Yukari Shirakata

Autologous Transplantation of the Internal Limiting Membrane for Refractory Macular Holes

PURPOSE To determine the effectiveness of autologous transplantation of the internal limiting membrane (ILM) for refractory macular holes. DESIGN Prospective, interventional case series. PATIENT AND METHODS Ten eyes of 10 consecutive patients who underwent autologous transplantation of the ILM for the treatment of refractory macular holes were studied. The primary diseases in these patients were large idiopathic macular holes that had existed for more than 1 year (4 eyes), a traumatic macular hole (1 eye), myopic foveoschisis (2 eyes), foveoschisis resulting from pit-macular syndrome (2 eyes), and proliferative diabetic retinopathy (1 eye). Apart from the 5 eyes with idiopathic or traumatic macular holes, macular holes developed in the other 5 eyes after initial vitrectomies with ILM removal. In all eyes, regular macular hole surgery failed to achieve closure. The main outcome measures used in this study were macular hole closure and best-corrected visual acuity (BCVA). RESULTS Macular holes were closed successfully in 9 eyes (90%) after autologous transplantation of the ILM. The postoperative BCVAs were significantly better than the preoperative BCVAs (P = .007, paired t test). Postoperative BCVAs improved by more than 0.2 logarithm of the minimal angle of resolution units in 8 eyes (80%) and were unchanged in 2 eyes (20%). CONCLUSIONS Although this is a pilot study, the results suggest that autologous transplantation of the ILM may contribute to improved anatomic and visual outcomes in the treatment of refractory macular holes and may warrant further investigation.

Six-month results of intravitreal aflibercept injections for patients with polypoidal choroidal vasculopathy

Background This study aims to evaluate the therapeutic effect of intravitreal aflibercept injection for polypoidal choroidal vasculopathy (PCV). Methods Eighteen eyes of 17 consecutive patients with PCV received three consecutive monthly intravitreal injections of aflibercept and one additional injection 2 months later (four injections totally). All patients underwent eye examinations, which included best-corrected visual acuity (BCVA), fluorescein angiography, indocyanine green angiography, and optical coherence tomography. The primary endpoint of the study was the regression of polypoidal lesions. The secondary endpoints were BCVA, central retinal thickness (CRT) and changes in retinal exudation. Results Six months after the first aflibercept injection, the polypoidal lesions were completely resolved in 14 eyes (77.7%) and partially resolved in 4 eyes (22.2%). Although branching choroidal vascular networks were still present in all eyes, retinal exudative changes had completely resolved in 17 eyes (94.4%), and the mean CRT decreased significantly from 407.2±100.1 µm to 229.1±57.2 µm (p<0.0001). BCVA (logarithm of the minimal angle of resolution, logMAR) improved significantly from 0.414±0.384 at baseline to 0.297±0.334 after 6 months (p=0.016). Conclusions At 6 months, aflibercept monotherapy effectively reduced polyps, retinal exudation and CRT in patients with PCV.

Modified vitreous surgery for symptomatic lamellar macular hole with epiretinal membrane containing macular pigment.

