Ulrik C. Christensen

Vitrectomy with Internal Limiting Membrane Peeling versus No Peeling for Idiopathic Full-Thickness Macular Hole

OBJECTIVE To determine whether internal limiting membrane (ILM) peeling improves anatomic and functional outcomes of full-thickness macular hole (FTMH) surgery when compared with the no-peeling technique. DESIGN Systematic review and individual participant data (IPD) meta-analysis undertaken under the auspices of the Cochrane Eyes and Vision Group. Only randomized controlled trials (RCTs) were included. PARTICIPANTS AND CONTROLS Patients with idiopathic stage 2, 3, and 4 FTMH undergoing vitrectomy with or without ILM peeling. INTERVENTION Macular hole surgery, including vitrectomy and gas endotamponade with or without ILM peeling. MAIN OUTCOME MEASURES Primary outcome was best-corrected distance visual acuity (BCdVA) at 6 months postoperatively. Secondary outcomes were BCdVA at 3 and 12 months; best-corrected near visual acuity (BCnVA) at 3, 6, and 12 months; primary (after a single surgery) and final (after >1 surgery) macular hole closure; need for additional surgical interventions; intraoperative and postoperative complications; patient-reported outcomes (PROs) (EuroQol-5D and Vision Function Questionnaire-25 scores at 6 months); and cost-effectiveness. RESULTS Four RCTs were identified and included in the review. All RCTs were included in the meta-analysis; IPD were obtained from 3 of the 4 RCTs. No evidence of a difference in BCdVA at 6 months was detected (mean difference, -0.04; 95% confidence interval [CI], -0.12 to 0.03; P=0.27); however, there was evidence of a difference in BCdVA at 3 months favoring ILM peeling (mean difference, -0.09; 95% CI, -0.17 to-0.02; P=0.02). There was evidence of an effect favoring ILM peeling with regard to primary (odds ratio [OR], 9.27; 95% CI, 4.98-17.24; P<0.00001) and final macular hole closure (OR, 3.99; 95% CI, 1.63-9.75; P=0.02) and less requirement for additional surgery (OR, 0.11; 95% CI, 0.05-0.23; P<0.00001), with no evidence of a difference between groups with regard to intraoperative or postoperative complications or PROs. The ILM peeling was found to be highly cost-effective. CONCLUSIONS Available evidence supports ILM peeling as the treatment of choice for patients with idiopathic stage 2, 3, and 4 FTMH.

Visual loss after use of intraocular silicone oil associated with thinning of inner retinal layers

Purpose:  To investigate the incidence and cause of severe visual loss following use and removal of intraocular silicone oil (SiO) after uncomplicated vitrectomy and SiO injection for primary rhegmatogenous retinal detachment (RRD).

Prognostic Significance of Delayed Structural Recovery after Macular Hole Surgery

PURPOSE To assess the prognostic significance for visual function of persistent subfoveal fluid and persistent photoreceptor layer discontinuity in eyes in which hole closure had been obtained 3 months after macular hole surgery. DESIGN Ancillary study of subjects enrolled in a randomized clinical trial. PARTICIPANTS Participants were recruited from a randomized clinical trial evaluating internal limiting membrane (ILM) peeling in macular hole surgery. The study included 74 eyes in which a contiguous retinal surface or a full attachment with a flat neuroretinal rim had been reestablished after macular hole surgery. METHODS Contrast-enhanced optical coherence tomography was used to detect closure defects involving substrata of the retina with particular emphasis on the photoreceptor layer. Outcomes were compared with best-corrected visual acuity (BCVA) 12 months after surgery. MAIN OUTCOME MEASURES Postoperative foveal configuration and foveal photoreceptor layer discontinuity diameter 3 months after macular hole surgery. RESULTS Persistent subfoveal fluid 3 months after macular hole surgery, which was found in 36.5% of eyes, was not associated with a significantly different BCVA after 12 months compared with eyes with a fully attached fovea at 3 months (70.9 letters vs. 72.0 letters; P = 0.59). Receiver operating characteristics curve analysis identified persistent photoreceptor layer discontinuity of a diameter of more than 1477 microm after 3 months to be associated with poorer BCVA after 12 months (P<0.001), yet an overall reduction in discontinuity diameter from 3 to 12 months (P<0.001) was not correlated with a concurrent improvement in BCVA (r = -0.040; P = 0.81). Persistence of fluid and diameter of discontinuity at 3 months were not related to whether ILM peeling was used; however, secondary macular hole surgery had a significant influence on diameter of photoreceptor layer discontinuity at 3 months. CONCLUSIONS Structural recovery in the form of photoreceptor layer discontinuity with a diameter of more than approximately 1500 microm 3 months after macular hole surgery was associated with poorer visual acuity after 12 months than less extensive discontinuity. Subfoveal fluid persisting after 3 months had disappeared after 12 months in all but 5 of 74 eyes and had no effect on final visual outcome.

