Micol Alkabes

Visual and anatomical outcome after macular buckling for macular hole with associated foveoschisis in highly myopic eyes

Background Macular hole (MH) with associated foveoschisis is very specific to highly myopic eyes with a pronounced posterior staphyloma. A high axial length increases the risk of foveoschisis, MH formation and retinal detachment secondary to a macular hole (MHRD). These highly myopic MH show poor surgical outcomes after vitrectomy and internal limiting membrane peeling compared with non-myopic MH. The posterior staphyloma seems to play an important role, and thus macular buckling could prove useful to improve both visual and anatomical results. Methods Sixteen highly myopic eyes with MH and associated foveoschisis that underwent macular buckling were studied. Vitrectomy combined with macular buckling was performed in all 16 eyes. Optical coherence tomography was performed to confirm MH closure in all cases. Results Combined vitrectomy and macular buckling resulted in MH closure in all patients. Best-corrected visual acuity (BCVA) improved in 13 out of 16 eyes (81.25%), remained stable in 2 eyes (12.5%) and worsened in 1 eye (6.25%). Mean preoperative BCVA was 20/125, whereas mean postoperative BCVA was 20/50. Conclusions Combined vitrectomy and macular buckling is a safe and effective approach to achieve primary closure of MH in eyes with posterior staphyloma and associated foveoschisis. Eyes with a high axial length show a less favourable prognosis, which can be partially overcome by means of macular buckling.

Macular buckling for previously untreated and recurrent retinal detachment due to high myopic macular hole: a 12-month comparative study.

PurposeTo evaluate postoperative outcomes after macular buckling together with pars plana vitrectomy (PPV) in previously untreated and recurrent retinal detachment secondary to macular hole (MH) in highly myopic eyes.MethodsIn a retrospective cohort study, 42 eyes of 42 high myopic patients with retinal detachment due to MH were evaluated. Patients were divided into previously untreated retinal detachment (group 1, 21 eyes) and recurrent retinal detachment (group 2, 21 eyes). Macular buckling and PPV were performed in all patients. Main outcomes included retinal reattachment rate, macular hole closure rate and best-corrected visual acuity (BCVA) at 3, 6, and 12 months. Optical coherence tomography (OCT) was performed both pre- and postoperatively in all patients to assess the anatomical status of the macula.ResultsPrimary retinal reattachment rate in group 1 was 95% (20/21), which increased to 100% (21/21) after a second surgery. MH closure was achieved in 81% of patients (17/21) after one surgery. The mean preoperative BCVA (logarithm of the minimum angle of resolution, LogMAR) improved from 1.32 (95% CI 1.19;1.44) to 0.76 (95% CI 0.56;0.96) 12 months postoperatively. In all except one case, gas tamponade was preferred. Primary reattachment and MH closure rate in group 2 were 90.5% (19/21) and 57% (12/21) respectively, and did not improve after a second surgery. Preoperative BCVA (LogMAR) was 1.39 (95% CI 1.29;1.49) and improved to 0.95 (95% CI 0.75;1.15) at 12 months. Silicone oil tamponade was used in seven of 21 patients, and finally was removed in five of them.ConclusionsMacular buckling combined with PPV should be considered a preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes. Nevertheless, visual outcomes seem to be better when macular buckling is chosen as first-line treatment.

Illuminated Ando Plombe for Optimal Positioning in Highly Myopic Eyes With Vitreoretinal Diseases Secondary to Posterior Staphyloma

Retinal detachment secondary to a macular hole and retinoschisis are complications that can occur in highly myopic eyes. The posterior staphyloma plays an important role in the pathogenesis of these complications in conjunction with other factors such as anteroposterior traction caused by the vitreous cortex, tangential forces due to epiretinal membranes or the internal limiting membrane, and stretched retinal arteries. Varioussurgicalprocedureshavebeendescribedforthetreatment ofretinaldetachment inmyopicmacularholeandfoveoschisis, includingparsplanavitrectomywithintraoculartamponadeandwithorwithout internal limitingmembraneremoval,scleralshortening,andmacular buckling. Several recently published reports describe the success rate of episcleralmacular buckling in highlymyopic eyes.1-10 Different types of macular buckles have been proposed, but proper alignment of the buckle under the fovea is still a major concern in this technique. Siam et al7 reported the use of external posterior landmarks to allow better positioning of the indenting head, but this technique required superior oblique tendon rupture. Stirpe et al10 reported an adjustable macular buckle but indicated that the lateral rectus should be disinserted to ensure correct positioning of the indenting platform. To avoid any damage to extraocularmuscle and to enhance visualization, we propose the insertion of an optical fiber coupled to Video at jamaophthalmology.com

FEATURES OF POSTERIOR STAPHYLOMAS ANALYZED IN WIDE-FIELD FUNDUS IMAGES IN PATIENTS WITH UNILATERAL AND BILATERAL PATHOLOGIC MYOPIA.

