Clinicopathologic Correlation of Surgically Removed Macular Hole Opercula: Author Reply (original) (raw)
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Role of Posterior Vitreous Detachment in Idiopathic Macular Holes
Ophthalmology, 1990
The role of posterior vitreous detachment in the formation of idiopathic macular hole was evaluated in 310 eyes. The eyes were classified according to the stage of the initial macular pathology: group 1, macular cyst; group 2, early macular hole; and group 3, fully developed macular hole. The initial prevalence of posterior vitreous detachment was 0% (none of 15 eyes) in group 1, 6% (three of 50 eyes) in group 2, and 27% (67 of 245 eyes) in group 3. During the study, all 15 eyes in group 1 and all 43 eyes in group 2 for which data were obtained progressed to fully developed macular holes without the occurrence of posterior vitreous detachment. The findings strongly suggested that most idiopathic macular holes develop in the absence of posterior vitreous detachment and that the pathogenesis of the holes may be independent of the occurrence of posterior vitreous detachment. Ophthalmology 1990; 97:1610-1613 Although many reports l-16 have implicated vitreous traction on the macula in the pathogenesis of idiopathic macular holes, the vitreous condition that produces traction on the macula and the nature of the traction are still controversial. Some authors4-8,1O speculated that posterior vitreous detachment may play an important role in the formation of idiopathic macular holes, since they observed a posterior vitreous detachment prevalence of 88-100% in eyes with a macular hole. Reese et ae and Maumenee 4 suggested that traction through the residual vitreomacular adhesion after posterior vitreous detachment may cause the macular hole. McDonnell et al 8 proposed that the transient vitreous traction on the macula during the development of posterior vitreous detachment may be the prime pathogenetic factor. On the other hand, A vila and colleagues,9 finding posterior vitreous detachment in only 48% of their patients, proposed that anteriorly oriented intravitreous macular traction, rather than posterior vitreous detachment, may cause macular hole. Gass l4 later proposed the hypothesis that tangentially oriented contraction of the prefoveal Originally
Histopathological Features of Vitreous Removed at Macular Hole Surgery
Archives of Ophthalmology, 1999
Objective: To describe the histopathological features of the vitreous removed at surgery for macular holes in 200 consecutive cases. Methods: The complete vitrectomy specimen in each case was concentrated by means of cellulose membrane filters and stained for light microscopy. The cases were organized into 5 categories: (1) all cases (N = 200), (2) eyes without previous vitrectomy (n = 174), (3) eyes with previous vitrectomy (n = 26), (4) idiopathic cases (n = 143), and (5) traumatic (accidental or surgical) cases (n = 31). The type and frequency of tissue fragments present in the vitreous were determined for each case. Results: Fibrocellular and cellular membrane fragments were found in a minority of cases in all categories. Retinal fragments were a rare finding, present in only 4 cases. Inflammation was present in 57 (28.5%) of all cases. Conclusions: The absence of fibrocellular and cellular membrane fragments in the majority of cases suggests that mechanisms other than cellular proliferation are important in the pathogenesis of macular holes. These fragments are, however, the likely histopathological correlate of the opercula that are often observed clinically in patients with macular hole. Opercula rarely if ever contain retinal fragments, and thus are better termed pseudo-opercula, as has been previously suggested. The cellular proliferation and inflammation that are observed in some of the cases are likely a secondary or reactive process.
Pathogenesis and Management of Macular Hole: Review of Current Advances
Journal of Ophthalmology, 2019
Macular hole has been believed to be a disorder of vitreomacular interface, which forms as a result of abnormal vitreous traction from incomplete vitreous detachment. However, our recent studies demonstrated that dynamic forces, caused by mobile posterior cortical vitreous with fluid currents, exist already at early stages of macular hole development. erefore, in eyes with flexible vitreous, the contributions of tractional forces due to vitreous shrinkage are unlikely. ese facts indicate that in the development of idiopathic macular holes, there is a greater contribution of dynamic forces than has been previously reported. is review also evaluates the recent findings in the assessment of the idiopathic macular holes and the recent therapeutic strategies for optimal management. Inner limiting membrane is considered to improve anatomical closure rate; however, it is still questionable if peeling is necessary in holes less than 250 µm. ere are plenty of publications indicating that in the management of small and medium size hole (less than 400 µm), use of long-lasting gas and face-down position is not always required; however, it may be necessary for the treatment of large holes. Ocriplasmin and expansile gas had been reported to be successful for management of small-and medium-sized holes and vitreomacular attachment.
