on the effect of postoperative face-down posturing following combined phacoemulsification and vitrectomy for macular hole surgery in order to assist in the design of a larger definitive study.

Methods

Thirty phakic patients with stage II–IV full-thickness macular hole had combined phacoemulsification and pars plana vitrectomy with internal limiting membrane peel and 14% perfluoropropane (C₃F₈) gas. At the conclusion of surgery, patients were randomised either to face-down posture or to no posture, for 10 days. The primary outcome was macular hole closure.

Results

The macular hole was successfully closed in 93.8% of the face-down posture group and in all of the no-posture group. Mean visual improvement was 0.63 (SD=0.21) logMAR units in the face-down group and 0.53 (SD=0.22) in the no posture patients.

Conclusion

Following combined phacoemulsification and vitrectomy, postoperative face-down posturing appears to make little difference to the final anatomical or visual outcome. If we assume a success rate of 95% in the posturing arm, and that there is no difference between posturing and non-posturing, then 798 patients would be required to be 90% sure that the 95% confidence interval will exclude a difference of more than 5%.     

Long-term outcomes of pars plana vitrectomy without internal limiting membrane peeling for optic disc pit maculopathy

Purpose

To evaluate the results of surgical treatment of maculopathy secondary to congenital optic pit anomaly with pars plana vitrectomy (PPV), endolaser to the temporal edge of the optic disc and C3F8 tamponade without internal limiting membrane (ILM) peeling.

Patients and methods

Thirteen eyes of 12 patients with serous macular detachment and/or macular retinoschisis secondary to congenital optic disc pit (ODP) were included in the study. All eyes underwent PPV, posterior hyaloid removal, endolaser photocoagulation on the temporal margin of the optic disc and 12% C3F8 gas tamponade. Anatomic success and functional outcome determined retrospectively by optical coherence tomography and measurement of best corrected visual acuity (BCVA), respectively were the main outcome parameters.

Results

Two lines or more improvement in BCVA was obtained in 11 eyes and 6 of these eyes had 20/40 or better BCVA at the final visit. Subretinal or intraretinal fluid was completely resorbed postoperatively in 12 eyes but a little intraretinal fluid persisted in one eye at the 16-month follow-up. Better visual improvement was observed in patients treated by earlier surgical intervention.

Conclusion

PPV, C3F8 gas tamponade and endolaser to the optic disc margin without ILM peeling may yield favourable results in the treatment of ODP maculopathy.     

The Expansion of RPE Atrophy after the Inverted ILM Flap Technique for a Chronic Large Macular Hole

Purpose

To report a case of the expansion of submacular retinal pigment epithelium (RPE) atrophy after using the inverted internal limiting membrane (ILM) flap technique for a persisting, large, stage IV macular hole (MH).

Case Report

A 79-year-old woman presented with a chronic large MH that remained open despite pars plana vitrectomy (PPV). The surgery was performed twice for the MH closure 14 years earlier. ILM peeling was not performed during the previous surgeries. The best-corrected visual acuity (BCVA) with the Landolt ring chart was 0.08 at her visit. The minimum MH diameter was 1,240 μm. Inverted ILM flap technique with 20% SF6 gas tamponade was performed for the MH closure. For the inverted ILM flap technique, 25-gauge PPV and ILM staining with indocyanine green were used. The ILM was peeled off for 2 disc diameters around the MH, but the ILM was not removed completely. The ILM was then inverted and covered the MH.

Results

One month after surgery, the MH was closed, accompanied by glial cell proliferation spreading from the inverted ILM flap (as reported before). On the other hand, the area of the submacular RPE atrophy, which was already observed 1 week after surgery, gradually increased in size. BCVA improved to 0.3 six months after the surgery.

Conclusions

The inverted ILM flap technique may be promising even for persisting large MH which were not closed in previous surgeries, but long-term observation is needed because the detailed behavior of the inverted ILM and the Müller cells after surgery is not yet known.Key words: Macular hole, Inverted internal limiting membrane flap technique, Chronic macular hole, Indocyanine green, Retinal pigment epithelium atrophy     

Double-Vitrectomy for Optic Disc Pit Maculopathy

Background

The origin of the fluid and precise pathophysiology of optic pit maculopathy remain unclear. It has been suggested that submacular fluid originates either from vitreous or cerebrospinal fluid. We report a case of optic pit maculopathy which was unsuccessfully treated with vitrectomy and internal limiting membrane (ILM) peeling, and subsequently resolved with revision of vitrectomy and gas tamponade.

