Hydromassage of macular hole edges for large and persistent full-thickness macular holes

●AIM:To introduce the macular hole(MH)hydromassage technique as a potentially beneficial approach for the treatment of large or persistent MH.●METHODS:This retrospective observational case series comprised 16 consecutive patients(17 eyes)diagnosed with MH.Inclusion criteria involved a hole aperture diameter larger than 600μm or the presence of an unclosed MH larger than 600μm following the previous vitrectomy.Standard MH repair procedures were administered in all cases,involving the manipulation and aspiration of the hole margin through the application of water flow with a soft-tip flute needle.A comprehensive assessment was conducted for each case before and after surgery,and optical coherence tomography(OCT)images were captured at every follow-up point.●RESULTS:The mean preoperative aperture diameter was 747±156μm(range 611-1180μm),with a mean base diameter of 1390±435μm(range 578-2220μm).Following surgery,all cases achieved complete anatomical closure of MH,with 13 cases(76.5%)exhibiting type 1 closure and 4 cases(23.5%)demonstrating type 2 closure.No significant differences were observed in the preoperative OCT variables between the two closure types.Eyes with type 1 closure showed a significantly improved visual acuity(0.70±0.10,range 0.50-0.80)compared to those with type 2 closure(0.90±0.12,range 0.80-1.00,P=0.014).●CONCLUSION:The MH hydromassage technique demonstrates promising results,achieving acceptable closure rates in cases of large or persistent MH.This technique may serve as an effective adjunctive maneuver during challenging MH surgery.

Parafoveal retinal massage combined with autologous blood cover in the management of giant,persistent or recurrent macular holes

AIM:To assess the efficacy and safety of parafoveal retinal massage combined with autologous whole blood cover in the treatment of refractory macular holes(MHs)and present the surgical procedure.METHODS:Patients with giant(minimum diameter>800 pm),recurrent or persistent MHs who underwent PPV combined with parafoveal retinal massage and autologous whole blood cover using C3F8 as tamponade agent from February 2018 to May 2019 were enrolled in this retrospective study.After surgery,all patients were informed to maintain a prone position for at least 7d.Preoperative and postoperative best-corrected visual acuities(BCVAs)were compared and MH closure rate was measured as the main outcome.RESULTS:A total of 13 MH patients consisted of 6 giant MHs,4 persistent holes and 3 recurrent holes(5 men and 8 women;average age was 56.40±11.72y)were enrolled in this study.MH closure was achieved in 11 eyes by this modified surgical technique while 2 eyes failed.Revitrectomy with autologous neurosensory retinal patch transplantations was applied for those 2 patients and then both holes were closed.No intraoperative complications were observed.BCVA improved from 1.73 IogMAR to 0.74 IogMAR at 6mo postoperation.There was significant difference in BCVA before versus after the surgery(P<0.05).There were no adverse events occurred during the follow-up period.CONCLUSION:With easier surgical procedure,parafoveal retinal massage combined with autologous whole blood cover is an effective addition to the surgical options for the management of refractory MHs.

Internal limiting membrane dragging and peeling:a modified technique for macular holes closure surgery

AIM:To introduce a modified technique of internal limiting membrane(ILM)centripetal dragging and peeling to treat idiopathic macular hole(IMH)and to observe the ILM-retina adhesive forces.METHODS:Twenty-six consecutive patients with stage 3 to 4 IMH and followed up at least six months were enrolled.All patients underwent complete par plana vitrectomy,ILM dragging and peeling,fluid and gas exchange,15%C3 F8 tamponade and 2-week prone position.The best corrected visual acuity,macular hole evaluation by optical coherence tomography,and complications were evaluated.RESULTS:The mean diameter of IMH was 524±148μm(range:201-683μm),with 21 cases(80.8%)greater than 400μm.ILM dragging and peeling were successfully performed in all cases.Most of the ILM-retina adhesive forces are severe(42.3%,11/26),followed by mild(38.5%,10/26),and moderate(19.2%,5/26).The mean follow-up duration was 21.2±6.1 mo.The IMH was closed in 25(96.3%)eyes.Visual acuity(logMAR)improved significantly from 1.2±0.6 preoperatively to 0.7±0.5 postoperatively(P<0.001).CONCLUSION:Preexisting ILM-retina adhesive force is found in IMH patients.With assistance of this force,this modified technique may help to release the IMH edges and improve the closure rate of large IMH.