Formation of idiopathic macular hole—reappraisal
Graefe's Archive for Clinical and Experimental Ophthalmology, 2010
Purpose The study is intended to examine the development of macular hole in idiopathic conditions. Methods A 2-year case file of optical coherence tomography (OCT) with the initial diagnosis of idiopathic impending hole (IH) or lamellar hole (LH) was reviewed. All cases of IH or LH were sequentially examined for more than 9 months. All cases with IH had vitreo-foveal adhesion, and were separated into type A (foveal detachment ± inner retinal cysts) and type B (inner retinal cysts only). Results Eight cases had type A IH, 15 cases had type B IH, and 27 cases had LH. Seven cases of type A IH developed full-thickness macular hole (FTMH) at an average of 5.1± 2.2 months, and the one other case was operated. Five cases of type B IH were operated. For the other ten cases, at an average of 11.4±3.5 months, none had developed foveal detachment or FTMH, but five had developed LH. Three cases with initial LH subsequently developed FTMH. Conclusion In idiopathic cases, vitreo-foveal traction with foveal detachment may lead to FHMH, while inner cysts only without foveal detachment seem tend to evolve into LH instead of FHMH. Furthermore, LH may develop into FTMH.
Macular holes: vitreoretinal relationships and surgical approaches
Eye, 2008
Idiopathic full-thickness macular holes develop as a result of anteroposterior and tangential traction exerted by the posterior vitreous cortex at the fovea. Vitreoretinal relationships during the development of macular holes can be demonstrated in detail by ocular coherence tomography, facilitating an improved understanding of their pathogenesis and guiding clinical management. Surgical strategies for the repair of macular holes are designed to relieve vitreofoveal traction and to promote flattening and reapposition of the macular hole edges by intraocular gas tamponade. A period of facedown positioning postoperatively is conventionally advised. However, the evidence to support this recommendation is weak and practice varies considerably. Surgical removal of the inner limiting membrane (ILM) is advocated to ensure thorough removal of any tangential tractional components including any residual cortical vitreous. Current evidence suggests that ILM peeling can improve anatomical outcomes but the effect on visual function is less predictable; unsuccessful attempts to peel the ILM can be associated with poor visual outcome. The use of vital dyes can facilitate visualisation of the ILM and help achieve complete, atraumatic peeling. Indocyanine green dye can enable high rates of macular hole closure but has been associated with poorer visual outcomes suggesting a dosedependent toxicity. Trypan blue dye offers an alternative that may have a more favourable risk profile. An improved understanding of vitreoretinal relationships may facilitate a tailored approach to surgery in individuals with macular holes. Vitrectomy to relieve anteroposterior traction is central in the management of all full-thickness holes. The use of long-acting gases, prolonged face-down positioning, and ILM peeling may be more valuable for larger holes, longstanding holes, and those that have failed to close following conventional surgery. Vitreoretinal relationships and surgical approaches J Bainbridge et al 1302 Eye Vitreoretinal relationships and surgical approaches J Bainbridge et al Vitreoretinal relationships and surgical approaches J Bainbridge et al 1307 Eye Vitreoretinal relationships and surgical approaches J Bainbridge et al 1309 Eye
Spontaneous closure of small full‐thickness macular holes: Presumed role of Müller cells
Acta Ophthalmologica
To document with spectral domain optical coherence tomography the formation and spontaneous closure of small full-thickness macular holes and to propose the active role of M€ uller cells in macular hole closure. Methods: A retrospective case series of five patients with spontaneous closure of macular holes is reviewed. In one patient, foveal images were recorded over a period of 18 months. Results: In a 66-year-old man, vitreofoveal traction caused a detachment of the inner M€ uller cell layer of the foveola from the outer nuclear layer (ONL) which was associated with a large pseudocyst and a horizontal gap in the central ONL. The traction caused an elongation and subsequent disruption of the stalk of the M€ uller cell cone in the foveola. A small full-thickness macular hole developed when a portion of the inner M€ uller cell layer of the foveola was pulled out. After phacoemulsification and shortly before the subsequent spontaneous closure of the hole, there were rapid increases in the number and size of the cystic cavities in the foveal walls resulting in a narrowing of the hole. The hole closed by bridging the gap in the inner part of the central ONL; a new inner M€ uller cell layer of the foveola was formed, and the gap of the external limiting membrane (ELM) was closed. The cystic cavities in the foveal walls rapidly disappeared within 2 weeks after the closure of the hole. One to 2.5 months after hole closure, the thickness of the central ONL increased which decreased the distance between the central ELM and retinal pigment epithelium. In three of the four other patients, the hole also closed by bridging the gap in the inner part of the ONL. Conclusion: It is suggested that the spontaneous closure of small macular holes and the subsequent reconstruction of the normal foveal structure are mediated by active mechanisms of M€ uller cells which resemble those involved in ontogenetic foveal development.
