玻璃体视网膜手术治疗病理性近视黄斑劈裂的疗效观察及视力预后影响因素分析

目的 观察玻璃体视网膜手术治疗病理性近视黄斑劈裂的临床效果,分析视力预后的影响因素.方法 临床确诊为病理性近视黄斑劈裂并接受玻璃体视网膜手术治疗的23例患者27只眼纳入研究.患者均行最佳矫正视力(BCVA)、眼压、裂隙灯显微镜、直接检眼镜、双目间接检眼镜、眼底照相、A型超声、B型超声及光相干断层扫描等检查并行23G或25G经结膜无缝合微创玻璃体切割手术治疗.手术后随访6.00～36.00个月,平均随访时间(19.40±10.03)个月.观察视网膜劈裂复位、视力预后以及手术并发症发生情况.采用多因素Logistic回归分析法分析患者年龄、性别、病程、屈光度、眼轴长度、手术前BCVA、是否合并黄斑前膜、周边视网膜裂孔以及手术中是否注气、是否剥除内界膜和手术后末次随访时光感受器内外节连接(IS/OS)是否连续与视力预后的关系.结果 27只眼中,首次手术后视网膜解剖复位成功21只眼,占77.78％;未完全解剖复位6只眼,占22.22％.视力提高24只眼,占88.89％;未提高3只眼,占11.11％.随访期间,所有患者均未发生眼底出血、低眼压、高眼压、眼内炎等并发症.多因素Logistic回归分析显示,手术前BCVA(OR=9.11,P=0.007)、眼轴长度(OR=0.31,P=0.038)及末次随访IS/OS层连续性(OR=4.32,P=0.001)与视力预后密切相关.结论 玻璃体视网膜手术治疗病理性近视黄斑劈裂,能使大部分患者视网膜解剖复位成功,视力提高.手术前BCVA、眼轴长度及末次随访IS/OS连续性是影响视力预后的重要因素.     

Posterior vitreous detachment and macular hole formation in myopic foveoschisis

PURPOSE: To report two cases of macular hole (MH) associated with myopic foveoschisis (MF). DESIGN: Interventional case report. METHODS: Two women presented with metamorphopsia. Preoperative optical coherence tomography (OCT) showed an MH and MF. We performed vitrectomy, internal limiting membrane (ILM) peeling and gas tamponade. RESULTS: Preoperative OCT examination and intraoperative microscopic observation revealed partial posterior vitreous detachment (PVD) at the posterior retina and vitreous strands adhering to the edge of the MHs. The MF resolved in both patients, but the MHs remained open postoperatively. CONCLUSIONS: Although the contribution of tangential traction cannot be excluded, the mechanism of MH formation in eyes with MF may be anteroposterior traction via abnormal vitreofoveal adhesion resulting from partial PVD.     

Macular hole size as a prognostic factor in macular hole surgery

BACKGROUND/AIM: In 1991 there was a series of successful closures of a macular hole after vitrectomy and membrane peeling. Today this technique has become a standard procedure. The aim of this study was to evaluate the role of optical coherence tomography in diagnosing and staging, as well as in predicting, the functional and anatomical outcome after macular hole surgery. METHOD: In a prospective study 94 consecutive patients (20 male, 74 female) with a mean age of 67.6 (SD 6.0) years and a macular hole stage II (n = 8), III (n = 72), and IV (n = 14) according to the classification by Gass were examined with optical coherence tomography (OCT) before pars plana vitrectomy. Macular hole diameters were determined at the level of the retinal pigment epithelium (base diameter) and at the minimal extent of the hole (minimum diameter). Calculated hole form factor (HFF) was correlated with the postoperative anatomical success rate and best corrected visual acuity. The duration of symptoms was correlated with base and minimum diameter of the macular hole. RESULTS: In eyes without anatomical closure of the macular hole after one surgical approach (13/94) the base diameter (p1) and the minimum diameter (p2) were significantly larger than in cases with immediate postsurgical closure (p1 = 0.003; p2 = 0.028). There was a significant negative correlation between both the base and the minimum diameter of the hole and the postoperative visual function (p1 = 0.016; p2 = 0.002). In all patients with HFF >0.9 the macular hole was closed following one surgical procedure, whereas in eyes with HFF <0.5 anatomical success rate was 67%. Better postoperative visual outcome correlated with higher HFF (p = 0.050). There was no significant correlation between the duration of symptoms and base or minimum diameters (p1 = 0.053; p2 = 0.164), respectively. CONCLUSION: Preoperative measurement of macular hole size with OCT can provide a prognostic factor for postoperative visual outcome and anatomical success rate of macular hole surgery. The duration of symptoms did not correlate with the diameters measured. Base and minimum diameters especially seem to be of predictive value in macular hole surgery.     