Methods

We report a case of optic disc pit maculopathy, well documented by spectral- domain optical coherence tomography, before and after pars plana vitrectomy with ILM peeling, and its revision with gas tamponade.

Results

After ILM peeling, there was no improvement either in visual acuity or in the tomographic aspect of the retina. A revision of the surgery was then needed and gas tamponade was performed, which resulted in a complete resolution of the optic pit maculopathy.

Conclusion

The absence of improvement after ILM peeling during the first surgical procedure, accompanied by resolution of the clinical picture with gas tamponade during the second surgical procedure, sustained the hypothesis of a subarachnoidal origin of the fluid.Key Words: Optic pit maculopathy, Internal limiting membrane peeling, Gas tamponade     

Spontaneous Closure of a Full-Thickness Stage 2 Idiopathic Macular Hole without Posterior Vitreous Detachment

Objective

We report a 50-year-old female patient with a stage 2 idiopathic macular hole that closed spontaneously.

Method

The case is presented on the basis of an observational case report.

Results

The stage 2 idiopathic macular hole closed spontaneously in 6 weeks with a lamellar defect in the outer retina due to the formation of the bridging retinal tissue, but without any evidence of the common mechanisms of spontaneous closure such as posterior vitreous detachment or epiretinal membrane formation.Key words: Macular holes, Posterior vitreous detachment, Retina, Optical coherence tomography     

Pilot randomised controlled trial of face-down positioning following macular hole surgery

Objective

This was a pilot randomised controlled trial (RCT) to investigate the effect of post-operative face-down positioning on the outcome of macular hole surgery and to inform the design of a larger definitive study.

Methods

In all, 30 phakic eyes of 30 subjects with idiopathic full-thickness macular holes underwent vitrectomy with dye-assisted peeling of the ILM and 14% perfluoropropane gas. Subjects were randomly allocated to posture face down for 10 days (posturing group) or to avoid a face-up position only (non-posturing group). The primary outcome was anatomical hole closure.

Results

Macular holes closed in 14 of 15 eyes (93.3% 95% confidence interval (CI) 68–100%) in the posturing group and in 9 of 15 (60% 95% CI 32–84%) in the non-posturing group. In a subgroup analysis of outcome according to macular hole size, all holes smaller than 400 μm closed regardless of posturing (100%). In contrast, holes larger than 400 μm closed in 10 of 11 eyes (91% 95% CI 58–99%) in the posturing group and in only 4 of 10 eyes (40% 95% CI 12–74%) in the non-posturing group (Fisher''s exact test P=0.02).

Conclusion

Post-operative face-down positioning may improve the likelihood of macular hole closure, particularly for holes larger than 400 μm. These results support the case for a RCT.     

Management of Pediatric Traumatic Macular Holes – Case Report

Purpose

To report and describe the clinical course of four pediatric traumatic macular hole (TMH) cases and respective management.

Case Report

Four pediatric patients with macular hole following blunt ocular trauma underwent early pars plana vitrectomy, with consecutive hole closure. Initial visual acuity was <20/400 or worse in all patients. After surgery, all patients had visual acuity improvement, with final visual acuity being <20/50 in 2 of the patients by the end of the follow-up. Macular hole closure was achieved in all patients with a single procedure, and anatomical success was confirmed by optical coherence tomography until the end of the follow-up.

Conclusions

Although spontaneous closure of TMH is not uncommon, especially in pediatric patients, early pars plana vitrectomy seems to be a safe and effective choice in pediatric TMH management. The risk/benefit ratio of surgery seems to be better than observation.Key words: Macular hole, Trauma, Pediatric patients     

Pneumodescemetopexy with perfluoroethane (C2F6) for the treatment of acute hydrops secondary to keratoconus

Purpose

To evaluate the efficacy and safety of pneumodescemetopexy with intracameral perfluoroethane (C₂F₆) gas for the treatment of acute hydrops secondary to keratoconus.

