Mariko Furukawa

Vitreous surgery with and without internal limiting membrane peeling for macular hole repair.

Purpose: To compare surgical results for idiopathic macular holes with and without internal limiting membrane (ILM) peeling in a series of consecutive patients during an 8-year period. Methods: A retrospective, nonrandomized, comparative trial. Four hundred seventeen eyes with macular holes without ILM peeling were compared with 175 eyes with ILM peeling. All eyes underwent pars plana vitrectomy with intravitreous gas, followed by head-down positioning. No adjunctive therapies were used. Comparison of closure and reopening rates and visual acuity with and without ILM peeling was analyzed. Results: Initial success rate significantly improved from 81% to 92% with ILM peeling. ILM peeling significantly improved the initial success rates in all categories of preoperative features. Reopening rates significantly decreased from 7% to 0.6% with ILM peeling. Among successful cases, line improvement was 6.0 in ILM-reserved eyes and 5.8 in ILM-peeled eyes. Among all cases, line improvement was 5.4 in ILM-reserved eyes and 5.7 in ILM-peeled eyes. Initial success rate of holes measuring more than 400 &mgr;m was significantly less than that of holes measuring less than 400 &mgr;m with or without ILM peeling. Initial success rate of holes older than 6 months old was significantly less than that for holes less than 6 months old without ILM peeling. Conclusions: Internal limiting membrane peeling shows high closure and low reopening rates in macular hole surgery. ILM peeling is beneficial in older holes but is limited in larger holes. ILM peeling does not significantly improve visual acuity.

Long-term follow-up of vitrectomy for diffuse nontractional diabetic macular edema.

Purpose: To report the long-term results of pars plana vitrectomy for diffuse nontractional diabetic macular edema. Design: Interventional, retrospective, consecutive case series. Methods: Clinical records of 332 consecutive patients (496 eyes) with diabetic macular edema without a thickened and taut posterior hyaloid on contact lens examination were reviewed. Four hundred eighty-six eyes of 326 consecutive patients were included in this study. All patients underwent pars plana vitrectomy with the creation of a posterior vitreous detachment by one surgeon. Simultaneous phacoemulsification with intraocular lens implantation was performed on 456 phakic eyes. Internal limiting membrane peeling was performed on 178 (36.6%) of 486 eyes. The main outcome measured was best-corrected visual acuity results during follow-up periods. Results: Postoperative follow-up ranged from 12 to 170 months (mean, 74.0 months). Five year follow-up data were available for 356 (71.8%) of 496 eyes. Mean preoperative best-corrected visual acuity significantly increased from 0.19 (20/105) to 0.32 (20/63) at 1 year after surgery (P < 0.0001), and 0.30 (20/67) at the final visit (P < 0.0001). The final best-corrected visual acuity improved in 256 (52.7%) of the 486 eyes, remained unchanged in 152 eyes (31.3%), and worsened in 78 eyes (16.0%). Postoperative major complications included neovascular glaucoma in 19 eyes (3.9%), recurrent vitreous hemorrhage in 10 eyes (2.1%), hard exudate deposits in the center of the macula in 21 eyes (4.2%), and glaucoma in 22 eyes (4.5%). Conclusions: Pars plana vitrectomy with and without internal limiting membrane peeling appears to be beneficial in eyes with diffuse nontractional diabetic macular edema, and its effectiveness is maintained long term.

Long-term outcomes of internal limiting membrane peeling with and without indocyanine green in macular hole surgery.