Refractive outcomes after vitrectomy combined with phacoemulsification of idiopathic macular holes

AIM:To report the refractive outcomes after vitrectomy combined with phacoemulsification and intraocular lens(IOL)implantation(phaco-vitrectomy)in idiopathic macular holes(IMH).METHODS:A total of 56 eyes with IMH(IMH group)that underwent phaco-vitrectomy and 44 eyes with age-related cataract(ARC group)that underwent cataract surgery were retrospectively reviewed.The best corrective visual acuity(BCVA),predicted refractive error(PRE),actual refractive error(ARE),axial length(AL),were measured in both groups before and 6 mo after operation.The power calculation of IOL and the predicted refractive error(PRE)were calculated according to the SRK/T formula.The difference of PRE and ARE between the two groups were compared and analyzed.RESULTS:In the IMH group,the diameters of macular holes were 271.73±75.85μm,the closure rate was 100%.The pre-and post-operative BCVA were 0.80±0.35 and 0.40±0.35 log MAR.The PRE of A-ultrasound and IOL Master in the IMH group was-0.27±0.25 and 0.10±0.66 D.The postoperative mean absolute prediction error(MAE)was observed to be 0.58±0.65 and 0.53±0.37 D in the IOL Master and A-ultrasound(P=0.758).The PRE and ARE of the IMH group were 0.10±0.66 D and-0.19±0.64 D(P=0.102).The PRE and ARE of the ARC group was-0.43±0.95 and-0.31±0.93 D(P=0.383).The difference between PRE and ARE was-0.33±0.81 and 0.09±0.64 D in the IMH and ARC groups(P=0.021).The proportion of myopic shift was 67.9%in the IMH group and 27.3%in the ARC group(P=0.004).CONCLUSION:The myopic shift can be observed in patients with IMH after phaco-vitrectomy.

Different modes of foveal regeneration after closure of full-thickness macular holes by(re)vitrectomy and autologous platelet concentrate

AIM: To describe using spectral-domain optical coherence tomography the regeneration of the foveal morphology after pars plana(re)vitrectomy surgery and gas tamponade combined with injection of autologous platelet concentrate to treat full-thickness macular holes, and to describe different anatomical outcome. METHODS: A retrospective case series of 8 eyes of 8 patients was described. RESULTS: In all cases investigated, the plateletassisted closure of macular holes was associated with a rapid resolution of cystic cavities in the foveal walls. In two patients, there was a regular regeneration of the foveal morphology after hole closure;the regenerated central fovea had a regular structure with a foveola and photoreceptors. In three other patients, there was an irregular regeneration of the fovea;a foveola was not formed, photoreceptor cells were absent from the foveal center, and the center was composed of Müller and retinal pigment epithelial(RPE) cells. The foveal regeneration after hole closure may proceed with or without a temporary detachment of the foveal center from the RPE, and with or without a direct contact between the central outer nuclear layer(ONL) and the RPE. Contacts between the ONL and RPE were observed only in patients with an irregular foveal regeneration after hole closure.CONCLUSION: The data show that there are different modes of foveal regeneration after closure of macular holes with(re)vitrectomy and platelet concentrate. It is suggested that the regular regeneration of the foveal morphology proceeds by Müller cell-mediated tissue movements without cell proliferation, whereas the irregular foveal regeneration proceeds in part by proliferation of Müller and RPE cells.

Comparison of outcomes of idiopathic macular holes treated by vitrectomy with air or silicone oil tamponade based on the hole size

