Idiopathic macular hole (IMH) refers to full thickness defects of retina in macular area with no clear reasons. The management of IMH includes vitrectomy combined with internal limiting membrane (ILM) peeling and pharmacological vitreolysis. But ILM peeling may damage the inner retina; novel techniques, such as inverted ILM flap technique and foveola non-peeling ILM surgery, autologous ILM transplantation had made the method of ILM peeling more diversified with less damage. Pharmacological vitreolysis targeting fibronectin and laminin is considered to work in a two-step mechanism, involving both vitreoretinal separation and vitreous liquefaction. Furthermore, IMH judgment and prognosis indicators like ellipsoid zone, macular hole index, hole formation factor, diameter hole index and tractional hole index based on spectral domain optical coherence tomography enriched the assessment of macular hole diameter, depth and shape. How to make full use of new interventions to reduce the incidence of macular hole and obtain a better visual acuity with closed holes is an important direction for future research.
ObjectiveTo observe the different changes of macular microstructure in patients with large idiopathic macular hole (IMH) treated with vitrectomy combined with internal limiting membrane (ILM) transplantation or not. MethodsForty eyes in 40 consecutive patients with giant IMH (≥500 μm) were included in the study. Twenty eyes received vitrectomy with ILM transplantation (ILM transplantation group) and others with ILM peel off (ILM removal group). During the operation, a proper size of the ILM was removed and filled in the bottom of the macular hole. The age, duration of disease and the ocular laterality of the two groups of patients were not statistically significant (P>0.05). Minimum resolution angle in logarithmic (logMAR) best corrected visual acuity (BCVA) and frequency domain optical coherence tomography (SD-OCT) scan were examined. There was no statistically significant difference in logMAR BCVA, average defect diameter of photoreceptor ellipsoid (IS/OS) and average defect diameter of external limiting membrane (ELM) between two groups (t=0.128, 1.452, 1.321; P>0.05). The logMAR BCVA and SD-OCT were examined on 1, 3, 6, 12 months postoperatively. ResultsOn 1 month after the surgery, there was no statistically significant difference in logMAR BCVA, average defect diameter of IS/OS and average defect diameter of ELM between two groups (t=1.226, 1.435, 1.018; P>0.05). On 3, 6, 12 months after the surgery, compared with ILM removal group, the logMAR BCVA (t=2.059, 2.871, 2.415) increased and the average defect diameter of IS/OS (t=2.070, 2.110, 2.121) and ELM (t=2.034, 3.647, 3.556) significantly reduced in ILM transplantation group (P<0.05). On 1 month after the surgery, there was statistically significant difference in CRT between two groups (t=2.113, P<0.05). On 3, 6, 12 months after the surgery, there was no statistically significant difference in CRT between two groups (t=0.428, 0.847, 0.849; P>0.05). ConclusionCompared with vitrectomy combined with ILM peeling surgery, the diameter of IS/OS and ELM defect were significantly decreased after vitrectomy combined with ILM transplantation in the patients with large IMH.
Myopic foveoschisis (MF) has mild early symptoms, however, its course is progressive. When the secondary macular detachment or macular hole occurs, it can cause severe vision loss. Therefore, it is generally believed that MF patients should undergo surgical intervention early after the onset of symptoms to prevent them from further developing into a macular hole or macular hole retinal detachment.It is generally believed that the traction of the vitreous cortex and posterior scleral staphyloma to the retina plays an important role in the occurrence and development of MF. The operation mode is divided into vitreoretinal surgery and macular buckling, the former release the retinal traction via the vitreous body and the latter reattaches the retina via the extrascleral approach. There is no consensus on whether to perform internal limiting membrane peeling and gas tamponade in vitreoretinal surgery and the fovea-sparing internal limiting membrane peeling has become a hot topic in recent years. Compared with vitreoretinal surgery, macular buckling can release the traction of the retina caused by posterior scleral staphyloma, but it cannot relieve the traction in the tangential direction of the retina. Vitreoretinal surgery and extrascleral surgery seems to make up the shortcomings of both, however, the effect of treatment on patients still needs further verification. In clinical work, it is necessary to conduct individualized analysis of MF patients, weigh the advantages and disadvantages of each operation, and choose the most suitable operation mode for patients with different conditions. In the future, the emphasis of our work is to develop operation mode with great curative effect and less complications.
