A. Gaudric

Late reopening of successfully treated macular holes.

BACKGROUND Most idiopathic macular holes can be closed by a surgical procedure combining vitrectomy, posterior hyaloid ablation, and fluid-gas exchange followed by postoperative positioning. Reopening of closed macular holes has been reported, but its frequency is not known. Here the incidence of reopening after successful macular hole surgery is reported. METHODS 77 consecutive cases of idiopathic macular holes operated with autologous platelet injection between July 1993 and October 1995 were reviewed. The procedure consisted of three port vitrectomy, posterior hyaloid removal, non-expansile fluid-gas exchange, and autologous platelet injection followed by face down positioning. The incidence of reopening was analysed in the cohort of the 72 anatomical successes. RESULTS Mean follow up was 12.3 months. The macular hole reopened in five eyes of five patients (five out of 72 patients, 6.9%), in four cases after cataract extraction. In four cases too, an epiretinal membrane was noted, either clinically or during reoperation, and fluorescein leakage in the macular area was present in two cases. Three of the five cases of reopening were reoperated and all three were anatomical successes. CONCLUSION Late macular hole reopening occurred in five out of 72 patient, and in four cases after cataract surgery. The presence of an epiretinal membrane around the hole in four of them suggested that tractional forces were responsible for the reopening. Reoperation, performed in three cases, again closed the macular holes.

Decreased retinal sensitivity after internal limiting membrane peeling for macular hole surgery.

Aims To compare the retinal sensitivity and frequency of microscotomas found by spectral domain optical coherence tomography (SD-OCT) combined with scanning laser ophthalmoscopy (SLO) microperimetry after idiopathic macular hole closure, in eyes that underwent internal limiting membrane (ILM) peeling and eyes that did not. Methods This was a retrospective, non-randomised, comparative study. Combined SD-OCT and SLO microperimetry was performed in 16 consecutive eyes after closure of an idiopathic macular hole. A customised microperimetry pattern with 29 measurement points was used. The ILM was peeled in 8/16 eyes. The main outcome measure was mean retinal sensitivity. Results Mean retinal sensitivity (in dB) was lower after peeling: 9.80±2.35u2005dB with peeling versus 13.19±2.92 without (p=0.0209). Postoperative microscotomas were significantly more frequent after ILM peeling: 11.3±6.6 points with retinal sensitivity below 10u2005dB in eyes that underwent peeling versus 2.9±4.6 in those that did not (p=0.0093). Conclusions These results suggest that ILM peeling may reduce retinal sensitivity, and significantly increase the incidence of microscotomas. Until a prospective trial confirming or not these results, it seems justified to avoid peeling the ILM when its potential benefit seems minor or unproved, and when peeling is carried out, to limit the surface peeled to the bare minimum.

A Randomized Controlled Trial of Alleviated Positioning after Small Macular Hole Surgery

OBJECTIVEnTo establish whether the success rate of surgery for small idiopathic macular holes (diameter, ≤ 400 μm) is significantly reduced if facedown positioning is replaced by simply taking care to avoid the supine position.nnnDESIGNnRandomized, controlled, parallel-assignment, open-label, interventional, multicenter clinical trial.nnnPARTICIPANTSnSixty-nine patients from 6 specialized vitreoretinal units, randomized into 2 parallel groups and followed up after surgery for 3 months.nnnMETHODSnAll patients underwent pars plana vitrectomy, peeling of any epiretinal membrane, and 17% C₂F₆ gas filling. Patients then were advised randomly to observe either strict facedown positioning for 22 of 24 hours or simply to avoid the supine position for 10 days.nnnMAIN OUTCOME MEASURESnThe primary outcome measure was the rate of anatomic closure 3 months after surgery. Main secondary measurements included Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity, progression of cataract, and frequency of complications.nnnRESULTSnThe mean size of macular holes was approximately 300 μm in both groups. Closure rates were more than 90% in both groups: 32 (91.4%) of 34 eyes in the alleviated positioning group versus 32 (94.1%) of 35 eyes in the facedown positioning group (lower margin of 95% confidence interval of difference, -14.88%). The ETDRS scores at 3 months increased in both groups by 10.23 ± 14.64 and 10.52 ± 14.54 letters, respectively. Progression of cataract and the rate of other complications were not significantly different in the 2 groups.nnnCONCLUSIONSnThe success rate of surgery for idiopathic macular holes of 400 μm or smaller is not significantly reduced if facedown positioning is replaced by simply taking care to avoid the supine position. These macular holes can be treated by streamlined surgery, that is, with no internal limiting membrane peeling and no facedown positioning (only avoidance of the supine position) with a closure rate of more than 90% and a mean gain in visual acuity of more than 2 ETDRS lines at 3 months.