AIM:To compare the efficacy of vitrectomy combined with air or silicone oil in the treatment of idiopathic macular hole(IMH).METHODS:According to the results of high-definition optical coherence tomography(HD-OCT),75 cases(75 eyes)of IMH in stage II-IV(Gass stage)in the General Hospital of Chinese PLA from January 2017 to December 2019 were collected for this retrospective study.The best corrected visual acuity(BCVA)and minimum diameter of IMH(MMHD)were measured.Eyes underwent vitrectomy combined with internal limiting membrane peeling operation,and were divided into disinfection air group(30 eyes)and silicone oil group(45 eyes)according to the intraocular tamponade.For MMHD≤400μm(MMHD1),there were 23 eyes in air group and 16 eyes in silicone oil group.For MMHD2>400μm(MMHD2),there were 7 eyes in air group and 29 eyes in silicone oil group.One month after surgery,the closure rates of IMH and BCVA were compared and analyzed.According to HD-OCT,the closure shape was graded with A(bridge closure)and B(good closure).RESULTS:The closure rates of air group and silicone oil group were 86.67%and 95.56%respectively with no significant difference(P>0.05);For MMHD1,those of air group and silicone oil group were 95.65%and 100%respectively with no significant difference(P>0.05);For MMHD2,those of air group and silicone oil group were 57.14%and 93.10%respectively,and those of the silicone oil group were higher than the air group(P<0.05).There was no significant difference in the closure shape grade between MMHD1 air group and silicone oil group(P>0.05).The proportion of Grade B in MMHD2 silicone oil group was higher than that in the air group(P<0.05).BCVA of each group after operation was better than that before operation,and there was no significant difference between air group and silicone oil group.While among them,MMHD1 air group was better than silicone oil group(P<0.05),and there was no significant difference between MMHD2 air group and silicone oil group(P>0.05).CONCLUSION:For smaller IMH(≤400μm),the efficacy of vitrectomy combined with air should be considered better than silicone oil;for larger IMH(>400μm),the efficacy of silicone oil may be better than air.

Impact of OCT scan-patterns in identifying morphological features of lamellar macular holes and macular pseudoholes

AIM:To evaluate the impact of the optical coherence tomography(OCT)scan patterns on the detection of the features associated with lamellar macular hole(LMH)and macular pseudohole(MPH).METHODS:This is a retrospective analysis of 100 consecutive eyes with LMH(n=41)and MPH(n=59)having at least three of the following OCT features,which include mandatory criteria for the diagnosis of LMH and MPH:Epiretinal membrane,epiretinal proliferation,verticalization,intraretinal cystoid spaces,foveoschisis,irregular foveal contour,foveal cavity with undermined edges,and ellipsoid line disruption.Primary outcome measurement was the detection frequency of the features in three different OCT scan patterns:1)volume scan;2)six radial scans(R6);and 3)vertical and horizontal radial scans(R2).RESULTS:Of the total eight features,the maximal detection frequency was found as 4.45±1.45,4.35±1.47,and 3.70±1.59,by the volume,R6 and R2,respectively.R2 was inferior to the other patterns in detection of the total features(P<0.001),whereas R6 and volume patterns were found comparable(P=0.312).CONCLUSION:The physician should be aware that the selection of the OCT-scan pattern may influence the detection of mandatory morphological criteria for the diagnosis of LMH and MPH.

Inverted Internal Limiting Membrane Flap Technique for Repair of Large Macular Holes： A Short-term Follow-up of Anatomical and Functional Outcomes

Background：Inverted internal limiting membrane （ILM） flap technique has recently been reported in a limited number of studies as an effective surgical technique for the management of large macular holes （MHs） with fair MH closure rates as well as gains in visual acuity.In the current study,longitudinal changes in multi-focal electroretinogram （mfERG） responses,best-corrected visual acuity （BCVA） and spectral-domain optical coherence tomography （SD-OCT） were evaluated in eyes with large MHs managed by this technique.Methods：A prospective noncontrolled interventional study of eight patients （eight eyes） with large MHs （minimum diameter 〉400 μm） was conducted.All MHs were treated with pars plana vitrectomy and indocyanine green-assisted inverted ILM flap technique.SD-OCT images were used to assess the anatomical outcomes of surgery while BCVA and mfERG were used to evaluate the functional outcomes during a 3-month follow-up.Results：All patients underwent successful intended manipulation and translocation of the ILM flap without flap dislocation and achieved complete anatomical closure.Partial microstructural reconstruction,demonstrated on SD-OCT as restoration of the external limiting membrane and the ellipsoid zone,was observed in all cases as early as 1 month after surgery.Functionally,as compared to baseline,all patients showed improvements in BCVA and all but one in mfERG response during follow-up.However,Pearson＇s test revealed no significant correlations between BCVA and mfERG responses of the fovea and of the macular area at each evaluation time point.Conclusions：Inverted ILM flap technique appeares to be a safe and effective approach for the management of large idiopathic MHs with favorable short-term anatomical and functional results.Postoperative reconstruction of the microstructure generally shows good consistency with improvements in both BCVA and mfERG response,of which the latter might be a supplement for the former in postoperative functional follow-up.