Purpose: Pigmentary alterations along the presumed edge of staphyloma in wide-field fundus images have been reported to be highly correlated with the eye shape in three-dimensional magnetic resonance images. The purpose of this study was to analyze Optos images in a large series of highly myopic patients to determine the prevalence, types, and features of staphylomas. Methods: One thousand and sixty eyes of 541 patients with high myopia (axial length ≥ 26.5 mm) in at least one eye were retrospectively analyzed in Japan and Spain. To determine the presence and types of staphyloma, the authors focused on pigmentary abnormalities along the presumed edge of staphylomas with at least one positive finding in fundus images, autofluorescent images, and infrared images by Optos. Results: Posterior staphyloma was detected in 552 of 1,060 eyes (55%) in Optos images. Wide macular type was the most common (79%), followed by narrow macular (15%), then peripapillary (3%), inferior, and finally nasal. In the 60 non-highly myopic eyes of patients with unilateral high myopia, staphyloma was detected in 40%, suggesting that unilateral high myopia might be a bilateral disorder with marked differences in the degree of staphyloma between the two eyes. Combined staphylomas such as the peripapillary type within the wide macular type were also found. Conclusion: Posterior staphyloma was found in 55% of 1,060 eyes with bilateral or unilateral pathologic myopia. Wide macular was the most common type, although there were much more variations in the shape of staphylomas than that had been previously believed.

Spectral-domain optical coherence tomography measurements of central foveal thickness before and after cataract surgery in children

Purpose To compare macular thickness before and after cataract surgery and intraocular lens (IOL) implantation in pediatric eyes. Design Retrospective cohort study. Setting University Eye Clinic, San Giuseppe Hospital, University of Milan, Milan, Italy. Methods The study analyzed spectral‐domain optical coherence tomography (SD‐OCT) images of the macula in pediatric eyes in which cataract surgery had been performed and that were examined preoperatively and 1, 3, 6, 9, and 12 months postoperatively. Results The mean age of the 11 patients (11 eyes) was 5.8 years ± 2.2 (SD) (range 3 to 14 years). The mean macular thickness at 1 month and 3 months was significantly higher than at baseline (273.7 ± 26.8 &mgr;m and 266.0 ± 22.8 &mgr;m, respectively, versus 244.8 ± 19.5 &mgr;m; P < .0001). It reached the baseline value after 3 months and remained stable over the 12‐month follow‐up. The mean thicknesses at 6, 9, and 12 months were 249.1 ± 17.6 &mgr;m, 245.7 ± 18.5 &mgr;m, and 246.2 ± 18.1 &mgr;m, respectively (P > .05 versus baseline). Conclusions Spectral‐domain OCT was useful in evaluating the macular changes in the eyes of a cohort of pediatric patients 3 years and older. Cystoid macular edema was not observed during the 12‐month follow‐up. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Management of macular edema secondary to retinal vein occlusions

Retinal vein occlusions are the second most common type of retinal vascular disease and include branch vein occlusions, hemiretinal vein occlusions and central vein occlusions; in most patients, macular edema is the predominant cause of vision loss. Until recently, laser photocoagulation was the only treatment for edema secondary to retinal vein occlusion supported by data from high-quality randomized trials; data are now also available from several trials assessing the use of intraocular glucocorticoids and agents inhibiting VEGF. As data from randomized clinical trials accumulate, a precise role for each of these therapies may become clearer.

Direct Transretinal Removal of Subfoveal Perfluorocarbon Liquid: The Role and Timing of Internal Limiting Membrane Peeling

Purpose To describe a case series including 4 patients undergoing direct transretinal aspiration of subfoveal perfluorocarbon liquid (PFCL) and internal limiting membrane (ILM) peeling after macula-off retinal detachment surgery. Methods Four patients who had undergone vitreoretinal surgery due to primary rhegmatogenous retinal detachment were further treated because of retained subfoveal PFCL. Direct transretinal aspiration of PFCL through a self-sealing foveal retinotomy was performed in all cases using a 41-G needle placed on the top of the bubble. The ILM was peeled off prior to and after PFCL removal in 2 cases, respectively. Optical coherence tomography (OCT) scans were obtained preoperatively and postoperatively to assess the status of the macula. Results Subfoveal PFCL was successfully removed in all cases. Two patients had silicone oil tamponade at the time of the second surgery, which was temporarily removed in both cases and then reapplied in one. Best-corrected visual acuity improved in all cases. No postoperative macular hole was observed by OCT. Conclusions Direct transretinal aspiration of subfoveal PFCL with a 41-G cannula combined with conventional ILM peeling is a safe and effective technique to avoid long-term damage to the retinal layers with good functional outcomes. Performing the ILM peeling immediately before or after the PFCL aspiration does not seem to influence anatomic results.

