Effect of inverted internal limiting membrane flap technique on small-medium size macular holes

Inverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for small-medium size MH. We recruited patients who underwent vitrectomy for small-medium size (< 400 μm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score, 21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. We compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for small-medium size MHs and may delay recovery of retinal integrity.

Ellipsoid Zone and External Limiting Membrane-Related Parameters on Spectral Domain-Optical Coherence Tomography and Their Relationships With Visual Prognosis After Successful Macular Hole Surgery

Purpose: To compare structural diameters of the ellipsoid zone (EZ) and external limiting membrane (ELM) bands on spectral domain-optical coherence tomography (SD-OCT) images between vision-improved (group A) and vision-unimproved (group B) patients, and investigate the connection between these parameters and visual prognosis.Materials and Methods: Forty-five eyes of 43 patients with idiopathic full-thickness macular hole closed after vitrectomy were retrospectively reviewed. Best-corrected visual acuity (BCVA) and SD-OCT were conducted preoperatively and at 1 week, 1 month and 6 months postoperatively. Structural and functional parameters were then measured using ImageJ software.Results: Among structural and functional parameters, the relative reflectivity of EZ and the ratio of continuous ELM and EZ in group A were significantly higher than in group B from the 1-month postoperative visit. At the 6-month follow-up, the diameter of EZ disruption in group A was significantly smaller than in group B, and the relative reflectivity of ELM/EZ was significantly higher than group B. At 6-months, BCVA was statistically significantly correlated with baseline BCVA, basal diameter (BD), macular hole index (MHI), and diameter of ELM/EZ disruption. Change in BCVA from baseline was found to be significantly correlated with axial length and diameter hole index (DHI).Conclusions: Postoperative BCVA outcome was significantly correlated with integrity, thickness and reflectivity of the EZ band. Patients with smaller diameter of EZ disruption and higher reflectivity of EZ band tended to have better visual outcomes. Given that the EZ band reflects the recovery of mitochondria in photoreceptors, it is a promising parameter for their functional evaluation.

Vitrectomy for diabetic macular edema and the relevance of external limiting membrane

Purpose To evaluate the relevance of external limiting membrane (ELM) on the visual and morphological results in eyes with diabetic macular edema (DME) that underwent pars plana vitrectomy (PPV) with epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling. Methods Medical records of patients with DME who underwent PPV at our unit between January 2017 and December 2019 were reviewed. We assessed preoperative and postoperative best-corrected visual acuity (BCVA), central macular thickness (CMT) using spectral domain OCT (optical coherence tomography). Exclusion criteria were previous PPV; incomplete data; concomitant diseases including retinal vein occlusion, age-related macular degeneration, uveitis; and a follow-up of less than 12 months. The surgeries were performed using 23- or 27-gauge vitrectomy. The ELM was graded depending on its configuration (grade 0 = intact, grade 1 to 3: disruption of varying extent). Results Ninety-nine eyes were enrolled. The postoperative follow up averaged 23.7 months. The preoperative and final BCVA averaged 0.71 ± 0.28 and 0.52 ± 0.3 logMAR, respectively (p = 0.002). The CMT averaged 515.2 ± 209.1 μm preoperatively and 327 ± 66.1 μm postoperatively (p = 0.001). Eyes with intact ELM (n = 8) had a significantly better BCVA compared to those with ELM disruption (0.28 ± 0.14 vs. 0.7 ± 0.25 logMAR, p = 0.01). The final CMT was similar among the groups (intact ELM: 317 ± 54.6 μm; ELM disruption: 334 ± 75.2, p = 0.31). Conclusions PPV with ERM and ILM peeling is an effective treatment of DME. Eyes with intact ELM preoperatively had a significantly better final visual outcome. To maximize the benefit for patients with DME we recommend early PPV as long as ELM is intact.

Delayed Detection of Predominantly Pericentral Hydroxychloroquine Toxicity in a Dominican Patient

Purpose: To describe delayed detection of pericentral hydroxychloroquine (HCQ) toxicity. Methods: 67-year-old Dominican woman with rheumatoid arthritis on HCQ presented for examination. Results: Spectral-domain optical coherence tomography (SD-OCT) demonstrated bilateral cystoid macular edema with parafoveal attenuation of the external limiting membrane (ELM) and the ellipsoid zone (EZ). ELM and EZ disruption was present in inferior macula. While subtle superior defects were present on 10-2 visual fields, superior pericentral defects were noted on 24-2 testing. Hyperautofluorescence along inferior arcades corresponded to SD-OCT and visual fields. Examination 2 years prior demonstrated nonspecific points of depression on 10-2 visual fields and normal central SD-OCT findings. EZ and ELM disruption was present in the perifoveal inferior macula. Conclusions: Early pericentral distribution of HCQ toxicity is not limited to Asian patients. Detecting pericentral HCQ toxicity involves reviewing entire macular cube on OCT. When OCT changes are suspected on parafoveal OCT B-scans, visual field testing with 24-2 may be more sensitive than 10-2.