ObjectiveTo observe the histopathological changes in peripheral retinal lesions under intraoperative optical coherence tomography (iOCT). Methods A retrospective case series study. Eighty-eight patients (194 eyes) who underwent vitreoretinal surgery in the Department of Ophthalmology at the East Ward of the First Affiliated Hospital of Zhengzhou University from October 2021 to May 2022 in 94 eyes were included in the study. Among them, 49 cases were male and 39 cases were female, with the mean age of (50.93±17.55) years. Ninety-four eyes included 32 eyes with retinal detachment, 6 eyes with proliferative diabetic retinopathy, 28 eyes with vitreous hemorrhage, 8 eyes with ocular trauma, 14 eyes with the macular lesion, 1 eye with uveitis, 1 eye with family exudative vitreoretinopathy (FEVR), 1 eye with acute retinal necrosis (ARN), and 3 eyes with lens dislocation. All affected eyes were examined with iOCT during vitreoretinal surgery. The iOCT scanning of the peripheral retina was performed with the help of episcleral pressure. The pre-equatorial and serrated edge anterior and posterior of retinas were scanned according to the characteristics of different fundus diseases. Various abnormal fundus manifestations were recorded. Results In 94 eyes, 53 eyes (56.38%, 53/94) have different types of retinopathy in the peripheral retina. Of these, 7 eyes (7.45%) have retinal cystoid degeneration; 19 eyes (20.21%) have lattice degeneration; and 8 eyes (8.51%) have pigment degeneration; 9 eyes (9.57%) have pavement-like degeneration; 7 eyes (7.45%) have small occult holes; 1 eye (1.06%) has familial exudative vitreoretinopathy (FEVR) serrated edge "dyke-like" proliferative degeneration; 4 eyes (4.26%) have vitreous and retinopathy adhesions; and one eye (1.06%) has ARN. Conclusion With clear refractive media, iOCT can provide clear scans of different peripheral retinal lesions.
ObjectiveTo evaluate the assistant effect of intraoperative OCT (iOCT) in vitreous retinal surgery for macular disease.MethodsA retrospective case study. A total of 71 patients (71 eyes) with macular disease who underwent vitrectomy in Eye Hospital of Wenzhou Medical University at Hangzhou from June 2015 to September 2016 were collected. There were 24 males (24 eyes) and 47 females (47 eyes), aged from 25 to 78 years, with the mean age of 63.35±10.01 years. Among 71 eyes, there were 26 eyes with idiopathic macular hole, 42 eyes with idiopathic epiretinal membrane, 3 eyes with vitreomacular traction syndrome. The examination of iOCT was performed on the patients during 23G minimally invasive vitreoretinal surgery combined with internal limiting membrane peeling. Use observational method to compare the difference between result of iOCT and observation under the microscope, record the change of treatment strategy.ResultsEight eyes (11.27%) iOCT results were different from the surgeon’s observation, which including 5 eyes (62.50%) with idiopathic macular hole, 2 eyes (25.00%) with idiopathic epiretinal membrane, 1 eye (12.50%) with vitreomacular traction syndrome. The treatment strategy was changed in 8 eyes (11.27%) based on iOCT result, which including 5 eyes (62.50%) with idiopathic macular hole, 2 eyes (25.00%) with idiopathic epiretinal membrane, 1 eye (12.50%) with vitreomacular traction syndrome.ConclusionsiOCT can help the surgeon find some subtle morphological changes which can hardly be seen by eyes. The surgeon can change and optimize the treatment strategy based on the result of iOCT.
