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PurposeTo report two cases of spontaneous closure of lamellar macular holes with epiretinal proliferation (ERP).MethodsObservational cases report.ResultsTwo patients affected with lamellar macular hole showed progressive and spontaneous closure of the hole associated with ERP development. At presentation, both patients presented with irregular foveal contour, and foveal cavitation with apparent loss of retinal tissue. In both cases, ERP, also called "lamellar hole-associated epiretinal proliferation", was present and increased in size over time. This proliferation progressively developed across the hole with apparent restoration of the foveal contour and preservation of visual acuity.ConclusionThis report describes two cases of lamellar macular hole in which ERP increased over time, resulting in lamellar macular hole closure. Such observations may suggest a spontaneous healing process driven by glial cell proliferation.

Background: The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on practical activities and didactic teaching of residents and fellows. This survey aimed to propose long-term changes for ophthalmology training based on the changes experienced by trainees and their perception of new training opportunities. Methods: An online survey was distributed to ophthalmology trainees in multiple countries. Descriptive statistics were used to analyse the data. Results: A total of 504 analyzable responses were collected from 32 different countries. The current impact of COVID-19 pandemic was described as “severe” by most trainees (55.2%); however, the future perspective was more optimistic as demonstrated by the greater number of responses reporting a presumed “moderate” (37.3%), “mild” (14.1%) or “slight” (4.2%) long-term impact. The vast majority of trainees reported a decrease ≥50% of clinical activity (76.4%) and >75% of surgical activity (74.6%). Although an initial gap in didactic teaching has been experienced by many (55.4%), regular web-based teaching was reportedly attended by 67.7% of the respondents. A strong agreement was found regarding the worthwhile role of web-based case-presentations in clinical training (91.7%), web-based discussion of edited surgical videos (85.7%) and simulation-based practice (86.9%) in surgical training. Conclusions: This survey, focusing on trainees’ perspective, strongly reinforces the need to promptly include new technology-based training tools, such as web-based teaching, virtual surgical simulators, and telementoring, in long-term reorganisation of ophthalmology training to ensure its continuity and effectiveness, which would remain available even in the face of another unpredictable crisis within the health system.

Background: To analyse the feasibility and efficacy of a novel autologous plasma rich in growth factor (PRGF) preparation as adjuvant to pars plana vitrectomy and internal limiting membrane peel in high myopic full-thickness macular hole (FTMH). Methods: Single-centre, single-surgeon retrospective chart review of consecutive patients with high myopic FTMH who underwent surgery with a minimum follow-up of 12 months. Patients were divided in group 1 (naïve) and group 2 (persistent). Quantitative and qualitative variables were analysed, compared among groups and correlated with best corrected visual acuity (BCVA). Results: Postoperatively, FTMH resolved in 28/31 eyes in group 1 (90%) and in 10/11 eyes in group 2 (91%), without significant differences ( p = 0.954). None of the preoperative anatomical variables analysed showed significant association with preoperative BCVA. Intraoperatively, no significant complications were registered. Postoperatively, BCVA improved significantly in the studied population ( p Conclusion: The use of PRGF as adjuvant to vitrectomy showed to be reproducible, straightforward and efficient, with primary anatomical success rate comparable to other surgical approaches and lower risk of complications.