Comparison of anatomical and functional outcomes of different surgical techniques in myopic macular hole without retinal detachment

AIM:To define the anatomic and functional outcomes of pars plana vitrectomy(PPV)with internal limiting membrane(ILM)peeling,inverted ILM flap and free ILM patch graft technique for the treatment of myopic macular hole(MH)without retinal detachment.METHODS:Sixty-four eyes of 64 patients who underwent PPV for myopic MH were included.Group 1 consists of patients underwent ILM peeling(n=26),and Groups 2 and 3 consists of patient underwent free ILM patch graft(n=20)and inverted ILM flap procedure(n=18)respectively.Outcomes following surgery were MH closure and best corrected visual acuity(BCVA)in logMAR at 6mo.RESULTS:Closure of MH was obtained in 20 eyes(76.9%)of the Group 1,in 16 eyes(80%)of the Group 2 and in 16 eyes(88.9%)of the Group 3.The mean preoperative and postoperative BCVA was 1.60±0.53 logMAR and 1.27±0.58 logMAR,respectively(P<0.05).There was no significant difference in the postoperative BCVA and anatomical closure rates in the three groups.Although the anatomical closure rate did not differ significantly in the groups,closure of MH tended to be better in the inverted ILM flap technique group at 6mo.CONCLUSION:Different surgical techniques may provide favorable visual and anatomical results for myopic MH surgery.ILM flap techniques offer higher closure rates compared to ILM peeling technique.However,in terms of visual outcomes,the study reveals no difference in three surgical techniques.

Predicting anatomical results of surgical treatment of idiopathic macular hole

AIM： To determine the parameters most informative in predicting the anatomical results of surgical treatment of idiopathic full-thickness macular hole （IMH）. METHODS： One hundred and sixty-two consecutive patients （170 eyes） after primary operation for IMH were enrolled. Outcomes were classified as anatomical success when both IMH closure and restoration of the outer retinal structure were achieved. ＂Prospective＂ group included 108 patients （115 eyes） followed with optical coherence tomography （OCT） and microperimetry for ly after surgery. Potential prognostic criteria, except microperimetry data, were tested in ＂retrospective＂ group （54 patients, 55 eyes）. Prognostic value of each parameter was determined using receiver operating characteristic （ROC） analysis. Combined predictive power of the best prognostic parameters was tested with the use of linear discriminant analysis. RESULTS： IMH closure was achieved in 106 eyes （92%） in the prospective group and 49 eyes （89%） in the retrospective group. Despite anatomical closure, the outer retinal structure was not restored in two eyes in the first group and in one eye in the second group. Preoperative central subfield retinal thickness demonstrated the best discriminatory capability between eyes with anatomical success and failure： area under the ROC-curve （AUC） 0.938 （95% Ch 0.881-0.995）, sensitivity 64% at fixed specificity 95% （cut-off value 300um） in the prospective group; sensitivity 57% and specificity 90% in the retrospective group. Other continuous parameters except tractional hole index （AUC： 0.796, 95% Ch 0.591- 1.000） had significantly lower AUCs （P〈0.05）. The best combination of the parameters, established by discriminant analysis in the prospective group, could not confirm its predictive value in the retrospective group. CONCLUSION： Preoperative central subfield retinal thickness is a strong and probably the best predictor of anatomical results of IMH surgical treatment.

Area and volume ratios for prediction of visual outcome in idiopathic macular hole

