This consecutive nonrandomized comparative interventional study was designed to examine the association between pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peeling in the treatment of idiopathic macular holes (IMH). The ILM is the innermost layer of the retina. The macula is located within the retina, and is responsible for central vision. Although IMH manifests in a relatively small region within the retina, patients notice significant drops in visual acuity up to the 20/400 - 20/800 level (legally blind in the affected eye). In the literature, the anatomic success rate of macular hole surgery has been reported between 48% - 94%. To best treat idiopathic macular holes, it is imperative that physicians have access to the most up-to-date information regarding the treatment outcomes. This study included 55 eyes of 52 patients who received surgery at the Beth Israel Deaconess Medical Center for idiopathic macular holes between December 1999 and January 2015. Patients were non-randomly assigned to PPV with or without ILM peeling. Early patients did not receive ILM peeling, while more recent patients did. The primary endpoint measured was macular hole (MH) status as established by ocular coherence tomography (OCT) within 6 to 12 months of the vii procedure. 36 out of 39 (92.3%) eyes in the ILM peeling group had closed MH. In the comparison group without ILM peeling, 11 out of 16 (68.8%) eyes had closed MH. In comparison to the conventional PPV without ILM peeling, these findings suggest that PPV with ILM peeling is associated with a significantly higher anatomic success rate (OR, 5.45; [95% CI, 1.12 to 26.55]; P = 0.023). / 2018-06-16T00:00:00Z

ObjetivosEstudiar el papel de la extracción de la membrana limitante interna (MLI) durante la vitrectomía posterior por vía pars plana (VPP), en el tratamiento quirúrgico de lo agujero macular (AM) y de lo edema macular crónico diabético (EMCD). Hemos estudiado las tasas de éxito clínico de la extracción de la MLI durante la VPP. Además hemos analizado el procedimiento técnico de extracción de la MLI, el aporte de la extracción de la MLI en la resolución clínica del EMCD después de la VPP y el valor de la tomografía de coherencia óptica (TCO) en el seguimiento de pacientes con EMCD y AM.El objetivo secundario consistía en establecer una correlación clínico-patológica mediante el examen histológico de la MLI. Este estudio abarcaba los descubrimientos histológicos y las diferencias de la MLI observadas mediante microscopia electrónica de transmisión (MET) y microscopia óptica (MO).Material y MétodosEstudio prospectivo de un año de 28 pacientes, no randomizado, no comparativo, con dos grupos de pacientes: 1) grupo con AM; 2) grupo con EMCD resistente al tratamiento láser.Los pacientes habían sido sometidos, antes y después de la VPP, a un examen oftalmológico: refracción objetiva, mejor agudeza visual (AV) corregida con teste de Snellen, medición de la presión intraocular, biomicroscopia, examen del fondo ocular y oftalmoscopia indirecta. El seguimiento postoperatorio fue efectuado durante el primer año a un día, una semana, 1, 3, 6 y 12 meses del postoperatorio. Los pacientes fueron sometidos a angiografía fluoresceínica digital, fotografía del fondo de ojo y mapado macular con TCO, como exámenes diagnósticos complementarios. Todos los pacientes fueron sometidos a la VPP y el objetivo principal era la disección epiretiniana y extracción de la MLI. Las MLIs fueron preparadas para un análisis con MO y MET. ResultadosEn el grupo con AM formado por diez ojos, seis tenían AM de tipo 2 y 3 y cuatro de tipo 4 (clasificación de Gass). Cinco pacientes presentan AM idiopáticos. Todos, salvo uno, mantuvieron o mejoraron la mejor AV corregida al final del estudio. La mejora de la VA era significativa estadísticamente sólo después del tercer mes del postoperatorio. El seguimiento mediante OCT demostró que el cierre del los AM fue alcanzado en nueve de ellos. La TCO pudo acompañar la evolución anatómica del cierre del agujero. En los 18 pacientes con EMCD, trece ojos mejoraron la AV, en dos no se produjo ningún cambio y tres empeoraron la AV, al final del seguimiento. La mejora de la AV comenzó a ser significativa entre el tercer y sexto mes