Phaco-vitrectomy for full-thickness macular holes

PURPOSE: To investigate the role of combined phaco-vitrectomy surgery in the management of full-thickness macular holes. METHODS: Thirteen eyes with full-thickness macular holes had combined phacoemulsification cataract removal and vitrectomy surgery with instillation of 20% C2F6 gas. RESULTS: The mean duration of macular holes prior to surgery was 6.5 months. Eleven holes closed, 2 remained opened. All patients except one had an improvement in visual acuity. Laser treatment was performed to treat retinal breaks noted intraoperatively in 4 patients. CONCLUSION: Combined cataract and vitrectomy surgery for full-thickness macular holes enables good visibility during surgery. A large gas bubble can be obtained with excellent tamponade of the hole. Combined surgery prevents the patients having to return for cataract surgery.     

Autologous platelet concentrate for the treatment of full-thickness macular holes

Background: To improve the anatomic success rate in the surgery of full-thickness macular holes, we tested, in a prospective pilot study, the effects of autologous platelet concentrate deposited on the macula at the end of surgery. Methods: Two consecutive groups of patients were compared. Twenty eyes (group 1, mean symptom duration 11 months) were operated on with injection of an autologous platelet concentrate on the macula after fluid-gas exchange. Another 20 eyes (group 2, mean symptom duration 11 months) were subsequently operated on without autologous platelet concentrate. For all stage 3 holes, posterior hyaloid was detached en bloc at the level of the optic disc. The patient was left supine for 24 h after surgery, and then remained face down for 10 days. Results: In group 1, 19 cases were an anatomic success, i.e. there was flattening of the retina surrounding the hole and reattachment of the edge of the hole to the retinal pigment epithelium; in 9 cases the hole was even undetectable. Final visual acuity was 0.5 or more in 9 eyes, and 0.4 or more in 14. Visual acuity improved by two lines or more in 17 of the 19 successfully operated eyes. In group 2, only 13 cases were an anatomic success. The functional results for the successfully operated eyes were identical to those of group 1. Conclusion: These results strongly suggested that autologous platelet concentrate could significantly improve the success rate in macular hole surgery and led us to begin a comparative, prospective, randomized trial.Paper presented at the 17th meeting of the Club Jules Gonin, Versailles, September 1994     

全层黄斑裂孔手术的视力预后

目的 报告特发性全层黄斑裂孔（IFMH）施行平坦部玻璃体切除（PPV）手术后的解剖学结果与视力预后。方法 11例手术后至少随访12个月，手术方法为一标准的PPV手术，术中切除后玻璃体皮质，气-液交换，眼内注入15％C3F8气体，术后低头位至少5天。结果 一次手术后11例中有9例（81.9％）获得解剖学的裂孔闭合，最佳矫正视力由术前平均0.13（0．02～0．3）增至术后平均0．24（0．01～0．6）（P〈0.01）．73％病例获得视力增进，有2例在术后1．5～2年又做了白内障摘除和眼内人工晶状体植入术，未见术后视网膜前膜形成及术后黄斑裂孔再裂开。结论 IFMH手术不用辅助剂治疗，大多数病例术后视功能可获良好的远期结果。     

Comparison of full-thickness traumatic macular holes and idiopathic macular holes by optical coherence tomography

Background

The optical coherence tomography (OCT) and clinical characteristics of traumatic macular holes (TMHs) can be compared to those of idiopathic macular holes (IMHs) to gain insights into the pathogenesis of both.

Methods

The demographic data and visual acuity of 73 consecutive patients with unilateral, full-thickness TMHs and 182 consecutive patients with idiopathic IMHs were recorded. All patients with TMH and 60 patients with IMH underwent OCT scanning and quantitative measurements. The apical and basal diameters and marginal retinal thicknesses were recorded for each hole. The hole areas and eccentricities were calculated. These parameters were compared between the two types of macular holes, and correlated with visual acuity.