Objective The central bouquet (CB) of the fovea comprises a dense array of cone photoreceptors intertwined with Muller cells. The aim of this investigation was to study visual outcomes and structural alterations in the foveal CB associated with cystoid macular edema (CME) of different etiologies. Design Retrospective case series. Participants and Methods This study analyzed eyes with various etiologies of CME, including diabetic macular edema, central retinal vein occlusion (CRVO), pseudophakic or Irvine–Gass (IG) syndrome, uveitis, and retinitis pigmentosa using spectral-domain optical coherence tomography (SD-OCT). SD-OCT was used to classify the CB alterations as either (1) thickened hyper-reflectivity associated with indistinct ellipsoid zone (EZ), or (2) subretinal fluid with intact EZ. Comparisons were made using the Students t test and Fisher's exact test. Results The total cohort consisted of 61 eyes from 61 patients with various etiologies of CME. CB alterations were observed in 91% of uveitis eyes, 82% of CRVO eyes and 50% of IG eyes. Presence of CB alteration correlated with greater central macular thickness (p = 0.0020), horizontal extent of edema (p = 0.0042), and worse baseline visual acuity (p = 0.0195). Type 2 CB alterations were associated with worse logMAR vision compared with type 1 at baseline and final examinations (p = 0.0002, p = 0.0470). Conclusions CB alterations were noted in the majority of eyes with CME from CRVO, uveitis, and IG. The association observed between CB alterations and central macular thickness suggests that these alterations may develop as a result of mechanical stress of Muller cells on the CB.

Purpose: To analyze the anatomical and functional outcomes of a standardized scleral buckling approach in patients with noncomplex primary rhegmatogenous retinal detachment (RRD). Methods: Retrospective institutional case series of 135 eyes of 131 patients diagnosed with noncomplex primary RRD. All patients underwent scleral buckling surgery with the placement of an encircling 5 mm oval sponge at 15 ± 2 mm posteriorly from the limbus, cryopexy, subretinal fluid drainage, and air tamponade. Results: Final anatomical success at 12 months was achieved in all 135 eyes (100%). Primary anatomical surgical success was obtained in 127 out of 135 eyes (94%), while re-detachment occurred in eight out of 135 cases (6%). Primary anatomical success was significantly lower in pseudophakic eyes ( p Conclusion: A standardized scleral buckling approach for primary noncomplex RRD may be effective. The technique is reproducible, easier, and quicker to perform if compared to classic scleral buckling procedures, suggesting that it may represent a valuable surgical option. Special care is needed in the management of pseudophakic RRD due to higher risk of RRD recurrence.

PurposeTo determine clear-cut distinctions between tractional and exudative intraretinal cystoid spaces subtypes.DesignRetrospective, multicenter, observational case series.MethodsA cohort of patients diagnosed with intraretinal cystoid spaces and imaged with optical coherence tomography (OCT), fluorescein angiography (FA), blue fundus autofluorescence (BFAF), en face OCT, and OCT angiography (OCT-A) was included in the study. All images were qualitatively and quantitatively evaluated.ResultsIn this study were included 72 eyes of 69 patients. Exudative intraretinal cystoid spaces (36/72 eyes, 50%) displayed a "petaloid" morphology as seen with en face OCT, FA, and BFAF. Tractional intraretinal cystoid spaces (24/72 eyes, 33.3%), displayed a radial "spoke-wheel" en face OCT pattern. There was no leakage with FA and BFAF did not reveal specific patterns. Eyes with full-thickness macular hole (FTMH, 12/72 eyes, 16.7%) displayed a "sunflower" en face OCT appearance. FTMH showed OCT, OCT-A, and BFAF features of both exudative and tractional cystoid spaces, but without any FA leakage. Inner nuclear layer (INL) thickness was significantly lower in tractional cystoid spaces (P < .001). There were a greater number of INL cystoid spaces in both the exudative and FTMH subgroups (P= .001). The surface area of INL cystoid spaces was significantly lower in the tractional subgroup (P < .001). There was a significant reduction of the microvascular density in eyes with exudative vs tractional (P= .002) and FTMH (P < .001) subgroups.ConclusionsExudative and tractional intraretinal cystoid spaces displayed characteristic multimodal imaging features and they may represent 2 different pathologic conditions with equally different clinical implications.