Morphologic Characterization of Dome-Shaped Macula in Myopic Eyes With Serous Macular Detachment

PURPOSEnTo analyze dome-shaped maculas topographic features and related serous retinal detachment (SRD) in eyes with myopic staphyloma.nnnDESIGNnRetrospective, observational case series.nnnMETHODSnWe reviewed the records of 48 eyes in 33 patients with dome-shaped maculas who were referred because of decreased vision. Ophthalmologic examination included axial length measurement, spectral domain optical coherence tomography (OCT), and fluorescein and indocyanine green angiography. The height of the macular bulge was measured, and the choroidal thickness was mapped.nnnRESULTSnPatient mean age was 55.0 ± 13.6 years. Mean axial length was 27.49 ± 2.53xa0mm. Mean best-corrected visual acuity (BCVA) was 0.50 ± 0.33 logMAR. Three dome-shaped macula patterns were observed: round dome in 10/48 (20.8%) eyes; horizontal oval-shaped dome in 30/48 (62.5%) eyes; and vertical oval-shaped dome in 8/48 (16.7%) eyes. The mean macular bulge height was 407.7 ± 215.1xa0μm (120-1130) and was significantly greater in vertical oval-shaped domes. The mean central choroidal thickness (CCT) was 146.5 ± 56.0xa0μm, significantly greater than at 3xa0mm nasal and temporal to the fovea (P < 0.0001). The CCT was positively correlated to macular bulge height but not to BCVA. Foveal SRD was present in 25/48 eyes and significantly increased for macular bulge height greater than 350xa0μm (Pxa0= 0.0047). BCVA was significantly lower when SRD was present (Pxa0= 0.043).nnnCONCLUSIONSnMost dome-shaped maculas did not display a round but a horizontal or vertical oval-shaped dome and could be missed on a single OCT scan. Chronic foveal SRD was associated with decreased vision and was more common when the macular bulge was highly elevated.

Flat Irregular Retinal Pigment Epithelium Detachments in Chronic Central Serous Chorioretinopathy and Choroidal Neovascularization

PURPOSEnTo evaluate the incidence of flat, irregular pigment epithelium detachments (PEDs) in chronic central serous chorioretinopathy (CSC) and to determine whether they are consistent with active choroidal neovascularization (CNV).nnnDESIGNnRetrospective case series.nnnMETHODSnReview of medical records of patients with chronic CSC who were examined in the Ophthalmology Department of Lariboisière Hospital between June 1, 2007 and May 31, 2013. Multimodal imaging of the fundus, including optical coherence tomography (OCT), fundus autofluorescence, and indocyanine green and fluorescein angiography, was available in most cases.nnnRESULTSnOne hundred and ten patients with chronic CSC were identified. Fifty-three eyes of 38 patients showed flat irregular PED on macular OCT examination. Mean age was 58.6 ± 13.2 years. Twenty-eight patients (73.6%) patients were male. Fifteen patients (39.4%) had bilateral flat irregular PEDs. The mean follow-up duration was 14.6 years (range: 2-39 years). PEDs were suggestive of type 1 CNV in 10 eyes, but no other signs of AMD, specifically no drusen, were present. In the remaining 43 eyes, flat irregular PEDs were stable over time (mean follow-up duration: 15 years) with no evidence of active neovascularization.nnnCONCLUSIONnAlthough the possible occurrence of type 1 CNV complicating the course of chronic CSC should not be ignored, all cases of flat irregular PED should not be mistaken for active CNV and systematically treated with anti-VEGF. Nevertheless, in some cases with worsened vision not responding to usual CSC therapy, anti-VEGF could be considered as a therapeutic test to rule out the presence of secondary CNV.

Macular Pseudoholes With Lamellar Cleavage of Their Edge Remain Pseudoholes

PURPOSEnTo reappraise macular pseudohole characteristics using spectral-domain optical coherence tomography (OCT) and characteristics and postoperative outcomes of macular pseudoholes.nnnDESIGNnRetrospective, observational case series.nnnMETHODSnIn this institutional study, 54 eyes with macular pseudohole were selected among 369 patients examined for an epiretinal membrane (ERM) by Cirrus spectral-domain OCT (Carl Zeiss Meditec) within a 2-year period. The diagnosis of macular pseudohole was based on the presence of a deep foveal pit, with verticalized edges and a macula thickened by the contraction of an ERM. All eyes underwent color fundus photography and spectral-domain OCT examination comprising a macular map, line raster scans, and en face images of the inner retinal surface. The main outcome measures were the morphologic description of the foveal profile in macular pseudoholes in relation to the pattern of the ERM contraction and the postoperative changes.nnnRESULTSnIn 24 eyes, the foveal pit had vertical, straight, smooth edges on the OCT scan corresponding to centripetal contraction of the ERM. Thirty other eyes exhibited some degree of stretching and cleavage of the foveal pit edge resulting from asymmetrical tangential traction of the ERM between multiple epicenters of contraction. Thirty-three patients underwent surgery, and their macular profile and visual acuity improved whatever their initial foveal profile.nnnCONCLUSIONSnThe OCT profile of macular pseudohole varies according to the pattern of the causal ERM contraction. Macular pseudoholes with a stretched foveal edge respond to ERM peeling as positively as other eyesxa0and should not be confounded with macular lamellar holes.