External Limiting Membrane Disruption Predicts Long-Term Outcome in Strict Treat-And-Extend Regimen in Neovascular Age-Related Macular Degeneration

The use of anti-vascular-endothelial growth factor agents for neovascular age-related macular degeneration (nAMD) in different treatment schemes is widely common in clinical practice. However, there is currently limited data on the long-term outcomes of a strict treat-and-extend regimen (TER) and imaging biomarkers to predict both functional outcome and the potential for a TER exit due to success. In this retrospective study we followed treatment-naïve subjects with nAMD starting treatment with either ranibizumab or aflibercept in a TER without loading dose but with predefined exit criteria for up to 8 years. We evaluated both the functional outcome and several spectral-domain optical coherence tomography parameters in a follow-up mode using a standardized protocol. Within the 211 eyes followed for a mean of 60.3 ± 20.9 months, follow-up adherence was high with major part of discontinuations of TER being due to success. Mean best-corrected visual acuity (BCVA) increased from initially 63.9 ± 15.5 ETDRS letters to 70.0 ± 14.7 after 1 year (+6.1 letters, p &lt; 0.001) and to 68.5 ± 18.1 (+4.6 letters, p = 0.028) at 5 years. A worse BCVA (p = 0.001) and a better external limiting membrane (ELM) disruption score at baseline predicted (p = 0.019) BCVA gain at 5 years. The probability of reaching the exit criteria was significantly associated with a better ELM disruption score (p = 0.044) and the absence of a central pigment epithelial detachment (PED) (p = 0.05) at baseline. Significant visual gains were sustained in a long-term TER in a real-world setting. Integrity of ELM at baseline predicted BCVA gain at 5 years and the potential for TER exit due to success.

Effect of Inverted Internal Limiting Membrane Flap Technique on Normal Size Macular Holes

Inverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for normal size MH. We recruited patients who underwent vitrectomy for normal size (< 400 µm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score,21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. we compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for normal size MHs and may delay recovery of retinal integrity.

Swept-source optical coherence tomography changes and visual acuity among Palestinian retinitis Pigmentosa patients: a cross-sectional study

Background Retinitis pigmentosa (RP) is a heterogeneous group of inherited ocular diseases that result in progressive retinal degeneration. This study aims to describe different Swept-source Optical Coherence Tomographic (SS-OCT) changes in Palestinian RP patients and to explore possible correlations with Visual Acuity (VA). Methods A cross-sectional observational study was conducted on Retinitis Pigmentosa patients diagnosed with RP in a tertiary eye hospital. Full history and ocular examination were made. SS-OCT imaging was done for all eyes assessing the presence of cystoid macular edema, epiretinal membrane, macular holes, and external limiting membrane, ellipsoid zone status. Also, central macular thickness and choroidal vascular thickness were measured. Results The study was run on 161 eyes of 81 patients; 53 males and 28 females. The average age at examination was 26.1 (6–78) years. Twenty-six eyes (16.1%) were of syndromic RP patients, mostly Usher syndrome; 20 eyes (12.4%). The mean Logaritmic minimal angle of resolution (LogMAR) of Best Corrected Visual Acuity (BCVA)of the study sample was 0.66 ± 0.7. The most prevalent change was cystoid macular edema [28 eyes, (17.4%)], followed by epiretinal membrane [17eye, (10.6%)]. A macular hole was noted only in one eye (0.6%). Ellipsoid zone and external limiting membrane were absent in 55 eyes (35.0%) and 60 eyes 37.5%. Vitreous hyperreflective foci were found in 35 eyes (43.8%). LogMAR of BCVA was associated significantly with cystoid macular edema (p = 0.001), ellipsoid zone(p = 0.001), and external limiting membrane (p = 0.001). Conclusions Detailed SS-OCT assessment in Palestinian patients diagnosed with RP identified different morphologies from other populations. Cystoid macular edema and vitreous hyperreflective foci may reflect signs of early or intermediate stages of the disease. Disease progression can be monitored by measuring the length/width (area) of ellipsoid zone +/− external limiting membrane and choroidal vascular thickness, which should be evaluated serially using high-resolution OCT.

Automated Sectoral Quantitative Analysis of Parafoveal Microvascular Status and Association with Structure in Diabetic Macular Edema

Purpose: To evaluate the integrity of the capillary plexuses, their relationship with each other, and their association with structural changes in a sectoral manner in diabetic macular edema (DME).Methods: The vessel density (VD) was measured in inferior, superior, nasal and temporal (İ, S, N, T) parafovea in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) were evaluated in B-scan images.Results: In the SCP, only superior and nasal VD was significantly lower (P: 0.0001 and P: 0.020, respectively) while in the DCP, only temporal VD was significantly lower in the DME eyes (P: 0.034). There was no correlation between the VD of SCP and DCP in the corresponding quadrants (all P > 0.05). The FAZ area was significantly greater (both superficial and deep) in DME eyes than in control eyes (P > 0.05). ELM disruptions were not affected by the corresponding VDs in the SCP (all P> 0.05), but nasal and temporal quadrant ELM disruptions were affected by VDs in the DCP in the corresponding quadrants (P: 0.005 nasal, P: 0.001 temporal). EZ disruptions were not affected by the corresponding VDs in the SCP and DCP (all P> 0.05).Conclusions: The SCP was affected in more quadrants than the DCP and probably independently from each other. There was an association with the ELM and the DCP, especially in nasal and temporal quadrants, but there was not an association between the EZ and SCP or DCP.