del postoperatorio. El espesor foveal postoperatorio se redujo de manera significativa y progresiva respecto al observada en el preoperatorio. Hemos observado una disminución graduada y evidente del espesor macular paralelamente con una mejora progresiva de la AV: cuanto menos espessa era la fovea (TCO), mayor resultaba la mejor AV corregida. Hemos analizado las características ultraestructurales de la MLI normal en las retinas extraídas de dos donadores de ojos y comparado la MLI obtenida de los ojos sometidos a la VPP. Hemos realizado el examen histopatológico en 10 muestras del grupo con AM. Hemos podido observar la presencia de la MLI en 9 muestras. Hemos encontrado residuos de retina neurosensorial asociada con la superficie retinal de la MLI en 3 muestras. Pocas MLI presentaban un componente celular asociado con la superficie vítrea. En algunas MLI, hemos observado la presencia de fragmentos condensados de la hialoides posterior, a veces asociado con componente celular. Hemos llevado a cabo 75 mediciones correspondientes a distintos segmentos de la MLI. Los resultados han demostrado una significativa diferencia (p = 0.00011) entre el promedio del espesor de la MLI en el grupo con AM y en máculas normales. Al comparar el promedio de espesor observado en el grupo con AM con los obtenidos en el grupo con EMCD (2.2 ± 0.78 µm), la diferencia era siempre significativa (p = 0.03).En las muestras diabéticas examinadas mediante MET, hemos podido observar la presencia de la MLI en 7 muestras sobre 10. En 3 muestras sobre 10 no había ninguna MLI y la membrana epiretiniana presentaba una gran cantidad de matriz extracelular (colágeno y una gran variabilidad de células). El único descubrimiento histopatológico observado en 5 muestras mediante MET consistía en segmentos de MLI sin componentes fibrilares o celulares. Cuatro muestras presentaban una abundante disposición de colágeno compatible con el espesoramiento de la membrana hialoides o MER. Distintos tipos que rodeaban el colágeno extracelular componen la población celular asociada al tejido diabético: a) células glials; b) células fibroblásticas; c) células epiteloides; d) células plasmáticas macrófagas. En la MET hemos podido demostrar la presencia de componentes retinales neurosensoriales asociadas con la superficie retiniana de la MLI en 3 muestras.ConclusionesGrupo de Agujeros Maculares: 1. La VPP asociada a la extracción de la MLI es un procedimiento de utilidad para el tratamiento quirúrgico de los AM. En el presente estudio prospectivo de un año, la tasa de cierre anatómico fue de un 90% y la mejor media de la AV final corregida se obtuvo en los ojos con éxito anatómico.2. La TCO contribuyó para el diagnóstico, se presentó como una alternativa no invasiva para la evaluación del estado foveal y permitió documentar y analizar la evolución del cierre anatómico de los AM.Grupo de Edema Macular Diabético:1. El presente estudio clínico prospectivo de un año demostró los beneficios de la extracción de la MLI, mediante VPP, como tratamiento quirúrgico del EMCD. La extracción de la MLI conllevó a una disminución del engrosamiento de la retina, a la resolución clínica del edema macular y a una mejor AV.2. La TCO permitió un seguimiento cualitativo del perfil de la retina y un análisis cuantitativo de las pequeñas variaciones del espesor macular. El espesor de la macula ha disminuido significativamente al final del primer mes del postoperatorio (p = 0,00016) comparado con una mejoría significativa de la AV corregida a partir del sexto mes de seguimiento clínico (p = 0,05).3. Mediante MO y MET, el estudio histológico mostró la ausencia de fragmentos de MLI en algunos de los especimenes analizados. Algunas piezas histológicas eran membranas epirretinianas o la hialoides posterior engrosada. Ambos Grupos:1. La correlación clínico-patológica indicó que la presencia de elementos de la retina neurosensorial observados en la cara retiniana de algunos especimenes de MLI fue extraída de ojos que presentarían una peor AV final corregida.2. El espesor de la MLI observado en el grupo de AM fue mayor que el observado en el grupo de EMCD (p = 0,03) que, a su vez, fue mayor que el espesor observado en la MLI de la retina normal (p = 0,00003).