AIM： To predict the visual outcome in patients undergoing macular hole surgery by two novel three-dimensional morphological parameters on optical coherence tomography （OCT）： area ratio factor （ARF） and volume ratio factor （VRF）. METHODS： A clinical case series was conducted, including 54 eyes of 54 patients with an idiopathic macular hole （IMH）. Each patient had an OCT examination before and after surgery. Morphological parameters of the macular hole, such as minimum diameter, base diameter, and height were measured. Then, the macular hole index （Mill）, tractional hole index （THI）, and hole form factor （HFF） were calculated. Meanwhile, novel postoperative macular hole （MH） factors, ARF and VRF were calculated by three-dimensional morphology. Bivariate correlations were performed to acquire asymptotic significance values between the steady best corrected visual acuity （BCVA） after surgery and 2D/3D arguments of MH by the Pearson method with two-tailed test. All significant factors were analyzed by the receiver operating characteristic （ROC） curve analysis of SPSS software which were responsible for vision recovery. ROC curves analyses were performed to further discuss the different parameters on the prediction of visual outcome. RESULTS： The mean and standard deviation values of patients＇ age, symptoms duration, and follow-up time were 64.8＋8.9y （range： 28-81）, 18.6＋11.5d （range： 2-60）, and 11.4＋0.4mo （range： 6-24）, respectively. Steady-post-BCVA analyzed with bivariate correlations was found to be significantly correlated with base diameter （r＇0.521, P〈0.001）, minimum diameter （r=0.514, P〈0.001）, MHI （r -0.531, P〈0.001）, THI （r=-0.386, P=-0.004）, HFF （r=-0.508, P〈0.001）, and ARF （r=-0.532, P〈0.001）. Other characteristic parameters such as age, duration of surgery, height, diameter hole index, and VRF were not statistically significant with steady-post-BCVA. According to area under the curve （AUC） values, values of ARF, MHI, HFF, minimum diameter, THI, and base diameter are 0.806, 0.772, 0.750, 0.705, 0.690, and 0.686, respectively. However, Steady-post-BCVA analysis with bivariate correlations for VRF was no statistical significance. Results of ROC curve analysis indicated that the MHI value, HFF, and ARF was greater than 0.427, 1.027 and 1.558 respectively which could correlate with better visual acuity. CONCLUSION： Compared with MHI and HFF, ARF could effectively express three-dimensional characteristics of macular hole and achieve better sensitivity and specificity. Thus, ARF could be the most effective parameter to predict the visual outcome in macular hole surgery.

Inverted internal limiting membrane flap technique for very large macular hole

AIMTo assess the anatomical and visual outcome of idiopathic macular holes greater than 1000 &#x000b5;m using the inverted internal limiting membrane flap technique.METHODSThis retrospective case series included 5 eyes of 5 patients with idiopathic macular hole with base diameter greater than 1000 &#x000b5;m who underwent inverted internal limiting membrane flap technique along with standard 23G pars plans vitrectomy with posterior hyaloid detachment and fluid gas exchange with 12%-14% perfluoropropane (C3F8). Preoperative and postoperative visual acuity and spectral domain optical coherence tomography images were evaluated. The main outcome measures were visual outcome and macular hole closure.RESULTSMean age was 63.2&#x000b1;8.4y with all 5 subjects being females. Mean duration of symptoms was 11&#x000b1;14mo with a mean postoperative follow up of 13.2&#x000b1;13mo. The mean base diameter of the macular holes was 1420&#x000b1;84.8 &#x000b5;m (1280-1480 &#x000b5;m). Type 1 closure was achieved in four out of five patients, while one patient had type 2 closure using the inverted internal limiting membrane (ILM) flap technique. Median baseline BCVA was 0.79 logMAR (Snellen’s equivalent 20/120) and median final BCVA 0.6 logMAR (Snellen’s equivalent 20/80) with mean visual improvement of approximately three lines improvement. No complications related to surgical procedure were noted.CONCLUSIONThe inverted internal limiting membrane flap technique may be promising for very large macular holes with high rate of macular closure and good visual outcome.

Visual function and vision-related quality of life after vitrectomy for idiopathic macular hole: a 12mo followup study