Methods

Retrospective, non-comparative, interventional case series. Eight eyes of eight patients who presented with acute hydrops secondary to keratoconus between July 2009 and September 2013 were consecutively recruited. All were treated with intracameral 14% isoexpansile concentration of C₂F₆. Preoperative and postoperative best-corrected visual acuities (BCVA), intraoperative and postoperative complications, and time taken for resolution of corneal oedema were assessed.

Results

All the patients, except for one, were followed up for 1 year. The mean age of the cohort was 29.1±13.5 years. BCVA at presentation was 6/60 or less in all patients. Improvement of BCVA was achieved postoperatively in seven (87.5%) patients, with three (37.5%) patients achieving a BCVA of 6/18. The average time between initial presentation and complete resolution of corneal oedema was 60.0±32.1 days. The C₂F₆ gas persisted in the anterior chamber between 6 and 8 days. All the patients required only one injection during the treatment period. There was no intraoperative or postoperative complication noted during the follow-up period.

Conclusion

Pneumodescemetopexy with intracameral isoexpansile concentration of C₂F₆ gas serves as a safe and effective treatment modality for patients with acute hydrops secondary to keratoconus.     

Pars Plana Vitrectomy Combined with Internal Limiting Membrane Peeling to Treat Persistent Macular Edema after Anti-Vascular Endothelial Growth Factor Treatment in Cases of Ischemic Central Retinal Vein Occlusion

Objective

To evaluate the efficacy of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling in cases of ischemic central retinal vein occlusion (CRVO) where macular edema (ME) persisted after anti-vascular endothelial growth factor (anti-VEGF) treatment.

Methods

Fifteen eyes with ischemic CRVO-related ME were included in the study. Nine were treated with panretinal photocoagulation after initial examination. Anti-VEGF agents were injected intravitreally. Persistent ME was treated with PPV combined with ILM peeling. During surgery, laser photocoagulation was further applied to the non-perfused area.

Results

Mean retinal thickness gradually decreased after surgery (p = 0.024 at 6 months), although visual acuity did not improve significantly during the follow-up period (14.7 ± 11.6 months). Neovascular glaucoma subsequently developed in three cases and a trabeculectomy was performed in one case.

Conclusion

In eyes with ischemic CRVO, PPV combined with ILM peeling contributed to a reduction in persistent ME. However, there was no significant improvement in visual acuity.Key Words: Anti-vascular endothelial growth factor, Central retinal vein occlusion, Internal limiting membrane peeling, Macular edema, Pars plana vitrectomy     

Long-term decrease of retinal pigment epithelium defects in large stage iv macular holes with borders mechanically joined during surgery

Purpose

The aim of this paper is to present retinal pigment epithelium (RPE) defects in spectral domain optical coherence tomography (SD-OCT) and their gradual resolution over time.

Materials and Methods

Observational case series of 3 eyes of 3 patients who were followed for a period of 3-6 years after undergoing surgery to mechanically close the borders of large stage IV macular holes. Photoreceptor defects and RPE defects were measured during this period with SD-OCT.

Results

In all cases, a reduction in the size of the areas of photoreceptor and RPE defects was noted, which correlated with late improvement in visual acuity (VA).

Conclusions

In eyes with no underlying retinal pigment epithelial or choroidal disease, restoration of RPE is possible in vivo for up to several years after surgery for macular hole closure. An improvement in VA is possible, even lasting many years after successful macular hole surgery, which corresponds to a decrease in both RPE defects and the size of the defects in the junction between the inner and outer segments of photoreceptors.Key words: Macular hole, Photoreceptor defects, Retinal pigment epithelium defects, Spectral domain optical coherence tomography     

Outcome and Significance of Silicone Oil Tamponade in Patients with Chronic Serous Retinal Detachment

Purpose

To evaluate the effectiveness of silicone oil tamponade in patients with chronic serous retinal detachment (SRD) persisting for three months after the resolution of ocular inflammation.