No / The inner retinal complex is a well-defined layer in spectral-domain OCT scans of the retina. The central edge of this layer at the fovea provides anatomical landmarks that can be observed in serial OCT scans of developing full-thickness macular holes (FTMH). Measurement of the movement of these points may clarify the mechanism of FTMH formation. This is a retrospective study of primary FTMH that had a sequence of two OCT scans showing progression of the hole. Measurements were made of the dimensions of the hole, including measurements using the central edge of the inner retinal complex (CEIRC) as markers. The inner retinal separation (distance between the CEIRC across the centre of the fovea) and the Height-IRS (average height of CEIRC above the retinal pigment epithelium) were measured. Eighteen cases were identified in 17 patients. The average increase in the base diameter (368 microns) and the average increase in minimum linear dimension (187 microns) were much larger than the average increase in the inner retinal separation (73 microns). The average increase in Height-IRS was 103 microns. The tangential separation of the outer retina to produce the macular hole is much larger than the tangential separation of the inner retinal layers. A model based on the histology of the Muller cells at the fovea is proposed to explain the findings of this study.

No / BACKGROUND: A Full Thickness Macular Hole (FTMH) is often associated with vitreomacular traction, and this can be asymmetric with vitreomacular traction on one side of the hole but not the other. In cross-section, the elevated retinal rim around a developed FTMH is seen as a drawbridge elevation, and this drawbridge elevation may be used as a measure of morphological change. Examination of the drawbridge elevation of the retinal rim in FTMH with asymmetric vitreomacular traction may help to clarify the role of vitreomacular traction in the development of FTMH. METHOD: Cases of FTMH were identified with an initial OCT scan showing vitreomacular traction on one side of the hole only and that had a follow-up OCT scan showing progression of the hole. A tangent to the retinal surface at a distance of 700 microns from the axis of the hole was used as a marker of the drawbridge elevation of the retinal rim around the macular hole. Comparisons of the drawbridge elevation and change in drawbridge elevation between the sides with and without initial vitreomacular traction were made. RESULTS: There was no significant difference between the drawbridge elevation, or change in drawbridge elevation, on the side of the hole with initial vitreomacular traction compared to the side without initial traction. CONCLUSION: There is some intrinsic mechanism within the retina to link the morphological changes on the two sides of a FTMH. A bistable hypothesis of FTMH formation and closure is postulated to explain this linkage.

Objetivos: Avaliar a função e estrutura da retina de pacientes com membrana epirretiniana (MER) ou buraco macular (BM) antes e após a cirurgia, e determinar suas relações e os valores preditivos para a acuidade visual após tratamento com vitrectomia associada a peeling da membrana limitante interna. Casuística e Métodos: Foram incluídos 51 olhos de 50 pacientes com indicação de tratamento cirúrgico de MER ou BM idiopáticos. Foi realizada avaliação oftalmológica completa, incluindo melhor acuidade visual corrigida (MAVC) no pré-operatório e nas semanas 1, 3, 8, 24 e 48 após a cirurgia, enquanto que eletrorretinografia multifocal (mfERG) e tomografia de coerência óptica (OCT) foram realizadas antes da cirurgia e dois e doze meses após o procedimento. Os resultados da mfERG serão apresentados na forma da razão entre os valores encontrados nos dois anéis centrais, normalizados pelas médias dos três anéis periféricos (denominada razão P1), para minimizar a variabilidade interpessoal desse teste e ressaltar as alterações encontradas nos anéis centrais. A OCT foi usada para calcular o quociente entre medidas da altura e base do BM (IBM). Resultados: Quarenta e cinco pacientes (46 olhos; n = 30 BM e 16 MER) completaram as 48 semanas de seguimento. No pré-operatório, a média ± SE da MAVC (logMAR) para os grupos BM e MER, respectivamente, foi: 0,93 ± 0,22 (20/170; ou 0,12 decimal) e 0,58 ± 0,11 (20/76; ou 0,26 decimal), com melhora significativa após 48 