Characteristics of macular microvasculature before and after idiopathic macular hole surgery

AIM: To evaluate the macular microvasculature before and after surgery for idiopathic macular hole (MH) and the association of preoperative vascular parameters with postoperative recovery of visual acuity and configuration. METHODS: Twenty eyes from 20 patients with idiopathic MH were enrolled. Optical coherence tomography angiography (OCTA) images were obtained before, 2wk, 1, and 3mo after vitrectomy with internal limiting membrane peeling. Preoperative foveal avascular zone (FAZ) area and perimeter and regional vessel density (VD) in both layers were compared according to the 3-month best-corrected visual acuity (BCVA). RESULTS: The BCVA improved from 0.98±0.59 (logMAR, Snellen 20/200) preoperatively to 0.30±0.25 (Snellen 20/40) at 3mo postoperatively. The preoperative deep VD was smaller and the FAZ perimeter was larger in the 3-month BCVA<20/32 group (all P<0.05). A significant reduction was observed in FAZ parameters and all VDs 2wk postoperatively. Except for deep perifoveal VD, all VDs recovered only to their preoperative values. The postoperative FAZ parameters were lower during follow-up. Decreases in preoperative deep VDs were correlated with worse postoperative BCVA (Pearson's r=-0.667 and -0.619, respectively). A larger FAZ perimeter (Spearman's r=-0.524) and a lower deep perifoveal VD preoperatively (Pearson's r=0.486) were associated with lower healing stage. CONCLUSION: The status of the deep vasculature may be an indicator of visual acuity in patients with a closed MH. Except for the deep perifoveal region, VD recovers only to preoperative levels.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

Face-Down Posture versus Non-Face-Down Posture following Large Idiopathic Macular Hole Surgery: A Systemic Review and Meta-Analysis

Evidence regarding the effect of a face-down posture (FDP) for large idiopathic macular hole (IMH) is inconsistent. We conducted a systematic review and meta-analysis to determine whether a postoperative FDP is required for the treatment of large IMH. Eligible randomized controlled trials published before September 2021 were retrieved from the Medline, Embase, and Cochrane Library databases. The efficacy outcome was the IMH closure rate and the visual acuity improvement rate. A meta-analysis was performed using a random effects model. The “Grading of Recommendations Assessment, Development, and Evaluation” approach was implemented, and the numbers needed-to-treat (NNTs) were calculated. Seven studies comprising 640 patients were included. We performed a predefined subgroup analysis of IMH size using a cut-off point of 400 µm. Compared with non-FDP, a significant effect of FDP was found in the IMH > 400 µm group (OR = 3.34; 95% CI = 1.57–7.14; trial sequential analysis-adjusted CI = 1.20–11.58; NNTs = 7.9). After stratifying by the posturing periods, the beneficial effect of FDP lasting at least five days, but not three days was observed for large IMH. Maintaining a FDP for at least five days postoperatively is an effective strategy (certainty of evidence: “moderate”) for treating large IMH.

Comparison of Retinal Vascular Arcade Trajectory Between Eyes with an Idiopathic Macular Hole and the Healthy Fellow Eye

Purpose: We aimed to present a method to evaluate the retinal arcade vascular trajectory by measuring the distance between the retinal veins in eyes with idiopathic macular hole (IMH) and compare this measurement with healthy fellow eyes.Methods: In this Cross-sectional study18 patients with unilateral IMH were enrolled. We used standard fundus photographs, which were obtained from each eye with a digital fundus camera using a 55-degree lens. The calculation of the retinal arcade vascular trajectories was done by drawing and measuring 5 vertical lines within the macular area. Results: The mean age of the patients was 65±9 years. The between-groups differences of each vertical line were not statistically significant, except for the differences between the most temporal line, which was greater in the diseased group (9388 vs. 8322 mm; P=0.034). The ratio between the 5th (most temporal) and the third (fovea-center) vertical lines was greater than 1 (V-shape) in 72% of eyes with a macular hole, whereas it was less than one (U-shape) in 78% of control eyes (P=0.003). Conclusions: We demonstrated that in eyes with an IMH the vascular arcade has more tendency to diverge on its path temporal to the fovea.