Purpose: To compare the long-term anatomic closure rate and visual outcome in patients who underwent internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) dye staining for idiopathic macular hole repair. Design: Retrospective, nonrandomized, comparative study of consecutive case series. Methods: A total of 190 eyes of 182 patients with idiopathic macular holes underwent macular hole repair between March 1998 and June 2003. Surgery consisted of pars plana vitrectomy, lensectomy if phakic, ILM peeling, intravitreal gas tamponade, and 1 week’s face-down positioning. In the initial 94 consecutive eyes, ILM peeling was performed without adjuvants (non-ICG group). The subsequent 96 eyes underwent surgery with ICG-stained ILM peeling (ICG group), in which the ILM was stained with intravitreal application of 0.1 to 0.2 mL of 0.1% ICG solution. Results: Two groups of patients had comparable clinical backgrounds preoperatively. Mean follow-up time was 30.7 months in non-ICG group and 26.2 months in ICG group. Anatomic closure of the macular hole was achieved in 99% of the cases in both groups, with both groups showing statistically significant visual improvement. There was no statistically significant difference in visual acuity between the two groups at each follow-up visit. There were also no intraoperative or postoperative complications attributed to the use of ICG. Conclusions: Long-term follow-up of patients undergoing ILM peeling for idiopathic macular hole repair shows equivalent anatomic and visual outcomes with and without the use of ICG.

Factors correlated with postoperative visual acuity after vitrectomy and internal limiting membrane peeling for myopic foveoschisis.

Purpose:The purpose of this study was to determine the factors that are correlated with the visual outcomes in patients who underwent pars plana vitrectomy with internal limiting membrane peeling for myopic foveoschisis (MF). Methods:In this retrospective, interventional consecutive case series, 39 eyes of 39 consecutive patients who had undergone pars plana vitrectomy with internal limiting membrane peeling for MF were studied. Preoperative optical coherence tomography showed that none of the eyes had a macular hole or vitreoretinal traction. Eyes were divided into those with MF and a foveal detachment (FD; FD group, n = 27) and those with MF without an FD (no-FD group, n = 12). The main outcome measures were best-corrected visual acuity (BCVA) and the optical coherence tomography findings. Results:Optical coherence tomography showed a complete resolution of the MF with a reattachment of the fovea in all eyes, and the retina remained attached during the mean follow-up of 41 months. The final mean BCVA improved significantly in the FD group (P = 0.0003) but not in the no-FD group (P = 0.56). The final BCVA of the FD group and no-FD group improved in 70% and 42%, remained unchanged in 26% and 33%, and worsened in 4% and 25% of the eyes, respectively. A better final BCVA was significantly correlated with a better preoperative BCVA (P < 0.0001), a shorter axial length (P = 0.045), and the presence of an FD (P = 0.028). Conclusion:Pars plana vitrectomy with internal limiting membrane peeling results in long-term favorable anatomical and visual outcomes. Eyes with an FD may be good candidates for surgery.

Long-term visual outcomes after vitrectomy for macular edema with foveal hemorrhage in branch retinal vein occlusion.

Purpose: To determine the long-term visual outcomes after vitreous surgery for macular edema with foveal hemorrhage associated with branch retinal vein occlusion (BRVO). Methods: One hundred twenty eyes of 120 patients underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling for macular edema with foveal hemorrhage due to BRVO with a minimum 12 months of follow-up. Simultaneous cataract extraction with intraocular lens implantation was performed on 117 phakic eyes. Results: Follow-up after surgery ranged from 12 months to 129 months (average, 48 months). Visual acuity improved in 71% of cases at the 1-year visit. Mean visual acuity significantly increased from 0.24 (median, 0.3) before surgery to 0.57 (median, 0.7) 1 year after surgery (P < 0.0001) and 0.66 (median, 0.9) at the final visit (P < 0.0001). There was a significant difference between visual acuity at 1 year after surgery and visual acuity at the final visit (P < 0.0001). Of 120 patients, 95 (79%) had final visual acuity of ≥0.5, and 55 (46%) had final visual acuity of ≥1.0. ILM removal did not seem to have significant beneficial effects on visual outcomes in this series. No serious complications occurred during the follow-up period. Conclusion: After vitreous surgery for macular edema with foveal hemorrhage associated with BRVO, visual acuity continued to improve beyond 1 year after surgery. A randomized, multicenter clinical trial is warranted to determine the efficacy of this procedure.