Meaning of Visualizing Retinal Cone Mosaic on Adaptive Optics Images

PURPOSEnTo explore the anatomic correlation of the retinal cone mosaic on adaptive optics images.nnnDESIGNnRetrospective nonconsecutive observational case series.nnnMETHODSnA retrospective review of the multimodal imaging charts of 6 patients with focal alteration of the cone mosaic on adaptive optics was performed. Retinal diseases included acute posterior multifocal placoid pigment epitheliopathy (n = 1), hydroxychloroquine retinopathy (n = 1), and macular telangiectasia type 2 (n = 4). High-resolution retinal images were obtained using a flood-illumination adaptive optics camera. Images were recorded using standard imaging modalities: color and red-free fundus camera photography; infrared reflectance scanning laser ophthalmoscopy, fluorescein angiography, indocyanine green angiography, and spectral-domain optical coherence tomography (OCT) images.nnnRESULTSnOn OCT, in the marginal zone of the lesions, a disappearance of the interdigitation zone was observed, while the ellipsoid zone was preserved. Image recording demonstrated that such attenuation of the interdigitation zone co-localized with the disappearance of the cone mosaic on adaptive optics images. In 1 case, the restoration of the interdigitation zone paralleled that of the cone mosaic after a 2-month follow-up.nnnCONCLUSIONnOur results suggest that the interdigitation zone could contribute substantially to the reflectance of the cone photoreceptor mosaic. The absence of cones on adaptive optics images does not necessarily mean photoreceptor cell death.

Description des pratiques pour la réalisation des injections intravitréennes

Drugs to treat retinal diseases are often injected intravitreally. This procedure can cause severe complications. We present ways to minimize the risk for complications. Rigorous preoperative antisepsis with povidone iodine, a sterile environment (using gloves and a mask for the injector, a lid speculum, and a drape on the eye to be injected), and immediate follow-up after injection are key issues of the injection technique.

Contribution of scanning laser ophthalmoscopy to the functional investigation of subjects with macular holes

A study was designed to validate a functional investigation performed with the scanning laser ophthalmoscope before surgery for macular holes in 12 eyes: The assessment included fundus examination, a functional examination resulting in evaluation of the preferred retinal lows, visual acuity and recording of visual evoked potentials. The preferred retinal locus was evaluated by presenting a small square area, and visual acuity was determined by means of calibrated figures. The visual evoked potentials were evoked by three alternating checkerboards (check size, 30′, 2 Hz) centered over the hole and seen at an angle of 6.5 × 6.5°, 2.5 × 2.5° and 6.5 × 6.5° with central exclusion of 2.5 × 2.5°. The appearance of the fundus visualized by scanning laser ophthalmoscopy consisted of a clear central disk corresponding to the hole, surrounded by a very dark ring, associated with a second, less dark ring with unclear margins. Fixation was unstable in one case with a visual acuity of 20/70. In 11 cases, fixation was localized to the superior retina with a visual acuity superior to 20/70. The visual evoked potentials evoked by 6.5 × 6.5° were discernible in all 12 eyes; visual evoked potential by annular stimuli were discernible in 11 cases. The 2.5 × 2.5° stimulus evoked no response in eight cases, proving the area of the hole was nonfunctional. A response was recorded in the four other cases, where the dimension of the holes was less than 2°. The results of this scanning laser ophthalmoscopic assessment demonstrated a precise evaluation of the residual macular function in the cases of full-thickness macular holes.

Injections intra-vitréennes d’anti-VEGF pour la dégénérescence maculaire liée à l’âge exsudative : place des examens complémentaires dans les décisions de retraitement

But Les anti-VEGF constituent les traitements les plus recents de la neovascularisation choroidienne compliquant la DMLA. Leur mode d’administration est l’injection intravitreenne. Differentes etudes cliniques ont valide l’interet de ces produits. Cependant, les modalites de surveillance par examen complementaire de l’efficacite de ces traitements n’ont pas ete definies par ces memes etudes cliniques. Le but de cet article est de faire le point sur les pratiques realisees actuellement en France, par differents specialistes, et les examens complementaires necessaires au suivi therapeutique et aux decisions de retraitement. Methode Plusieurs reunions ont ete effectuees entre plusieurs specialistes exercant en milieu hospitalier et/ou en pratique liberale, pour definir leurs modalites actuelles de suivi et leur proposition pour un suivi rationnel et une harmonisation des pratiques. Resultats La tomographie a coherence optique (OCT) occupe une place croissante dans la surveillance post-injection intravitreenne d’anti-VEGF. Tous les auteurs reconnaissent la valeur de l’angiographie a la fluoresceine a l’initiation du traitement, mais aussi trois mois apres instauration du traitement, associee, pour certains d’entre nous, a la realisation d’une angiographie au vert d’indocyanine. Ils recommandent l’utilisation de l’angiographie a la fluoresceine chaque fois que les resultats fonctionnels ne sont pas a la hauteur de ce qu’en attendent le medecin ou le patient. Les auteurs proposent un organigramme decisionnel qui pourrait guider les decisions de retraitement. Conclusion Les auteurs suggerent l’utilisation d’un organigramme decisionnel visant a preciser, en fonction, essentiellement, de l’evolution de l’acuite visuelle et des resultats de l’OCT, les indications de retraitement les plus rationnelles pour eviter aux patients tout risque d’injection intra-vitreenne inutile.