Myopic foveoschisis is a disease caused by abnormal vitreoretinal interface status and progressive posterior scleral staphyloma. Its occurrence and development are associated with centripetal traction (posterior vitreous cortex, internal limiting membrane and stiff retinal vessel) and centrifugal traction (increasing axial lengths and posterior scleral staphyloma). Currently vitrectomy is the major option to treat this condition as it can alleviate or eliminate centripetal and centrifugal traction. However as myopic foveoschisis is a life-long progressive degenerative disease, often with abnormalities in retinal pigment epithelium, choroid and sclera; the therapeutic effect of current surgical strategy (vitrectomy or scleral surgery, or combined surgery) is limited and unsatisfactory. A full assessment macular structure, function and related factors before surgery is helpful to predict the anatomical and functional prognosis.
ObjectiveTo evaluate the efficacy and safety of 41G ultramicroneedle subretinal injection of balanced salt solution (BSS) in the treatment of large diameter macular holes (MH). MethodsA prospective clinical intervention study. A total of 22 eyes of 22 large-diameter full-layer MH patients diagnosed by examination in Tianjin Eye Hospital from March to June 2024 were included in the study. The minimum diameter of MH in the affected eyes was all greater than 400 μm. The affected eyes received 25G pars plana vitrectomy combined with internal limiting membrane peeling and 41G ultramicroneedle subretinal injection of BSS. The affected eyes underwent best-corrected visual acuity (BCVA), microperimetry, fundus autofluorescence, and optical coherence tomography (OCT) examinations before and 1 and 3 months after surgery. BCVA was measured using the standard logarithmic visual acuity chart and converted to logarithm of the minimum angle of resolution (logMAR) visual acuity for statistical analysis. The minimum and base diameter of MH were measured using OCT. Microperimetry was performed using a macular integrity assessment device, recording the macular integrity index (MII) and macular threshold (MT) within 10° of the macular. The changes in BCVA, MII, MT, and the closure of MH and the occurrence of complications were compared and analyzed before and after surgery. For the comparison of the same continuous indicators before and after surgery, Student's t-test was used if the data were normally distributed and had equal variances, and the Mann-Whitney U test was used if the data were not normally distributed; the correlation between different indicators was analyzed using Pearson correlation analysis. ResultsAmong the 22 cases (22 eyes), there were 4 males and 18 females; all were unilaterally affected. The age was 66 (60, 71) years. The duration of the disease was 5 (2.5, 12.0) months. The logMAR BCVA of the affected eyes was 1.24±0.57, and the MII and MT were 100.0 (99.53, 100.00) and 19.0 (13.23, 21.78) dB, respectively. One month after surgery, all MH were closed, with 20 (90.91%, 20/22) and 2 (9.09%, 2/22) eyes classified as typeⅠand Ⅱ closure, respectively. At the last follow-up, the logMAR BCVA was 0.62±0.58, and the MII and MT were 99.9 (59.45, 100.00) and 23.6 (19.33, 26.25) dB, respectively; compared with before surgery, the BCVA (t=3.579), MII (Z=－2.374), and MT (Z=－2.997) were significantly improved, and the differences were all statistically significant (P＜0.05). Correlation analysis showed that postoperative BCVA was significantly positively correlated with preoperative BCVA (r=0.41), the minimum and base diameter of MH (r=0.64, 0.58), disease duration (r=0.63), and age (r=0.50) (P＜0.05). No surgery-related complications occurred in all affected eyes during the follow-up period. Conclusion41G ultramicroneedle subretinal injection of BSS can effectively improve the hole closure rate of large diameter MH-affected eyes in the short term, improve visual function, and has good safety.