Long-term Outcomes Of Macular Hole Surgery With Triamcinolone Acetonide–assisted Internal Limiting Membrane Peeling

Purpose: To report long-term anatomical and functional results after pars plana vitrectomy with internal limiting membrane (ILM) peeling using triamcinolone acetonide (TA) for idiopathic macular holes. Design: Prospective, consecutive, interventional case series. Methods: Ninety-six eyes of 94 patients who underwent macular hole surgery with TA-assisted ILM peeling were included in the study. Patients with <12 months of follow-up were excluded. On 82 phakic eyes, simultaneous phacoemulsification with intraocular lens implantation was performed. Follow-up examinations included clinical examination, determination of best-corrected visual acuity, intraocular pressure measurement, optical coherence tomography, Goldmann perimetry, and static perimetry using the Humphrey visual field analyzer. The main outcome measures were postoperative visual acuity, macular hole status, and postoperative complications. Results: The mean follow-up period was 17 months (range, 12–30 months). TA improved visualization of the ILM, and the peeled area was seen as an area lacking white specks. All macular holes successfully closed after primary surgery. Mean visual acuity improved from 0.26 to 1.0 at the final visit (P < 0.0001), with 90 eyes (94%) having improvement of visual acuity. Postoperative complications included retinal detachment in one patient and transient intraocular pressure elevation in five patients. Conclusions: Although transient intraocular pressure elevation was observed in a few patients, the use of TA in macular hole surgery may be an effective and safe technique to facilitate visualization of the ILM and can lead to good long-term anatomical and functional results.

Retinal thickness after vitrectomy and internal limiting membrane peeling for macular hole and epiretinal membrane

Purpose To determine the retinal thickness (RT), after vitrectomy with internal limiting membrane (ILM) peeling, for an idiopathic macular hole (MH) or an epiretinal membrane (ERM). Also, to investigate the effect of a dissociated optic nerve fiber layer (DONFL) appearance on RT. Methods A non-randomized, retrospective chart review was performed for 159 patients who had successful closure of a MH, with (n = 148), or without (n = 11), ILM peeling. Also studied were 117 patients who had successful removal of an ERM, with (n = 104), or without (n = 13), ILM peeling. The RT of the nine Early Treatment Diabetic Retinopathy Study areas was measured by spectral domain optical coherence tomography (SD-OCT). In the MH-with-ILM peeling and ERM-with-ILM peeling groups, the RT of the operated eyes was compared to the corresponding areas of normal fellow eyes. The inner temporal/inner nasal ratio (TNR) was used to assess the effect of ILM peeling on RT. The effects of DONFL appearance on RT were evaluated in only the MH-with-ILM peeling group. Results In the MH-with-ILM peeling group, the central, inner nasal, and outer nasal areas of the retina of operated eyes were significantly thicker than the corresponding areas of normal fellow eyes. In addition, the inner temporal, outer temporal, and inner superior retina was significantly thinner than in the corresponding areas of normal fellow eyes. Similar findings were observed regardless of the presence of a DONFL appearance. In the ERM-with-ILM peeling group, the retina of operated eyes was significantly thicker in all areas, except the inner and outer temporal areas. In the MH-with-ILM peeling group, the TNR was 0.86 in operated eyes, and 0.96 in fellow eyes (P < 0.001). In the ERM-with-ILM peeling group, the TNR was 0.84 in operated eyes, and 0.95 in fellow eyes (P < 0.001). TNR in operated eyes of the MH-without-ILM peeling group was 0.98, which was significantly greater than that of the MH-with-ILM peeling group (P < 0.001). TNR in the operated eyes of the ERM-without-ILM peeling group was 0.98, which was significantly greater than that of ERM-with-ILM peeling group (P < 0.001). Conclusion The thinning of the temporal retina and thickening of the nasal retina after ILM peeling does not appear to be disease-specific. In addition, changes in RT after ILM peeling are not related to the presence of a DONFL appearance.