Methods

A total of 17 eyes of 17 patients diagnosed with chronic SRD persisting for three months after the resolution of ocular inflammation and with high risk of phthisis bulbi by secondary ocular hypotony and macular detachment by subretinal fibrous membrane formation were subjected to surgical intervention. Subjects underwent silicone oil tamponade after surgical drainage of subretinal fluid. Retrospective analyses on anatomical and functional success rates were then performed.

Results

Anatomical success with retinal reattachment was observed in ten of the 17 eyes (58.82%), while functional success measured as difference in the best-corrected visual acuity before and after the surgery were logarithm of the minimum angle of resolution (logMAR) 1.95 ± 0.66 and logMAR 1.51 ± 0.66, respectively (p < 0.05).

Conclusions

This study suggests that, in patients with chronic SRD despite prolonged medical treatment and resolution of inflammation, surgical drainage of subretinal fluid with silicone oil tamponade can achieve anatomical and functional success.     

Photoreceptor Outer Segment on Internal Limiting Membrane after Macular Hole Surgery: Implications for Pathogenesis

Purpose

This report presents a case, which highlights key principles in the pathophysiology of macular holes. It has been hypothesized that anteroposterior (AP) and tangential vitreous traction on the fovea are the primary underlying factors causing macular holes [Nischal and Pearson; in Kanski and Bowling: Clinical Ophthalmology: A Systemic Approach, 2011, pp 629–631]. Spectral domain optical coherence tomography (OCT) has subsequently corroborated this theory in part but shown that AP vitreofoveal traction is the more common scenario [Steel and Lotery: Eye 2013;27:1–21].

Methods

This study was conducted as a single case report.

Results

A 63-year old female presented to her optician with blurred and distorted vision in her left eye. OCT showed a macular hole with a minimum linear diameter of 370 µm, with persistent broad vitreofoveal attachment on both sides of the hole edges. The patient underwent combined left phacoemulsification and pars plana vitrectomy, internal limiting membrane (ILM) peel and gas injection. The ILM was examined by electron microscopy and showed the presence of a cone outer segment on the retinal side. Post-operative OCT at 11 weeks showed a closed hole with recovery of the foveal contour and good vision.

Conclusion

Our case shows the presence of a photoreceptor outer segment on the retinal side of the ILM and reinforces the importance of tangential traction in the development of some macula holes. The case highlights the theory of transmission of inner retinal forces to the photoreceptors via Müller cells and how a full thickness macular hole defect can occur in the absence of AP vitreomacular traction.Key Words: Macular hole, Tangential vitreomacular traction, Internal limiting membrane, Photoreceptors     

Traction-induced foveal damage predisposes eyes with pre-existing posterior vitreous detachment to idiopathic macular hole formation

Aim

To propose a new mechanism for the development of idiopathic macular hole in the setting of pre-existing posterior vitreous detachment (PVD).

Methods

Patients were examined clinically with fundus contact lens biomicroscopy and high-definition optical coherence tomography (OCT) was used to characterize the structural changes in the fovea following PVD.

Results

Two patients presented with vitreofoveal separation and were found by high-definition OCT to have subtle foveal disruption and irregularity of the foveal contour with no evidence of a full thickness macular hole. Sequential examination of these patients demonstrated delayed formation of idiopathic macular hole.

Conclusion

Traction-induced inner foveal damage occurring before or coincident with spontaneous vitreofoveal separation destabilizes the fovea and predisposes some eyes to delayed macular hole formation.     

Posttraumatic giant macular hole

Introduction

Large macular holes secondary to blunt trauma are sometimes seen in young patients within the spectrum of alterations produced by ocular trauma.

Methods

Observational case report. A 32-year-old woman who had received a blunt trauma (a blow from a fist) to her right eye 10 years previously had experienced a decrease in visual acuity ever since.

Results

Clinical photographs, fluorescein angiography and optic coherent tomography images revealed a very large macular hole of approximately 1,920 μm in diameter.

Conclusion

This case is an uncommonly large variant of a macular hole secondary to blunt trauma in a young patient.Key words: Trauma, Giant macular hole