The role of vitreoretinal surgery in the management of myopic macular hole without retinal detachment

PURPOSE: To evaluate the anatomic and functional outcome of vitreoretinal surgery in eyes with pathologic myopia and macular hole and to determine if surgery improves visual acuity. METHODS: Twenty-four consecutive highly myopic eyes with full-thickness macular hole without posterior retinal detachment were treated by vitrectomy. Posterior hyaloid dissection, removal of epiretinal and internal limiting membranes (ILM) if thickened, instillation of platelet concentrate, and flushing with 25% sulfur hexafluoride were performed. RESULTS: Patients' refractive error ranged between -8.0 and -17.5 diopters, and axial length ranged from 27.1 to 31.4 mm. Two epimacular membranes and 10 macular ILM were removed. Ten patients also underwent phacoemulsification and intraocular lens implantation at the same procedure. Mean preoperative best-corrected visual acuity was 20/200. Successful anatomic macular hole closure occurred 6 months postoperatively in 100% of eyes after one (21 eyes, 87.5%) or two surgeries (3 eyes, 12.5%). Visual acuity improved three or more lines in 83.3% of patients. Mean postoperative visual acuity was 20/70. No retinal detachment was observed during the follow-up period, which ranged from 12 to 45 months. CONCLUSION: Our results suggest that vitreoretinal surgery may effectively manage myopic macular holes, thus improving anatomic and visual outcomes. By closing the hole, vitreoretinal surgery may decrease the risk of posterior retinal detachment in highly myopic eyes.     

Treatment of myopic foveoschisis via macular buckling and vitrectomy

The aim of the present study was to evaluate the efficacy and safety of the treatment of myopic foveoschisis patients using the macular buckling with L-shaped titanium plate and silicon sponge combined with vitrectomy. The data of the patients who underwent macular buckling combined with vitrectomy was collected. The study recorded the following parameters: best corrected visual acuity (BCVA), axial length, intraocular pressure, central macular thickness, and the position of the titanium plate. Following the surgery, the BCVA of the included patients were improved, whereas the axial lengths were reduced followed by resolution of the foveoschisis compared with that noted prior to the operations. All patients had orbital CT examination and the results indicated that the titanium plates were appropriately placed and were not in contact with the optic nerve. Therefore, it is effective to treat myopic foveaschisis by macular buckling using the L-shaped titanium plate and silicon sponge in the presence of vitrectomy.     

Floating flap of internal limiting membrane in myopic macular hole surgery

Graefe's Archive for Clinical and Experimental Ophthalmology - To evaluate the surgical results of macular hole (MH) in patients with high myopia treated with pars plana vitrectomy (PPV)...     

Natural course of macular retinoschisis in highly myopic eyes without macular hole or retinal detachment

PURPOSE: To investigate the natural course of macular retinoschisis in highly myopic patients. DESIGN: A prospective, observational case series. METHODS: Seven consecutive patients (eight eyes) with macular retinoschisis without macular hole or retinal detachment determined by optical coherence tomography (OCT) were followed at least two years without surgical intervention. The changes in the OCT findings and best-corrected visual acuity (BCVA) were analyzed. RESULTS: During follow-up, two eyes that had vitreoretinal adhesions developed a macular hole, one with and one without retinal detachment (RD), and two eyes without detectable vitreoretinal adhesion developed RD without a macular hole. BCVA in these four eyes was significantly reduced. The remaining four eyes did not develop complications, although the thickness of the macula increased significantly. CONCLUSIONS: These findings suggest that macular retinoschisis might be a progressive condition, and that complications appeared to be related to the presence of vitreoretinal tractions.     