Objective To analyze the risk factors for persistent corneal epithelial defects (PCED) after pars plana vitrectomy (PPV) in patients with proliferative diabetic retinopathy (PDR). Methods A total of 201 PDR patients (201 eyes) who received PPV were enrolled in this retrospective study. There were 86 males (86 eyes) and 115 females (115 eyes). The patients aged from 30 to 81 years, with the mean age of (57.94±9.65) years. Among them, 159 patients were ≥50 years of age, and 42 patients were ＜50 years of age. There were 36 patients with HbA1c ＜7.0%, 165 patients with HbA1c ≥7.0%. There were 93 right eyes and 108 left eyes. There were 93 right eyes and 108 left eyes. The diabetic retinopathy stages were as follows: stage Ⅳ in 24 eyes, stage Ⅴ in 78 eyes and stage Ⅵ in 99 eyes. The operation time was ranged from 1 to 4 hours, with an average of 2 hours. Among the 201 eyes, corneal epidermis were scraped on 25 eyes; 70 eyes were combined with cataract surgery; a laser photocoagulation count ＜1000 points was performed in 78 eyes, and ＞1000 points were performed in 123 eyes. Sixty-one eyes involved intravitreal silicone oil tamponade, 18 eyes involved intravitreal tamponade with C3F8, and 122 eyes were not involved with intraocular tamponade. Postoperative persistent intraocular hypertension was defined as an intraocular pressure (IOP) ≥21 mmHg (1 mmHg=0.133 kPa) after PPV with necessary treatment using IOP-lowering medications for ≥2 weeks. The diagnostic criteria for corneal epithelial defects were taken from the Expert Consensus on Clinical Diagnosis and Treatment of Corneal Epithelial Defect in China (2016). The corneal epithelial defect was diagnosed as PCED if it was treated with common methods such as a lacrimal substitute or corneal contact lens, but showed no improvement and no signs of healing for ≥2 weeks. The incidence of PCED after eye surgery was recorded and its related risk factors were analyzed. A multivariate logistic regression was used to analyze the risk factors for PCED, which were expressed as a odds ratio (OR) and a 95% confidence interval (CI). Results Of 201 eyes, 16 eyes (7.96%) presented with PCED after surgery and 185 eyes (92.04%) with no PCED. There was no significant difference in the age, sex, and eyes between the patients with or without PCED (χ2=6.548, 0.927, 0.044; P=0.011, 0.336, 0.833). A multivariate logistic regression showed that intraoperative epithelial debridement (OR=13.239, 95%CI 2.999−58.442, P=0.001), intraoperative treatment in combination with cataract surgery (OR=7.448, 95%CI 1.975−28.091, P=0.003), intravitreal tamponade with C3F8 (OR=11.344, 95%CI 2.169−59.324, P=0.004), and postoperative persistent intraocular hypertension (OR=10.462, 95%CI 2.464−44.414, P=0.001) were risk factors for PCED after PPV. Conclusion Intraoperative epithelial debridement, intraoperative treatment in combination with cataract surgery, intravitreal tamponade with C3F8, and postoperative persistent intraocular hypertension are risk factors for PCED in patients with PDR after PPV.