semanas de seguimento (média ± EP da diferença entre as acuidades visuais medidas em logMAR em 48 semanas e a basal) -0,25 ± 0,07 para o grupo BM e -0,29 ± 0,06 para o grupo MER. O mfERG mostrou-se alterado antes da cirurgia para BM, com melhora da razão P1 após a cirurgia. Para o BM, houve correlação entre a razão P1 no pré-operatório e o ganho da MAVC na semana 8 após a cirurgia (r = -0,42; p = 0,033), mas essa correlação não foi observada para o grupo MER. Também não houve correlação entre o IBM e a acuidade visual após a cirurgia. Conclusões: Os resultados indicam que pacientes com BM apresentando mfERG com baixa razão P1 têm menor probabilidade de ganho de visão após a cirurgia, mas essa afirmativa não é válida para a MER. / Purpose: To evaluate retinal structure and function in eyes with macular hole (MH) or epiretinal membrane (ERM) before and after pars-plana vitrectomy with internal limitant membrane (ILM) peeling, to determine function/structural interrelations and predictive values of postoperative visual acuity. Casuistic and Methods: Fifty-one eyes of 50 patients with idiopathic MH or ERM were included. Comprehensive ophthalmologic evaluation including best-corrected visual acuity (BCVA) was performe date baseline, 1, 3, 8, 24 e 48 weeks after surgery, while optical coherence tomography (OCT) and multifocal ERG was performed before and at 2 and 12 months after surgery. mfERG results are show using the ratio between the amplitude averages of the 2 central rings and the 3 peripheral rings (P1 ratio) and OCT was used to calculate the macular hole index (MHI) defined by the quotient between hole height/base. Results: Forty-five patients (46 eyes; n = 30 MH and 16 ERM) finished follow-up. Mean ± SE (logMAR) preoperative BCVA was 0.93 ± 0.22 and 0.58 ± 0.11 for MH and ERM respectively, and improved in -0.25 ± 0.07 logMAR for MH and -0.29 ± 0.06 logMAR for ERM. mfERG P1 ratio was reduced in BM, and increased significantly after surgery. There was significant correlation between preoperative P1 ratio and BCVA gainat week 8 for MH group (r = -0,42; p = 0,033), but not for ERM group. There was no correlation between preoperative MHI and postoperative BCVA. Conclusion: This data indicates that patients with MH and poor mfERG amplitudes have worse prognoses for BCVA improvement, but does not apply for ERM.

Objetivos: Avaliar a função e estrutura da retina de pacientes com membrana epirretiniana (MER) ou buraco macular (BM) antes e após a cirurgia, e determinar suas relações e os valores preditivos para a acuidade visual após tratamento com vitrectomia associada a peeling da membrana limitante interna. Casuística e Métodos: Foram incluídos 51 olhos de 50 pacientes com indicação de tratamento cirúrgico de MER ou BM idiopáticos. Foi realizada avaliação oftalmológica completa, incluindo melhor acuidade visual corrigida (MAVC) no pré-operatório e nas semanas 1, 3, 8, 24 e 48 após a cirurgia, enquanto que eletrorretinografia multifocal (mfERG) e tomografia de coerência óptica (OCT) foram realizadas antes da cirurgia e dois e doze meses após o procedimento. Os resultados da mfERG serão apresentados na forma da razão entre os valores encontrados nos dois anéis centrais, normalizados pelas médias dos três anéis periféricos (denominada razão P1), para minimizar a variabilidade interpessoal desse teste e ressaltar as alterações encontradas nos anéis centrais. A OCT foi usada para calcular o quociente entre medidas da altura e base do BM (IBM). Resultados: Quarenta e cinco pacientes (46 olhos; n = 30 BM e 16 MER) completaram as 48 semanas de seguimento. No pré-operatório, a média ± SE da MAVC (logMAR) para os grupos BM e MER, respectivamente, foi: 0,93 ± 0,22 (20/170; ou 0,12 decimal) e 0,58 ± 0,11 (20/76; ou 0,26 decimal), com melhora significativa após 48 semanas de seguimento (média ± EP da diferença entre as acuidades visuais medidas em logMAR em 48 semanas e a basal) -0,25 ± 0,07 para o grupo BM e -0,29 ± 0,06 para o grupo MER. O mfERG mostrou-se alterado antes da cirurgia para BM, com melhora da razão P1 após a cirurgia. Para o BM, houve correlação entre a razão P1 no pré-operatório e o ganho da MAVC na semana 8 após a cirurgia (r = -0,42; p = 0,033), mas essa correlação não foi observada para o grupo MER. Também não houve correlação entre o IBM e a acuidade visual após a cirurgia. Conclusões: Os resultados indicam