Internal Limiting Membrane Peeling and Flap Inverting under Air in Large Idiopathic Macular Hole Surgery

Purpose. To evaluate the efficacy of internal limiting membrane (ILM) peeling combined with modified flap inverting under air in the treatment of large idiopathic macular hole (MH). Methods. Eyes with a large idiopathic MH (minimum diameter >550 μm) were included in this study. The surgical procedure included standard 23-gauge pars plana vitrectomy (PPV), ILM peeling, complete fluid-gas exchange, and ILM flap inversion under air. The patients underwent follow-up exam including optical coherence tomography (OCT) and best-corrected visual acuity (BCVA) measurement. Results. Sixteen eyes from 16 patients were included. Mean MH diameter was 681.43 ± 112.12 μm. After a mean follow-up time of 6.25 ± 2.65 months, in all cases, the MH was closed, and the ILM flap could be seen at the inner surface of the fovea. U-shaped and V-shaped MH closure was achieved in 11 and 5 cases, respectively. The BCVA improved significantly from 1.49 ± 0.35 logMAR to 0.89 ± 0.35 logMAR ( p < 0.05 ), and visual acuity of 20/100 or better was achieved in 8 eyes. Conclusion. ILM flap inverting under air was helpful in improving the functional and anatomic outcomes of vitrectomy for large idiopathic MH.

Displacement of the retina after idiopathic macular hole surgery with different internal limiting membrane peeling patterns

AIM: To explore retinal displacement after surgical treatment for idiopathic macular hole (IMH) with different internal limiting membrane (ILM) peeling patterns. METHODS: Totally 22 eyes from 20 patients with IMH were randomly allocated into two groups, N-T group (11 eyes) and T-N group (11 eyes). For patients in N-T group, ILM was peeled off from nasal to temporal retina. For patients in T-N group, ILM was peeled off from temporal to nasal retina. Preoperative, postoperative 1, 3, and 6mo, autofluorescence fundus images were collected for manual measurement of distances of fixed nasal (N), temporal (T), superior (S), and inferior (I) retinal points (bifurcation or crossing of retinal vessels) around the macula to the optic disc (OD). These were respectively defined as N-OD, T-OD, S-OD, and I-OD. The retinal displacement, macular hole closure rate, and best corrected visual acuity (BCVA) were compared between the two groups after surgery. RESULTS: At postoperative 1, 3, and 6mo, the macula slipped toward the OD, manifested by the decreased T-OD, N-OD, S-OD, and I-OD (P<0.05). No significant difference was found in the T-OD, N-OD, S-OD, and I-OD between N-T group and T-N group. IMH closure rate was 100% both in N-T group and T-N group. There was no significant difference in BCVA between two groups (P<0.05). CONCLUSION: The macula slips toward the OD after successful macular hole surgery. The two different ILM peeling pattern show similar visual outcome and retinal displacement, which means ILM peeling directions are not the influencing factor of postoperative retinal displacement.

Surgical treatment experience of a macular hole in the conditions of the Regional State ophthalmologic clinical hospital of Public Health Ministry of Udmurt Republic

Purpose. To evaluate the effectiveness of surgical treatment of idiopathic macular hole in the conditions of the Regional State ophthalmologic clinical hospital of Public Health Ministry of Udmurt Republic. Methods. The study included 32 patients (32 eyes), 30 women, 2 men, aged 54 to 73 years with idiopathic macular hole. The patients were divided into three groups: the first – 8 people with a small diameter of macular hole (206.1±31.1 microns), the second – 8 people with a medium diameter of macular hole (333.5±53.6 microns), the third – 16 people with a large diameter of macular hole (564.7±96.6 microns). All of them underwent a 25-gauge vitrectomy with removal of the internal limiting membrane, drainage of the macular opening, instillation of 1-2 drops of platelet-rich autoplasma and subsequent air tamponade of the vitreal cavity. At the same time, the patients occupied a forced position of the body face down for the next 2 hours after the operation. Examinations were carried out before surgical treatment, at discharge from the hospital, 1 month and 1 year after the operation. Results. In the postoperative period, the closure of the macular hole was noted in 100 % of cases. In the first group, the visual acuity improved from 0.09±0.04 to 0.2±0.1 after 1 month and became 0.24±0.21 after 1 year after surgery (p < 0.05, U-test). In the second group, the visual acuity improved from 0.12±0.08 to 0.25±0.14 after 1 month and became 0.35±0.22 after 1 year after surgery (p<0.05, U-test). In the third group, the visual acuity improved from 0.08±0.05 to 0.13±0.05 after 1 month and became 0.16±0.15 after 1 year after surgery (p < 0.05, U-test). Conclusion. The results obtained indicate 100% effectiveness of the applied method of surgical treatment of macular hole, but to achieve even better results, it is necessary to search for new methods of treatment without removing the ILM. Key words: idiopathic macular hole, platelet-rich autoplasma, vitrectomy.