Results

Compared to IMHs, TMHs were generally thinner, larger at the base, less circular, and were associated with worse vision. Vitreous detachment was more commonly associated with IMHs than TMHs. Both IMHs and TMHs were wider horizontally than vertically. Visual acuity was negatively correlated with the size of IMHs, but not with any tomographic parameters in TMHs.

Conclusion

The tomographic and clinical findings associated with TMHs and IMHs provide useful insights into the pathogenesis of these two types of macular holes.     

Treatment of full-thickness macular holes with autologous serum

A total of 28 patients (29 eyes) with stage 2–4 idiopathic full-thickness macular holes were treated with the use of autologous serum. Autologous serum (20–30 μL) was placed over each macular hole followed by injection of 16% perfluoropropane gas. Postoperatively, 28 eyes (97%) had flattening of the macular hole, and the hole could not be detected in 27 eyes (93%). Twenty-two eyes (76%) showed visual acuity improvement by at least two lines or more. Preoperative factors such as good visual acuity, earlier stage, and younger age were correlated with postoperative good visual acuity. These results suggest that autologous serum is beneficial in the treatment of full-thickness macular holes.     

Surgical repair of full-thickness idiopathic macular holes associated with significant macular drusen

OBJECTIVE: To evaluate the visual and anatomic results of surgically repaired macular holes in eyes with intermediate or large-sized macular drusen. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty-four eyes of 32 patients undergoing macular hole surgery with preoperative intermediate or large-sized macular drusen as defined by the Age-Related Eye Disease Study (AREDS). INTERVENTION: Pars plana vitrectomy for standard macular hole repair performed by multiple surgeons. MAIN OUTCOME MEASURES: Visual acuity, anatomic hole closure. RESULTS: Initial hole closure failed in 8 eyes (24%) overall, 5 of 28 eyes (18%) with AREDS category 2 drusen and 3 of 6 eyes (50%) with category 3 drusen (P = 0.1263). Final macular hole closure was seen in 93% of category 2 and 67% of category 3 eyes (P = 0.1347). Mean final visual acuity was 20/60 overall, 20/60 for category 2, and 20/50 for category 3 eyes. CONCLUSIONS: A trend of reduced initial macular hole closure was seen in eyes with significant macular drusen. Reoperation improved closure rates. If closure was accomplished, visual outcomes were excellent.     

Morphological evaluation of full-thickness idiopathic macular holes by optical coherence tomography.

PURPOSE: To assess the efficacy of optical coherence tomography (OCT) for the morphological evaluation of idiopathic full-thickness macular holes and for detecting any morphological changes with time. METHODS: Serial sagittal tomographs through the macula were taken by OCT in a consecutive series of 34 eyes of 34 patients with diagnosis of idiopathic full-thickness macular hole. The patients were divided into two groups on the basis of "recent" (group 1, 25 patients) or "not-recent" (group 2, 9 patients) onset of symptoms related to the macular hole. Fourteen of the 25 patients in group 1 and all nine in group 2 underwent vitrectomy. The 11 in group 1 who refused surgery were observed by OCT examination with follow-up from 6 to 13 months. RESULTS: In most eyes OCT scans revealed two different anatomical features of macular holes depending on the time of onset of symptoms. Eleven of the 14 "recent-onset" holes that underwent surgery showed "sharp", undermining edges at preoperative OCT; the other three had "rounded" edges. Seven of the nine eyes operated for long-standing full-thickness macular holes had preoperative "rounded" edges, while the edges in the remaining two eyes were "sharp". OCT of eight of the 11 non-operated eyes in group 1 showed a morphological evolution of the macular hole edges from a "sharp" to a "rounded" contour and an increase in the diameter of the hole. CONCLUSIONS: OCT can help in the morphological evaluation of idiopathic full-thickness macular holes and in the detection of morphological changes with time.     