高度近视黄斑部视网膜劈裂和非裂孔性视网膜脱离

目的 观察高度近视黄斑部视网膜劈裂(MRS)和非裂孔性视网膜脱离(MRDH)的临床表现和影像学特征.方法 高度近视患者186例349只眼中合并MRS和MRDH的19例24只眼纳入研究.所有患者均进行了主觉验光、双目间接检眼镜、裂隙灯显微镜联合Goldmann三面镜检查,以及眼底照相、A/B型超声和光相干断层扫描(OCT)检查.结果 349只眼中后极部存在MRS和(或)MRDH 24只眼,占6.9%.眼底检查结果 显示.所有患跟均有后巩膜葡萄肿(PS),占100.0%;玻璃体黄斑牵引条带(VMT)2只眼.占8.3%;黄斑部局限性视网膜浅脱离2只眼,占8.3%;黄斑全层裂孔1只眼,占4.2%.B型超声检查结果 显示,所有患眼均伴有PS,占100.0%;黄斑部局限性视网膜浅脱离7只眼,占29.2%,脱离的视网膜与PS锥顶形成弓样结构;VMT条带2只眼,占8.3%.OCT检查结果 显示,黄斑部外层视网膜劈裂(ORS)22只眼,占91.7%,其中合并黄斑部内层视网膜劈裂(IRS)8只眼,占黄斑部ORS的36.4%.MRDH 5只眼,占20.8%,其中合并ORS 3只眼,占MRDH的60.0%;单纯性MRDH 2只眼,占MRDH的40.0%,其中合并VMT 1只眼.VMT 13只眼,占54.2%;黄斑囊样水肿(CME)3只眼,占12.5%;黄斑板层裂孔4只眼,占16.7%.结论 MRS和MRDH是伴有PS的高度近视眼的常见并发症.与常规眼底检查和B型超声相比,OCT是发现MRS和MRDH的更为有效的检查手段.     

高度近视黄斑部视网膜劈裂和非裂孔性视网膜脱离

目的 观察高度近视黄斑部视网膜劈裂(MRS)和非裂孔性视网膜脱离(MRDH)的临床表现和影像学特征.方法 高度近视患者186例349只眼中合并MRS和MRDH的19例24只眼纳入研究.所有患者均进行了主觉验光、双目间接检眼镜、裂隙灯显微镜联合Goldmann三面镜检查,以及眼底照相、A/B型超声和光相干断层扫描(OCT)检查.结果 349只眼中后极部存在MRS和(或)MRDH 24只眼,占6.9%.眼底检查结果 显示.所有患跟均有后巩膜葡萄肿(PS),占100.0%;玻璃体黄斑牵引条带(VMT)2只眼.占8.3%;黄斑部局限性视网膜浅脱离2只眼,占8.3%;黄斑全层裂孔1只眼,占4.2%.B型超声检查结果 显示,所有患眼均伴有PS,占100.0%;黄斑部局限性视网膜浅脱离7只眼,占29.2%,脱离的视网膜与PS锥顶形成弓样结构;VMT条带2只眼,占8.3%.OCT检查结果 显示,黄斑部外层视网膜劈裂(ORS)22只眼,占91.7%,其中合并黄斑部内层视网膜劈裂(IRS)8只眼,占黄斑部ORS的36.4%.MRDH 5只眼,占20.8%,其中合并ORS 3只眼,占MRDH的60.0%;单纯性MRDH 2只眼,占MRDH的40.0%,其中合并VMT 1只眼.VMT 13只眼,占54.2%;黄斑囊样水肿(CME)3只眼,占12.5%;黄斑板层裂孔4只眼,占16.7%.结论 MRS和MRDH是伴有PS的高度近视眼的常见并发症.与常规眼底检查和B型超声相比,OCT是发现MRS和MRDH的更为有效的检查手段.     

OCT检查在外伤性黄斑裂孔中的应用

目的:观察光学相干断层成像技术(optical coherence tomography,OCT)在外伤性黄斑裂孔中的应用.方法:选择2015-01/2017-01来我院就诊的外伤性黄斑裂孔患者23例25眼,其中9眼未行手术治疗,16眼行手术治疗.采用OCT检查仪分析手术前后其图像特征.结果:外伤性黄斑裂孔患者OCT表现为神经上皮层部分或全层消失.均未见玻璃体后脱离,黄斑裂孔均未见牵引作用.其中黄斑部分缺损者4眼,黄斑全层裂孔者21眼.OCT检查发现全层黄斑裂孔表现:单纯性黄斑裂孔4眼,黄斑区全层裂开伴周围神经上皮水肿10眼,黄斑区全层裂孔伴神经上皮层局限性脱离7眼.25眼外伤性黄斑裂孔患者中,9眼未行手术治疗,其中7眼自行愈合;16眼行手术治疗,术后复查OCT显示裂孔愈合,其中12眼黄斑结构大致正常,视力平均提高了3行,4眼视网膜神经上皮层变薄,视力较术前没有明显改善.结论:OCT检查在外伤性黄斑裂孔的诊断和治疗中非常必要.     