· AIM: To investigate the visual function and the relationship with vision-related quality of life(VRQOL)after macular hole repair surgery.· METHODS: Prospective case series. Thirty-six consecutive eyes in 36 patients who underwent pars plana vitrectomy(PPV) and internal limiting membrane(ILM) peeling were included. The 25-item National Eye Institute Visual Function Questionnaire(VFQ-25) was answered by the participants before and 3 and 12 mo after operation. Follow-up visits examinations included best-corrected visual acuity(BCVA), clinical examination,and central macular thickness(CMT) measured by optical coherence tomography(OCT).·RESULTS: Macular-hole closure was achieved in 35 of36 eyes(97.2%). At baseline and months 3 and 12, the log MAR BCVAs(mean±SD) were 1.15±0.47, 0.68±0.53(P 【0.0001 versus baseline), and 0.55 ±0.49(P 【0.001 versus baseline, P =0.273 versus month 3), respectively; the CMTs(μm) were 330 ±81, 244 ±62(P 【0.001 versus baseline), and 225±58(P 【0.001 versus baseline, P =0.222 versus month 3), respectively; the median preoperative VFQ-25 composite score of 73.50(63.92-81.13) increased postoperatively to 85.50(80.04-89.63) at 3mo(P 【0.001)and 86.73(82.50-89.63) at 12mo(P 【0.001) respectively.The improved BCVA was correlated with improvements in five subscales(r =-0.605 to-0.336, P 【0.001 to P =0.046) at 12 mo.· CONCLUSION: PPV with ILM peeling improved anatomic outcome, visual function, and VRQOL. Theimproved BCVA was an important factor related to the improved VRQOL.

Treatment of refractory giant macular hole by vitrectomy with internal limiting membrane transplantation and autologous blood

AIM：To investigate the effect of internal limiting membrane transplantation and autologous blood on treating refractory giant macular hole.METHODS：Thirty-seven eyes with giant macular hole of the smallest hole diameter 〉700 μm,the maximum diameter of the substrate 〉1000 μm and hole formation factor 〈0.6 underwent surgical treatment.The patients were randomly divided into two groups.Nineteen eyes with surgical flip of the internal limiting membrane in group A,18 eyes with internal limiting membrane transplantation in group B who underwent the tamponade of internal limiting membrane into the hole,autologous plasma was used to seal the hole.The patients were followed up for 3 mo,optical coherence tomography and best corrected visual acuity（BCVA） were recorded before and after operation,and the results were statistically analyzed.RESULTS：At 3 mo after operation,BCVA of the two groups was significantly improved compared with that before operation（tA=4.192,tB=4.374,P〈0.05）.But there was no significant difference in visual acuity between the two groups（χ^2=0.128,P〉0.05）.At 3 mo after operation,the closure rate of group A was 68.4%,and 100% in group B.（χ^2=5.628,P〈0.05）.The defect diameter of inner segment/outer segment at 3 mo after the operation was significantly lower than that before operation（tA=12.287,tB=15.481,P〈0.05）,and the difference was statistically significant（t=2.552,P〈0.05）.CONCLUSION：Internal limiting membrane transplantation combined with autologous whole blood can improve the postoperative closure rate of the refractory large aperture,and can effectively improve the postoperative visual acuity.

The optic nerve head perfusion and its correlation with the macular blood perfusion in unilateral idiopathic macular hole： an optical coherence tomography angiography study

AIM： To compare the optic nerve head （ONH） perfusion in both eyes of unilateral idiopathic macular hole （IMH） with normal control group by using optical coherence tomography angiography （OCTA） and investigate its correlationship with the macular blood perfusion. METHODS： We performed a prospective and cross- sectional study that included 19 patients with full-thickness unilateral IMH and 24 age- and sex-matched controls. All participants received OCTA test. The ONH perfusion was evaluated by the regions of peripapillary and whole en face （the sum of peripapillary and optic disc）. The potential correlationship between ONH and parafovea were implied. All the data were performed using the nonparametric test. RESULTS： The mean values of ONH presented that normal control 〉IMH 〉unaffected eyes. A statistical variation was found between three groups in the region of temporal （P=-0.007）, Vessel density notablely decreased on the layers of superficial, deep and choroid of parafovea region in IMH group. The correlative coefficients showed that respectively whole en face and deep retina： r=0.528, peripapillary and deep retina： r=0.525, whole en face and choriocapillaries： r=0.569, peripapillary and choriocapillaries： t=0.504. CONCLUSION： Our study demonstrate a reduced ONH vessel density in both eyes of IMH patients and the vessel density of ONH in IMH eyes are positively correlated with both the retina capillary and choriocapillary in parafoveal. The reduction of vessel densities may indicate the hypoperfusion in IMH eyes,

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane(ILM)peeling is popular for the treatment of macular hole(MH).However,the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs.Currently,the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate.The ILM flap technique has many variations,including the difference of the size,shape,number,and manner in which the flaps put on the MHs.The ILM flap technique also has some auxiliary means including perfluoro-n-octane(PFO),dye,autologous blood and adhesive viscoelastics.There is controversy about the effects between several technique variations of ILM flap,and it needs to be explored in the future.