Macular morphology and visual acuity after macular hole surgery with or without internal limiting membrane peeling

Aim: To examine postoperative macular morphology and visual outcome after 12 months in relation to internal limiting membrane (ILM) peeling versus no peeling, indocyanine green (ICG) staining and re-operation in eyes that achieved macular hole closure after surgery. Methods: Seventy-four eyes with closed stage 2 or 3 macular holes were recruited from a randomised clinical trial comparing: (1) vitrectomy without ILM peeling; (2) vitrectomy with 0.05% isotonic ICG-assisted ILM peeling; and (3) vitrectomy with 0.15% trypan blue-assisted ILM peeling. Contrast-enhanced Stratus optical coherence tomography was used to assess central foveal thickness, central photoreceptor layer thickness (CPRT), central photoreceptor layer discontinuity (PRD) and relative reflectivity of the outer nuclear layer. Outcomes were correlated with best corrected visual acuity (BCVA) 12 months after surgery. Results: BCVA was correlated with CPRT and PRD. Regression analysis and receiver operating characteristics curve analysis showed that CPRT >33 μm (OR 12.5) and PRD <177 μm (OR 9.86) were highly predictive for regaining reading vision (⩾69 Early Treatment of Diabetic Retinopathy Study letters) 12 months after surgery. No significant difference was found in postoperative macular morphology between subgroups. Conclusions: Poor vision after 12 months despite macular hole closure was associated with attenuation and disruption of the foveolar photoreceptor matrix. The extent of attenuation and disruption was independent of peeling and staining. Trial registration number: NCT00302328

Deferral of surgery for epiretinal membranes: Is it safe? Results of a randomised controlled trial

Background/aims To compare the visual outcome in early versus deferred surgery in patients with idiopathic epiretinal membrane (ERM) and good presenting visual acuity and mild symptoms. Methods This study is a randomised clinical trial. 53 eyes of 53 patients with symptomatic ERM and best-corrected visual acuity (BCVA) at presentation ≥65 early treatment diabetic retinopathy study (ETDRS) letters were randomised to immediate surgery (20 eyes) or to watchful waiting (33 eyes) for 1 year. Primary end-point was BCVA after 12 months. Secondary end-points were central macular thickness and the number of patients that crossed over from the watchful waiting arm to the surgery arm due to deteriorated symptoms. Results Mean BCVA after 12 months in the watchful waiting group (81 letters) were not significantly different from patients undergoing immediate surgery (82.5 letters, p=0.647). During 1 year of follow-up, eight patients in the watchful waiting group (24%) crossed over to surgery and these patients gained a mean of 3.1 letters (SEM 1.38). Patients randomised to immediate surgery gained approximately one line. Watchful waiting patients who remained without surgery were stable. The visual acuity gain after surgery is slow and gradual until 9 months postoperatively. There were no serious complications such as retinal detachment or infectious endophthalmitis. Conclusions Vitrectomy for early symptomatic ERM is beneficial in preserving excellent vision. A watchful waiting approach with 1 year of follow-up is safe in the sense that this group does not lose five ETDRS letters in waiting. Deferral of surgery by regular monitoring of patients is a safe approach. Trial registration numbers H-C-2008-026 and NCT00902629.

Refractive outcome after pars plana vitrectomy for macular hole in pseudophakic eyes

Editor, W e read with great interest the article by Merry et al. (2016) on photobiomodulation (PBM) in dry age-related macular degeneration (AMD). The tremendous results of PBM in the improvement of bestcorrected visual acuity and contrast sensitivity notwithstanding, there were certain misgivings in their study which they succinctly highlighted as well. A previous similar study (TORPA) by the same authors found no difference in the preferential retinal locus (PRL) in 18 subjects treated with PBM on microperimetry (Merry et al. 2012, ARVO abstract). Preferential retinal locus (PRL) is a surrogate marker for improved and steady fixation. Microperimetry was not employed in this follow-up study. It would be interesting to see the subjective change in PRL and improvement in microperimetry in the subjects using PBM. Fundus autofluorescence (FAF), central retinal thickness (CRT) and retinal volume (RV) used as anatomical adjuncts for the change in dry AMD with PBM showed no significant improvement and in fact showed mild worsening of FAF at visit 2 (3 months). While drusen volume showed a significant change for the better, it seems odd that the FAF, which is a surrogate for retinal pigment epithelium function, showed worsening in area. The authors could try to explain this paradox. Despite these limitations, we are glad to see a novel therapeutic modality has a significant impact in dry AMD which offers more hope to AMD patients. We congratulate the authors for the outstanding results and hope to see a dose ranging of PBM would help identify the beneficial effect of specific wavelengths in AMD.