Internal limiting membrane removal in the management of full-thickness macular holes

PURPOSE: To determine the effectiveness of removal of the internal limiting membrane in the treatment of full-thickness macular holes. METHODS: Data were reviewed from a prospective study on 47 consecutive eyes with full-thickness macular holes undergoing vitrectomy, internal limiting membrane maculorhexis, and fluid-gas exchange. No eye underwent repeat macular hole surgery. A meta-analysis was performed to compare the outcomes of different surgical techniques in the treatment of full-thickness macular holes. RESULTS: The outcome measures were disappearance of the submacular fluid and the change in best-corrected visual acuity. The surgery was anatomically successful in 44 of the 46 eyes (96%) and 39 of the eyes (85%) showed an improvement of at least two Snellen lines. Best-corrected final vision was 20/40 in 18 (39%) eyes. No permanent complications specifically caused by the removal of the macular internal limiting membrane were detected; the minor hemorrhages and retinal edema seen in most eyes resolved spontaneously. Retinal detachment developed and was successfully treated in three eyes (7%). A meta-analysis on 1,654 eyes from published reports showed that internal limiting membrane maculorhexis appears to significantly (P <.0001) increase the anatomical and functional success rates in macular hole surgery. CONCLUSIONS: Internal limiting membrane removal is an important development in the evolving field of macular hole surgery. A randomized, prospective, multicenter clinical trial should be performed to determine which surgical technique is the most beneficial in patients with full-thickness macular holes.     

Comparative study of 1 DD and 2 DD radius conventional internal limiting membrane peeling in large idiopathic full-thickness macular holes: a randomized controlled trial

ObjectiveTo compare the surgical outcomes of 1-disc diameter (DD) and 2-DD conventional internal limiting membrane peeling (C-ILMP) in large full-thickness macular holes (FTMHs).Materials and methodsA prospective randomized controlled trial. One hundred patients with large idiopathic full-thickness macular hole (FTMH) were randomized into C-ILMP and extended C-ILMP (EC-ILMP) groups. The primary outcome was closure rate at 6 months after surgery. Secondary outcomes were visual acuity (VA), closure type, consequence of ILMP and complications.ResultsThe mean symptom duration was 12.19 ± 9.64 months. Mean preoperative VA was 1.25 ± 0.37 logMAR. The average minimum linear diameter was 633.05 ± 129.82 µm and basal linear dimension was 1158.49 ± 249.07 µm. The two groups did not differ in term of demographic data. Closure rate was significantly higher in the EC-ILMP group (76.47% vs. 51.02%, 95% CI 7.24–43.66; p = 0.008). There were also no significant differences in closure type, central foveal thickness, dissociated optic nerve fibre layer detection, or change in fovea-to-disc distance. There were also no significant differences in postoperative VA (p = 0.069) or visual improvement (mean 0.39 ± 0.43 logMAR; p = 0.286). According to subgroup analysis, EC-ILMP resulted in a higher closure rate in patients with chronic FTMH for >6 months, (p = 0.008). Furthermore, EC-ILMP resulted in better anatomical closure and visual result in patients with FTMH with macular hole closure index ≤0.5, p = 0.003 and p = 0.010, respectively.ConclusionExtended C-ILMP yielded a significantly higher closure rate in large FTMHs, but visual outcome did not differ significantly. According to subgroup analysis, extended C-ILMP was more effective in chronic large FTMH with MHCI ≤ 0.5.Subject terms: Retinal diseases, Outcomes research     

Laser treatment of macular holes

Macular holes have not been treated with the laser because of the rarity of subsequent total retinal detachment (RD). The authors attempted to clear the subretinal fluid of the halo by laser coagulation of the rim of the hole. Eighteen eyes with visual acuity of 20/200 or less were treated with a laser and followed for a mean of 34.8 months. Ten eyes (55.6%) improved three to eight lines, five eyes (27.8%) remained the same, and the vision of three (16.6%) deteriorated three to five lines. The best visual results noted in three eyes (20/400-20/70, 20/200-20/80, and 20/200-20/60) correlated with the least late loss of pigment epithelium and pigment migration.     

Intravitreal triamcinolone acetonide for diabetic macular edema: a prospective, randomized study.