Modified Vitreous Surgery for Symptomatic Lamellar Macular Hole With Epiretinal Membrane Containing Macular Pigment Lamellar macular hole (LMH) was first described by Gass in 1975 as an abortive process of fullthickness macular hole formation that resulted from cystoid macular edema. In contrast, macular pseudoholes (MPHs) were attributable to centripetal contraction of the epiretinal membrane (ERM). Because spectraldomain optical coherence tomography (SD-OCT) is able to show detailed configurations of various macular conditions, this examination can be used to differentiate LMH from MPH. However, Michalewski et al used SD-OCT to demonstrate that MPH may progress to LMH, and because it is an advanced stage of the same non–full-thickness macular disorder, progression of ERM may be the cause of both MPH and LMH. Chen et al hypothesized that both entities may be different manifestations of the same disease. The ERM has been shown to coexist in most of cases with LMH. When ERM coexists with macular edema associated with branch retinal vein occlusion or diabetic retinopathy, or when it occurs after cataract surgery, LMH is secondary. In contrast, when no causative retinal diseases are present, LMH should be referred to as idiopathic. Currently, vitrectomy for LMH remains controversial. Although the natural prognosis for idiopathic LMH is usually good, some patients exhibit a visual acuity decrease that may be amenable to surgical treatment. Because LMH is usually accompanied by typical ERM, surgical treatment regularly includes ERM removal and internal limiting membrane (ILM) peeling with or without gas tamponade. In our surgical experience, LMH is frequently accompanied by ERMcontaining macular pigment, and the ERM appearing to originate from inside the LMH. Because the degree of this migration is on a case-by-case basis, a dehiscence of inner from outer retina is accompanied by a translucent ERM (posterior hyaloid membrane) alone, but not an ERM with macular pigment, in some cases with LMH. Based on the previous findings, we have speculated that ERM may contain not only macular pigment but also some partial retinal tissues. In addition, in 1989, Margherio et al described the concept of preretinal membrane dissection toward the fovea in symptomatic eyes considered to be at high risk for idiopathic macular holes development. Thus, the aim of the current study was to examine a modified surgical method for LMH with ERM containing macular pigment and then to report on the morphologic and functional outcomes of this new surgical procedure.

Pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema due to branch retinal vein occlusion after antivascular endothelial growth factor treatments.

Purpose To evaluate the anatomic and functional outcomes of pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema (ME) due to branch retinal vein occlusion (BRVO) after intravitreal injections of antivascular endothelial growth factor (anti-VEGF) agents. Methods Twenty-four eyes of 24 patients with treatment-naive ME from BRVO were treated with intravitreal injections of anti-VEGF agents. Recurred ME was treated with pars plana vitrectomy combined with internal limiting membrane peeling. Results After the surgery, ME was significantly reduced at 1 month (P=0.031) and the reduction increased with time (P=0.007 at the final visit). With the reduction in ME, treated eyes showed a slow improvement in visual acuity (VA). At the final visit, improvement in VA was statistically significant compared with baseline (P=0.048). The initial presence of cystoid spaces, serous retinal detachment, or subretinal hemorrhage under the fovea, as well as retinal perfusion status, showed no association with VA improvement. However, the presence of epiretinal membrane showed a significant association with the visual recovery. Although eyes without epiretinal membrane showed visual improvement (−0.10±0.32 in logarithm of the minimum angle of resolution [logMAR]), eyes with epiretinal membrane showed greater visual improvement (−0.38±0.12 in logMAR, P=0.012). Conclusion For recurrent ME due to BRVO after anti-VEGF treatment, particularly when accompanied by epiretinal membrane, pars plana vitrectomy combined with internal limiting membrane peeling might be a possible treatment option.

Pars Plana Vitrectomy Combined with Internal Limiting Membrane Peeling to Treat Persistent Macular Edema after Anti-Vascular Endothelial Growth Factor Treatment in Cases of Ischemic Central Retinal Vein Occlusion

Objective: To evaluate the efficacy of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling in cases of ischemic central retinal vein occlusion (CRVO) where macular edema (ME) persisted after anti-vascular endothelial growth factor (anti-VEGF) treatment. Methods: Fifteen eyes with ischemic CRVO-related ME were included in the study. Nine were treated with panretinal photocoagulation after initial examination. Anti-VEGF agents were injected intravitreally. Persistent ME was treated with PPV combined with ILM peeling. During surgery, laser photocoagulation was further applied to the non-perfused area. Results: Mean retinal thickness gradually decreased after surgery (p = 0.024 at 6 months), although visual acuity did not improve significantly during the follow-up period (14.7 ± 11.6 months). Neovascular glaucoma subsequently developed in three cases and a trabeculectomy was performed in one case. Conclusion: In eyes with ischemic CRVO, PPV combined with ILM peeling contributed to a reduction in persistent ME. However, there was no significant improvement in visual acuity.