Macular buckle technique in myopic traction maculopathy: a 16-year review of the literature and a comparison with vitreous surgery

PurposeThe aim of this study is to review anatomical and functional outcomes following macular buckling (MB) in high myopia and to compare such results with those obtained by pars plana vitrectomy (PPV).MethodsPubMed articles on MB in high myopia (2000–2016) were reviewed. Main outcomes included retinal reattachment and macular hole (MH) closure rates, resolution of myopic foveoschisis (MFS), and postoperative visual acuity.ResultsThirty-one articles included 16 in patients with retinal detachment due to MH (MHRD group), 11 in MFS with or without foveal detachment (MFS group), and 4 in MH patients with MFS (MH-MFS group). Surgical techniques mainly differed in the type of buckle, rectus muscles involvement, and concurrent PPV. In eyes with persistent MH, prognosis in the MHRD and MH-MFS groups differed between eyes receiving MB compared to PPV: functional outcome was markedly poorer and there was a higher risk of retinal redetachment associated with PPV. In the MSF group, secondary MHs were more likely to develop in eyes treated with PPV and internal limiting membrane peeling than those undergoing MB alone or combined with PPV. Retinal pigment epithelium changes, malpositioning, perforation, and choroidal detachment were the main complications.ConclusionsAlthough different approaches are used, complete resolution of foveoschisis, retinal reattachment, and MH closure seem to be achieved more frequently with MB than PPV.

EARLY MICROVASCULAR AND NEURAL CHANGES IN PATIENTS WITH TYPE 1 AND TYPE 2 DIABETES MELLITUS WITHOUT CLINICAL SIGNS OF DIABETIC RETINOPATHY

Purpose: To assess and compare early modifications in inner retinal layer thickness and optical coherence tomography angiography parameters in patients with diabetes mellitus (DM) Types 1 and 2 without clinical signs of diabetic retinopathy. Methods: Ninety eyes of 90 subjects (24 Type 1 DM, 36 Type 2 DM, and 30 healthy controls) were prospectively evaluated with spectral domain OCT, swept-source OCT angiography, and color fundus photography (on the same day). Retinal nerve fiber layer, ganglion cell layer (GCL+), and nerve fiber layer + GCL+ (GCL++) thickness were automatically determined by the instrument in the 1, 3, and 6 central mm. On OCT angiography, the following parameters were evaluated: area of foveal avascular zone, number of focally dilated endings of the capillaries (detected only on OCT angiography), presence of regular/irregular foveal avascular zone, capillary loss, and capillary network irregularities in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). Results: Ganglion cell layer+ (P = 0.0099) and GCL++ (P = 0.0367) were significantly thicker in DM Type 1 versus DM Type 2 in 1 central mm, after adjustment for age and DM duration. The area of foveal avascular zone was significantly larger in DM Type 1 versus controls in both SCP and DCP and in DM Type 1 versus Type 2 only in DCP (P < 0.05 for all); the number of focally dilated endings of the capillaries was higher in DM Type 1 versus controls in both SCP and DCP (P < 0.01 for all); and in DM Type 2 versus controls only in DCP (P = 0.007). Perifoveal capillary loss in SCP and inner retinal layer thickness had the highest correlation in both DM types. Conclusion: There are specific neural and microvascular modifications even before clinical signs of diabetic retinopathy in DM Types 1 and 2. Perifoveal capillary loss in the SCP is highly correlated with inner retinal layer. These data may help in characterization of patients at the preclinical stage of diabetic retinopathy.

Macular Buckling Technique in High Myopia

High myopia is a clinical condition characterized by a progressive axial elongation of the eye associated with a posterior staphyloma, which leads to an increased risk of specific macular diseases, such as myopic foveoschisis (MF) and macular hole (MH) with or without retinal detachment. Currently, different surgical procedures have been proposed to treat MF, MH, and MHRD in highly myopic patients such as the macular buckling (MB) technique. Several studies in the last decade have shown that the reshaping of the posterior wall by correcting the disproportion between the retina and the elongated sclera provides better results when compared to the outcomes of the patients treated by pars plana vitrectomy (PPV) alone. The common belief that this surgical procedure is technically challenging, mostly due to difficulties related to the correct placement of the buckle and potential risk of damaging adjacent ocular structures, has raised questions concerning the best approach. Therefore, in this chapter we will endeavor to describe why we believe this surgical technique might be the preferred approach for treating patients who have developed the complications of high myopia.