ObjectiveTo observe the clinical effect of small-gauge vitrectomy (SGV) treatment for proliferative diabetic tractional (PDR) with retinal detachment (TRD). MethodsThe data of 42 patients (50 eyes) with PDR combined with TRD who had received SGV treatment were retrospectively analyzed. There were 22 males and 20 females, with an average age of (44.5±11.2) years. There were 16 eyes with TRD involving the macular area, 34 eyes without TRD involving the macular area. The eyes with rhegmatogenous retinal detachment or retinal hole were excluded. The best corrected visual acuity (BCVA) was worse than finger counting in 18 eyes, worse than 0.1 in 15 eyes, 0.1-0.3 in 16 eyes and better than or equal to 0.3 in 1 eye. Post-operative tamponade was delivered for patients with iatrogenic retinal breaks, including 5 eyes with long-acting gas and 7 eyes with silicone oil. The mean follow-up time was 9.7 months. The visual outcome, rate of retinal reattachment and complications were analyzed. ResultsThe visual acuity improved in 34 eyes (68.0%), unchanged in 12 eyes (24.0%) and decreased in 4 eyes (8.0%). The difference of visual acuity before and after surgery was statistically significant (t=7.087, P<0.01).The total rate of retinal reattachment was 96%, and 84% of eyes achieved anatomic reattachment after single surgery. The rate of retinal reattachment was 89.5% (34/38) for these eyes without iatrogenic retinal breaks, 4/38 eyes without iatrogenic retinal breaks still had retinal detachment in 3 months after surgery and received tamponade of long-acting gas or silicone oil. The rate of retinal reattachment was 66.7% (8/12) for these eyes with iatrogenic retinal breaks and received post-operative tamponade. There were 17 eyes experienced postoperative vitreous hemorrhage, which were treated with anti-vascular endothelial growth factor (VEGF) antibodies or vitreous cavity lavage. There were 9 eyes with transient ocular hypertension, and 4 eyes with neovascular glaucoma (NVG). Among 4 eyes with NVG, 2 of which were controlled through anti-VEGF treatment or laser treatment, and 2 eyes of 2 patients refused to have further treatment. ConclusionSGV is safe and effective treatment for PDR combined with TRD, and intraocular tamponade is not necessary in the absence of iatrogenic retinal break.
ObjectiveTo observe the efficacy of pars plana vitrectomy (PPV) combined with endoscopic cyclophotocoagulation (ECP) for refractory glaucoma. MethodsTwenty-eight patients (30 eyes) diagnosed with refractory glaucoma were enrolled in this study. The intraocular pressure was ranged from 28 to 55 mmHg (1 mmHg=0.133 kPa), with the mean of (46.3±10.3) mmHg. There were 24 eyes with initial visual acuity <0.05, 1 eye with 0.05-0.08 initial visual acuity and 5 eyes with ≥0.1 initial visual acuity. The mean number of intraocular pressure-decreased drugs was 4. All the eyes underwent PPV combined with ECP. The cyclophotocoagulation ranged from 90°-360°, with the mean of (232.5±77.6)°. The cyclophotocoagulation was <180° in 4 eyes, 180°-270° in 6 eyes, >270° in 20 eyes. The follow-up ranged from 12 to 20 months, with the mean of 15.2 months. The intraocular pressure, vision and the mean number of intraocular pressure-decreased drugs before and after surgery were comparatively observed. The relationship between cyclophotocoagulation area and postoperative intraocular pressure was analyzed. ResultsAt the final follow-up, the intraocular pressure ranged from 12 to 36 mmHg, with the mean of (18.5±4.4) mmHg, which decreased 49.4% compared with preoperative intraocular pressure (t=15.537, P<0.01). Among 30 eyes, the intraocular pressure was ≤21 mmHg without any intraocular pressure-decreased drugs in 24 eyes (80.0%), 1 eye (3.3%) with ≤21 mmHg who treatment by local intraocular pressure-decreased drugs, lose control of intraocular pressure in 5 eyes (16.7%). The vision was <0.05 in 15 eyes, 0.05-0.08 in 3 eyes and ≥0.1 in 12 eyes. The difference of vision distribution before and after surgery was not significant (χ2=6.197, P>0.05). Compared with preoperative vision, the postoperative vision was improved in 8 eyes (26.7%), stabled in 15 eyes (50.0%), decreased in 7 eyes (23.3%). The mean number of intraocular pressure-decreased drugs was reduced from 4 to 1 (t=8.402, P<0.01).The cyclophotocoagulation area was positive related to postoperative intraocular pressure (r=4.160, P<0.05). There were no ocular and systemic complications during and after surgery except slight inflammation. ConclusionPPV combined with ECP for refractory glaucoma can reduce intraocular pressure, stabilize or improve the visual acuity.