que pacientes com BM apresentando mfERG com baixa razão P1 têm menor probabilidade de ganho de visão após a cirurgia, mas essa afirmativa não é válida para a MER. / Purpose: To evaluate retinal structure and function in eyes with macular hole (MH) or epiretinal membrane (ERM) before and after pars-plana vitrectomy with internal limitant membrane (ILM) peeling, to determine function/structural interrelations and predictive values of postoperative visual acuity. Casuistic and Methods: Fifty-one eyes of 50 patients with idiopathic MH or ERM were included. Comprehensive ophthalmologic evaluation including best-corrected visual acuity (BCVA) was performe date baseline, 1, 3, 8, 24 e 48 weeks after surgery, while optical coherence tomography (OCT) and multifocal ERG was performed before and at 2 and 12 months after surgery. mfERG results are show using the ratio between the amplitude averages of the 2 central rings and the 3 peripheral rings (P1 ratio) and OCT was used to calculate the macular hole index (MHI) defined by the quotient between hole height/base. Results: Forty-five patients (46 eyes; n = 30 MH and 16 ERM) finished follow-up. Mean ± SE (logMAR) preoperative BCVA was 0.93 ± 0.22 and 0.58 ± 0.11 for MH and ERM respectively, and improved in -0.25 ± 0.07 logMAR for MH and -0.29 ± 0.06 logMAR for ERM. mfERG P1 ratio was reduced in BM, and increased significantly after surgery. There was significant correlation between preoperative P1 ratio and BCVA gainat week 8 for MH group (r = -0,42; p = 0,033), but not for ERM group. There was no correlation between preoperative MHI and postoperative BCVA. Conclusion: This data indicates that patients with MH and poor mfERG amplitudes have worse prognoses for BCVA improvement, but does not apply for ERM.

No description available.

Introduction A full-thickness macular hole (FTMH) is a round deformity in the fovea that involve alllayers of the neurosensory retina. The condition is usually symptomatic and is associatedwith a decreased visual acuity (VA). Large FTMHs are associated to a larger decrease in VA.To treat FTMH pars plana vitrectomy (PPV) is performed to repair the hole. There aredifferent dimensions of instruments in PPV but limited information on the outcome usingeach dimension. Aim This study aims to assess the healing rate of large FTMHs after 25-gauge vitrectomy. Methods The study is a retrospective record review. Patients were identified through the surgicalintervention registry at the Department of Ophthalmology, USÖ. The study included largeFTMHs (diameter > 400 μm) who underwent 25-gauge PPV at USÖ between 2015-2017. Results After 25-gauge PPV 19 (82.6%) out of 23 included eyes healed. No significant difference inhealing rate between subgroups of different sized FTMHs was discovered. Out of 4 eyes thatfailed to heal, 1 patient underwent a reoperation and the other 3 either chose not to or it wasdeemed not indicated. A statistically significant increase in mean VA postoperatively wasobserved. The most reported complications postoperatively were gas cataract and atemporary increase in intraocular pressure. In 7 cases the PPV led to an accelerateddevelopment of cataract and cataract surgery. Conclusion The majority of FTMHs healed after 25-gauge PPV and the mean VA increased after surgery.The most common complications were secondary cataract and temporary increase in IOP.

The purpose of this study was to investigate the ultrastructure of the membrana limitans interna (internal limiting membrane, ILM) and to evaluate alterations to the retinal cell layers after membrane peeling with vital dyes. Twenty-five patients (25 eyes) who underwent macular hole surgery were included, whereby 12 indocyanine green (ICG)- and 13 brilliant blue G (BBG)-stained ILM were analyzed using light, transmission electron and scanning electron microscopy. Retinal cell fragments on the ILM were identified in both groups using immunohistochemistry. Comparing ICG- and BBG-stained membranes, larger cellular fragments were observed at a higher frequency in the BBG group. Thereby, the findings indicate that ICG permits an enhanced separation of the ILM from the underlying retina with less mechanical destruction. A possible explanation might be seen in the known photosensitivity of ICG, which induces a stiffening and shrinkage of the ILM but also generates retinal toxic metabolites