Vitreous surgery in highly myopic retinal detachment resulting from a macular hole

Purpose: This study aimed to assess the therapeutic effect of vitreous surgery in conjunction with photocoagulation for highly myopic retinal detachment resulting from a macular hole. Methods: Sixty‐two consecutive highly myopic patients (65 eyes) with retinal detachment from macular holes underwent vitreous surgery. Gas tamponade in conjunction with laser photocoagulation was performed in 46 eyes (44 cases, group 1); gas tamponade only was performed in 12 eyes (11 cases, group 2); and silicone oil tamponade only was performed in seven eyes (seven cases, group 3). Additional laser photocoagulation was given in group 1 if necessary. The anatomical and functional success rates were compared between the groups. Results: Primary retinal reattachment was achieved in 43 eyes (93.5%) in group 1, seven eyes (58.3%) in group 2 and four eyes (57.1%) in group 3. Final visual acuity was 6/60 or more in 24 eyes (52.2%) in group 1, in six eyes (50.0%) in group 2 and in three eyes (42.9%) in group 3. The initial retinal reattachment rate was significantly higher in group 1 than in group 2 (P = 0.0075) and group 3 (P = 0.0248). The macular hole was completely closed in 18 eyes in group 1 and one eye in group 2 after 2 months or longer. A thin fibrous membrane and scar could be easily noticed beneath the macula in 15 eyes. Conclusion: Vitreous surgery in conjunction with laser photo­coagulation can improve the surgical success rate for highly myopic retinal detachment resulting from a macular hole.     

Scleral buckling with macular plombe for eyes with myopic macular retinoschisis and retinal detachment without macular hole

PURPOSE: To determine the effectiveness of scleral buckling with a macular plombe in eyes with myopic macular retinoschisis and retinal detachment without a macular hole. DESIGN: A prospective, consecutive interventional case series. METHODS: Setting: Clinical practice at university hospitals. Patient Population: Six eyes of five consecutive patients with myopic macular retinoschisis and retinal detachment without a macular hole. Intervention Procedure: Scleral buckling with a macular plombe. Main Outcome Measures: The best-corrected visual acuity (BCVA), ophthalmoscopic appearance of fundus, and optical coherence tomographic images were recorded preoperatively, and at two weeks, at one, three, and six months, and then every three months thereafter. RESULTS: The mean retinal thickness was reduced significantly by the macular plombe (P < .05). The BCVA was improved by 2 lines or more in four eyes (66%), and remained within 2 lines of the preoperative BCVA in two eyes (34%). The complications were subretinal hemorrhage without choroidal neovascularization in one eye, and a progression of choroidal neovascularization with subretinal hemorrhage, which caused a transient visual impairment in one eye. CONCLUSIONS: We recommend that macular scleral buckling with a macular plombe be considered for eyes with myopic macular retinoschisis and retinal detachment without a macular hole.     

Measured visual acuity of fellow eyes as a prognostic factor in macular hole surgery

PURPOSE: To investigate the effect of the vision of the fellow eye on the visual acuity of eyes after successful macular hole surgery. DESIGN: Prospective consecutive series. METHODS: A consecutive series of eyes with successful macular hole closure were studied and assigned to one of two groups according to the visual acuity of the fellow eye; a group with visual acuity less than 20/200 and a group with visual acuity of 20/200 or better. Preoperative and postoperative visual acuity in the two groups was measured based on the logarithm of the minimal angle of resolution (LogMAR), and postoperative visual acuity was also determined by using the multiple-letter visual acuity chart, which permitted measurement of visual acuity at an extrafoveal point. RESULTS: Group 1 (<20/200) consisted of 19 eyes and group 2 (>20/200) consisted of 51 eyes. LogMAR visual acuity at 6 months postoperatively was significantly better in group 1 than in group 2 (0.21 vs 0.41, P <.01). The logMAR change 6 months after surgery was significantly greater in group 1 than in group 2 (0.49 vs 0.23, P <.01). There was no significant difference between two groups in logMAR visual acuity at 6 months postoperatively determined with the multiple-letter visual acuity chart (0.20 vs 0.29, P >.05). CONCLUSIONS: Visual recovery after successful macular hole surgery is inversely correlated with vision in the fellow eye. Learning to use eccentric fixation may contribute to visual improvement after macular hole surgery.     