Vitrectomy with internal limiting membrane peeling versus its flap insertion for macular hole in high myopia: a Meta-analysis

AIM: To compare the anatomic and functional outcomes between vitrectomy with internal limiting membrane(ILM) peeling and internal ILM flap insertion technique for high myopia macular hole(MH).METHODS: Pub Med, Cochrane Library, EMBASE, and CNKI were systematically searched, and all studies involved MH were included. The closure rate of MH and the postoperative best-corrected visual acuity(BCVA) at 6 mo after the initial surgery were the primary measures. All statistical tests were performed in Review Manager 5.3.RESULTS: Five studies that included 151 eyes of 151 patients were finally included, all of which were retrospectively comparative studies. Between the pars plana vitrectomy(PPV) with ILM peeling surgery and the ILM insertion technique, the latter had significantly better efficacy with respect to the closure rate of MH(OR=21.32, 95%CI=7.25-62.67, P<0.001);However, regarding BCVA at 6 mo after the initial surgery in MH, there was no statistical significance between the groups(OR=-0.04, 95%CI=-0.22-0.14, P=0.66). In addition, regarding the rate of retinal reattachment after the initial surgery, the two different methods were not significantly different(OR=2.22, 95%CI=0.34-14.32, P=0.4).CONCLUSION: Both ILM peeling and ILM insertion technique could significantly improve anatomic outcomes of MH in high myopia with or without retinal detachment(RD), and anatomic outcomes are more effective. However, there is no statistical significance in BCVA at 6 mo after the initial surgery in MH, or in the rate of retinal reattachment after the first surgery, between the two methods.

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,2 wk,1,and 3 mo 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(log MAR,Snellen 20/200)preoperatively to 0.30±0.25(Snellen 20/40)at 3 mo 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 2 wk 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.

Episcleral macular buckling for posterior retinal detachment in silicone oil filled eyes associated with myopic macular hole

AIM: To evaluate anatomical and visual outcomes of episcleral macular buckling (EMB) for posterior retinal detachment in silicone oil filled eyes associated with myopic macular hole.METHODS: Five cases of EMB for initial failure of retinal reattachment after internal limiting membrane (ILM) peeling and silicone oil tamponade caused by myopic macular hole were retrospectively reviewed. A silicone sponge sutured directly across the macular region was performed on the silicone oil filled eyes. Silicone oil was removed no sooner than 1 month post- EMB. The duration of follow -up time after removal of silicone oil was more than 3 months.RESULTS: Retinas of five eyes were all reattached at the last follow-up. The postoperative vision ranged from counting fingers to 0.08.CONCLUSION: Anatomical results improved after EBM for posterior retinal detachment in silicone oil filled eyes associated with myopic macular hole, which was not evident for visual outcome.

Internal limiting membrane peeling with different dyes in the surgery of idiopathic macular hole: a systematic review of literature and network Meta-analysis

AIM: To evaluate the effect of internal limiting membrane(ILM) peeling with indocyanine green(ICG), brilliant blue G(BBG), triamcinolone acetonide(TA), trypan blue(TB), or without dye for the treatment of idiopathic macular hole(IMH). METHODS: A search was conducted using Pub Med, EMBASE, and CENTRAL(Cochrane Central Register of Controlled Trials) for related studies published before October 2018. RESULTS: A total of 29 studies and 2514 eyes were included in this network Meta-analysis. For IMH closure, the rank from the best to the worse treatment was: BBG, TB, TA, ICG, and no dye. There was a significant difference in postoperative IMH closure rate between BBG and no dye. The rank of the best to the worse treatment to improve visual acuity was: BBG, TB, no dye, TA, and ICG. The improvement rate of visual acuity after using BBG was significantly higher than ICG. The improvement rate of visual acuity was more favorable with TB than ICG, TA, and no dye. CONCLUSION: BBG can contribute to better anatomical and functional outcomes compared to other dyes for ILM peeling in patients with IMH. The results show that the best treatment of ILM peeling with dyes is BBG.