American Journal of Ophthalmology, 2002
PURPOSE: To report the foveal anatomy in patients with perifoveal posterior vitreous detachments (PPVD) using optical coherence tomography. • DESIGN: Retrospective observational case series. • METHODS: A retrospective study of fellow eyes of patients of patients with macular holes and those with early macular hole states were examined with optical coherence tomography, biomicroscopy, and contact bscan ultrasonography. Twenty-three eyes of 23 patients were discovered to have PPVD, which was defined as persistent attachment of the vitreous to the central macula with a limited detachment of the posterior vitreous in the perifoveal region. • RESULTS: The mean diameter of persistent vitreous attachment in eyes with no foveal deformation was 1829 m, flattening of the foveal depression 840 m, and with foveal cavitation 281 m (P < .001, Spearman rank correlation). The difference in the mean diameters was significant (P ؍ .001, Kruskal-Wallis test, all pairwise comparisons showing significant difference using the Mann-Whitney test). • CONCLUSIONS: This study found that the diameter of the vitreous attachment in eyes with PPVD correlated with induced changes in foveal anatomy. The diameters of vitreous attachment were consistent with known regions of robust attachment of the vitreous determined histologically. Although the actual force loading on the central macula cannot be determined in patients with perifoveal posterior vitreous detachments, the stress, which is force / unit area may well increase with smaller areas of attachment leading to mechanical failure of the macula. (Am J Ophthalmol 2002;133:226 -229.
American Journal of Ophthalmology, 2007
PURPOSE: To investigate the macular changes following silicone oil removal after surgery for complicated retinal detachment (RD) with proliferative vitreoretinopathy (PVR). • DESIGN: Retrospective interventional case series. • METHODS: SETTING: Vienna, Austria. STUDY POPULA-TION: Thirty-nine patients with attached retina after silicone oil removal following previous vitrectomy and silicone oil tamponade for complicated RD and PVR grade C3 and worse. OBSERVATION PROCEDURES: Examination of macular anatomy with biomicroscopy, optical coherence tomography (OCT), and fluorescein angiography (FA). Macular function was tested by assessing logMAR distance visual acuity (VA) using Early Treatment Diabetic Retinopathy Study (ETDRS) charts and reading acuity and reading speed using a standardized test (Radner charts). MAIN OUTCOME MEASURES: Macular anatomy, VA, reading acuity, and reading speed. • RESULTS: The macula was clinically normal in five patients (12.8%). Retinal pigment epithelium (RPE) irregularities were found in nine patients (23.1%). Eight patients (20.5%) had macular pucker, seven (18.0%) had cystoid macular edema (CME), and 10 (25.6%) had subretinal fibrosis. The mean VA of all patients was logMAR 0.67 ؎ 0.68 (range, ؊0.1 to 3.0). Six eyes did not achieve reading acuity. The distance VA of the remaining 33 eyes was logMAR 0.44 ؎ 0.29 and their mean reading acuity was logRAD 0.62 ؎ 0.35, with a reading speed ranging from 55 to 240 words per minute. • CONCLUSIONS: We found macular changes in 87% of the patients, one-third thereof being eligible for further treatment (macular pucker or CME). Thus, the majority of these patients do not seem to be eligible for a further improvement of anatomic or functional outcome. (Am J Ophthalmol 2007;144:872-877.