Outcomes of macular hole surgery in severely myopic eyes: a case-control study

PURPOSE: To evaluate the outcomes of macular hole surgery in highly myopic eyes and to compare these outcomes with a control group of eyes that were not severely myopic. METHODS: The study design was a matched, case-control, retrospective chart review. The participants included 26 eyes of 24 patients who had vitreous surgery for macular holes. The eyes were divided into two groups: 13 consecutive eyes with severe myopia (defined as -6.00 diopters of refractive error or greater) and 13 control eyes without severe myopia that were operated on immediately before or after each study eye, with the most recently operated eye chosen. The main outcome parameters were preoperative and final follow-up visual acuity, macular hole closure rates, reoperation rates, duration of preoperative symptoms, and follow-up time. RESULTS: Using the Snellen equivalent of logarithm of minimal angle of resolution (logMAR) units, visual acuity improved after macular hole surgery in severely myopic eyes from 20/152 to 20/89 (P =.041) and in control eyes from 20/152 to 20/47 (P <.001). At final follow-up, visual acuities were lower in severely myopic eyes compared with control eyes (P =.048). Macular hole closure rates, reoperation rates, duration of pre-operative symptoms, and follow-up intervals were not significantly different statistically between groups. CONCLUSIONS: Macular hole surgery results in anatomical and visual improvements in severely myopic eyes but generally yields poorer visual acuity outcomes compared with eyes that are not severely myopic.     

高度近视黄斑裂孔性视网膜脱离的玻璃体视网膜手术治疗进展

黄斑裂孔性视网膜脱离(macular hole retinal detachment,MHRD)是高度近视眼常见的并发症,常造成不可逆的视力损害。玻璃体视网膜手术(vitreoretinal surgery,VRS)是MHRD的主要治疗方式,但是由于此类患者伴有视网膜脉络膜萎缩、后巩膜葡萄肿、眼轴增长等异常解剖结构,故手术难度大、患者视力预后差,易复发。近年来,随着眼内填充物选择的多样化、内界膜处理技巧的发展以及眼科机器人等新技术的兴起,VRS治疗高度近视MHRD取得了令人满意的视网膜解剖复位率。如何在提高视网膜复位率及黄斑裂孔闭合率的基础上实现患者视功能的改善是目前VRS治疗高度近视MHRD的重点与难点。本文现就高度近视MHRD的VRS治疗进展进行综述。     

Chromatic contrast thresholds as a prognostic test for visual improvement after macular hole surgery: color vision and macular hole surgery outcome.

PURPOSE: To evaluate the relationship between preoperative chromatic contrast thresholds, postoperative visual acuities (VA), and visual improvement after macular hole surgery. METHODS: A consecutive series of patients with Stage II to IV macular holes was studied before macular hole surgery. Preoperative chromatic contrast thresholds, VA, and reading acuity were analyzed in relation to the postoperative visual function. The chromatic contrast thresholds were measured using a computerized cathode ray tube-based system along red-green and tritan confusion axes. RESULTS: Preoperative and postoperative chromatic contrast thresholds were elevated significantly in affected eyes (P < 0.001). Preoperative VA showed a strong correlation with postoperative VA (r = 0.66, P < 0.001) but a weak correlation with visual improvement (r = -0.33, P = 0.03). Red-green contrast threshold correlated strongly with both the distance visual improvement (r = -0.77, P < 0.001) and reading visual improvement (r = -0.61, P < 0.001). Tritan contrast threshold, however, showed a slightly weaker correlation (distance: r = -0.63, P < 0.001; reading: r = -0.47, P < 0.005). CONCLUSIONS: These results suggest that chromatic contrast thresholds, especially the red-green contrast threshold, represent a better prognostic guide for visual improvement after macular hole surgery than VA measurement.