PURPOSE: The aim of this study was to examine the visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide (TA) as treatment of diffuse diabetic macular edema (DDME). METHODS: This prospective, placebo-controlled, randomized, clinical interventional study included 40 eyes (38 patients) with DDME, with 28 (70%) eyes randomized to treatment and 12 (30%) eyes randomized to receive a placebo injection. Thirty-six (36) (90%) eyes completed the 3-month study visit, and 32 (80%) eyes completed the 6-month study visit. The treatment group received an intravitreal injection of approximately 20 mg of TA. RESULTS: Visual acuity increased significantly (P < 0.001) in the study group by 3.4 +/- 2.5 Snellen lines. In the control group, visual acuity did not change significantly (P = 0.07) during follow-up. Difference in change of best visual acuity was significant (P < 0.001) between both groups. At 3 months after baseline, 11 (11/26; 42%) eyes and 10 (10/26; 39%) eyes, respectively, improved by at least 2 and 3 lines, respectively, in the study group, versus 2 (2/10; 20%) eyes and 1 (1/10; 10%) eye in the control group. At 6 months after baseline, 11 (11/23; 48%) eyes and 9 (9/23; 39%) eyes, respectively, improved by at least 2 and 3 lines, respectively, in the study group, versus 0 (0%) eyes and 0 (0%) eyes in the control group. The difference was significant for the 2-line improvement (P = 0.01) and 3-line improvement (P = 0.03). CONCLUSIONS: Using a dosage of approximately 20 mg of intravitreal TA, visual acuity temporarily increases for 6 months after injection.     

Ocriplasmin versus vitrectomy for the treatment of macular holes

Objective

To compare the anatomical and visual outcomes of patients with bilateral macular holes (MH) who have been treated with pars plana vitrectomy in one eye and intravitreal ocriplasmin in the fellow eye.

Transforming growth factor-beta in the chicken fundal layers: An immunohistochemical study

In the chicken model of myopia, it has first been shown that imposing defocus to the retina results in active remodelling of the sclera which, in turn, results in axial length changes of the eye. Transforming growth factor-beta (TGF-β) is one of the scleral growth modulators but its cellular localization in the fundal layers, colocalization and function are not well known. The aim of the current study was to investigate the cellular distribution of the three isoforms TGF-β1, 2 and 3 by immunohistochemical labelling. Furthermore, the effects of visual experience that induces refractive errors on TGF-β2 labelling were examined. Transversal cryostat sections of the fundal layers were analyzed by indirect immunofluorescent labelling and cell counts. Visual experience was changed by having the chicks wear either diffusers, or positive or negative lenses of 7D power in front of the right eyes for various periods of time. Left eyes served as uncovered controls. All TGF-β isoforms were localized in both scleral layers. In choroid, diffuse labelling of all isoforms was found. In retina, TGF-β1 and 3 were detected in bipolar, amacrine and ganglion cells and TGF-β2 in amacrine and ganglion cells. To further characterize these cells, double-labelling with known amacrine and bipolar cell markers was performed (calbindin, cellular retinoic acid binding protein (CRABP), Islet1, Lim3 and protein kinase C (PKC)). TGF-β1, 2 and 3 could be colocalized with calbindin and CRABP in single amacrine cells. TGF-β1-positive bipolar cells were immunoreactive to Lim3. TGF-β1 and 3 were never colocalized with PKC in bipolar cells. Also, colocalization with peptides known to be involved in myopia development in chicks, such as glucagon, or vasointestinal polypeptide and the key enzyme for dopamine synthesis, tyrosine hydroxylase, was not observed. Lenses or diffusers, worn by the chicks for various periods of time, had no effect on TGF-β2 immunoreactivity in choroid or sclera, or on the number of TGF-β2 (active and latent form) expressing amacrine cells. This result did not change when the two identified populations of TGF-β2 expressing amacrine cells (one calbindin-positive and the other CRABP-positive) were separately considered. Also no modulation was seen in choroid, although an earlier study had found changes in TGF-β2 mRNA after lens treatment. The lack of any visually-induced changes in retina or choroid suggests that TGF-β may not represent a key molecule in the retino-choroidal signalling cascade although it has previously been shown to have a primary role in scleral remodelling.