Incidence and Factors Related to Macular Hole Reopening

PURPOSE To determine the incidence and the factors that can cause a reopening of a macular hole (MH) after a surgical closure. DESIGN Retrospective, comparative, consecutive case series. METHODS The medical charts of all patients who underwent vitrectomy with or without internal limiting membrane (ILM) peeling for an idiopathic full-thickness MH were reviewed. In all cases, the MH was closed successfully. Simultaneous phacoemulsification with intraocular lens implantation was performed on all phakic patients who were older than 40 years. RESULTS Eight hundred and seventy-seven eyes of 831 patients with a mean age of 64.9 +/- 8.0 years were studied. Combined cataract extraction with vitrectomy was performed on 763 eyes of 775 phakic eyes. The mean follow-up time after MH surgery was 57.7 +/- 38.4 months (range, 1 to 175 months). Two groups were studied: an ILM-off group (n = 514) and an ILM-on group (n = 363). The MH reopened in 2 eyes (0.39%) in the ILM-off group and in 26 eyes (7.2%) in ILM-on group (P < .0001). Kaplan-Meier analysis showed higher rates of reopening in the ILM-on group than in the ILM-off group (P< .0001, log-rank test). Factors related to the reopening in the ILM-on group were refractive error (r = -0.12; P = .049) and intraoperative peripheral tear formation (r = 0.13; P = .018). CONCLUSIONS ILM peeling significantly decreases the incidence of the reopening of an MH. Although the pathogenesis of the reopening of MHs is still undetermined, myopia and intraoperative retinal tears may be related to the reopening.

Surgical Outcomes for Patients who Develop Macular Holes After Pars Plana Vitrectomy

PURPOSE To characterize outcomes for patients who develop full-thickness macular holes after pars plana vitrectomy. METHODS We retrospectively analyzed data for 47 consecutive patients (47 eyes) who developed full-thickness macular holes after initial pars plana vitrectomy for a variety of indications. All patients underwent a second vitrectomy and gas tamponade with or without internal limiting membrane peeling. RESULTS Indications for initial vitrectomy included idiopathic epiretinal membranes (11 eyes), epiretinal membranes with a pseudohole (nine eyes), macular edema resulting from various conditions (nine eyes), proliferative diabetic retinopathy (nine eyes), rhegmatogenous retinal detachment (five eyes), and miscellaneous causes (four eyes). Mean interval from initial vitrectomy to macular hole formation was 20.4 months. Mean visual acuity (VA) in the affected eye was 0.13 (20/155, Snellen equivalent). The hole was closed in 32 eyes (68%) after a single procedure. With a mean follow-up of 53 months, mean final VA improved to 0.26 (20/77); 26 (55%) eyes improved, 18 (38%) were stable, and three (6%) worsened. No severe complications occurred except one macular hole that reopened after successful closure. CONCLUSIONS Macular holes may develop after pars plana vitrectomy. Although additional vitrectomy can successfully close the hole and improve vision in most patients, postsurgical outcome seems to depend on the underlying condition.

Internal Limiting Membrane Peeling in Vitreous Surgery for Diabetic Macular Edema

PURPOSE: To evaluate the effect of internal limiting membrane (ILM) peeling in vitreous surgery for diabetic macular edema. METHODS: This study was done on 135 eyes of 103 patients who all underwent diabetic macular edema surgery under the same surgeon. The subjects were 74 eyes of 55 males and 61 eyes of 48 females, aged 35-81 years, with an average of 62 years. The postoperative follow-up period ranged from 12 to 39 months, with an average of 20 months. The ILM peeling was performed in 74 eyes. The subjects were divided in two types of macular edema from the presence (type II, 81 eyes) or absence (type I, 54 eyes) of hard exudates in the macular region. We evaluated the effects of the ILM peeling on the absorption rate of macular edema, the period required for absorption of macular edema, and the postoperative visual acuity. RESULTS: The absorption rate of macular edema was more than 90% with or without the ILM peeling. The period required for absorption of macular edema in eyes with ILM peeling was shorter in type II. There was no difference in the postoperative visual acuity with or without ILM peeling. ILM peeling was not an important factor for the postoperative visual acuity. RESULTS: ILM peeling accelerates the absorption of edema in more severe diabetic macular edema, but we could not find any improvement of visual acuity.