Purpose To quantitatively and qualitatively evaluate the microvascular and structural abnormalities associated with inner retinal dimpling after internal limiting membrane peeling for full-thickness macular holes using sequential en face optical coherence tomography (OCT) and OCT angiography. Methods Thirteen eyes of 13 patients with idiopathic full-thickness macular holes were enrolled in the study. Patients were treated with pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade. Subjects were evaluated preoperatively and at postoperative Months 1, 3, and 6. At each visit, patients underwent a comprehensive ophthalmologic examination, en face OCT and OCT angiography. The morphology and number and proportionate area of inner retinal dimples were analyzed. Vessel density of the superficial vascular complex at all visits was also measured. Results Inner retinal dimples were identified 1 month after surgery in all cases. The number and proportionate area of inner retinal dimples significantly increased over the follow-up period (P = 0.05). Preoperative vessel density of the superficial vascular complex was 17.9 ± 1.9 and did not change significantly over the follow-up period (P = 0.15). Conclusion Inner retinal dimples are identified with en face OCT as early as the first month after internal limiting membrane peeling for idiopathic full-thickness macular holes and progressively increase in number and proportionate area in the subsequent 3 to 6 months after surgery. This may be the result of progressive deturgescence of the nerve fiber layer in the postoperative period.

BackgroundA consensus on an optical coherence tomography definition of lamellar macular hole (LMH) and similar conditions is needed.MethodsThe panel reviewed relevant peer-reviewed literature to reach an accord on LMH definition and to differentiate LMH from other similar conditions.ResultsThe panel reached a consensus on the definition of three clinical entities: LMH, epiretinal membrane (ERM) foveoschisis and macular pseudohole (MPH). LMH definition is based on three mandatory criteria and three optional anatomical features. The three mandatory criteria are the presence of irregular foveal contour, the presence of a foveal cavity with undermined edges and the apparent loss of foveal tissue. Optional anatomical features include the presence of epiretinal proliferation, the presence of a central foveal bump and the disruption of the ellipsoid zone. ERM foveoschisis definition is based on two mandatory criteria: the presence of ERM and the presence of schisis at the level of Henle’s fibre layer. Three optional anatomical features can also be present: the presence of microcystoid spaces in the inner nuclear layer (INL), an increase of retinal thickness and the presence of retinal wrinkling. MPH definition is based on three mandatory criteria and two optional anatomical features. Mandatory criteria include the presence of a foveal sparing ERM, the presence of a steepened foveal profile and an increased central retinal thickness. Optional anatomical features are the presence of microcystoid spaces in the INL and a normal retinal thickness.ConclusionsThe use of the proposed definitions may provide uniform language for clinicians and future research.

Author(s): Figueroa, Marta S; Govetto, Andrea; Steel, David H; Sebag, J; Virgili, Gianni; Hubschman, Jean Pierre | Abstract: PurposeFunctional and anatomical outcomes of vitrectomy with membrane peeling were compared in tractional lamellar macular holes (LMH)/macular pseudoholes (MPH) versus degenerative LMH.MethodsThis multicenter retrospective study enrolled patients with a minimum follow-up of 6 months. The association of spectral domain optical coherence tomography parameters with preoperative and postoperative best-corrected visual acuity was analyzed.ResultsSeventy-seven (74.8%) tractional LMH/MPH and 26 (25.2%) degenerative LMH were included. Preoperative best-corrected visual acuity was better in tractional LMH/MPH (0.39 ± 0.2 logarithm of the minimal angle of resolution, 20/50 Snellen equivalent) than degenerative LMH (0.56 ± 0.2 logarithm of the minimal angle of resolution, 20/66 Snellen equivalent; P l 0.001). Premacular membranes were found in all tractional LMH/MPH, whereas LMH-associated epiretinal proliferation (LHEP) was present in all degenerative LMH. Primary anatomical success was achieved in 97/103 eyes (94.2%), with foveal restoration occurring earlier in degenerative LMH (1.6 ± 2.3 vs. 3.3 ± 3.6 months; P = 0.025). Best-corrected visual acuity improved in both tractional LMH/MPH and degenerative LMH (P l 0.001 and P = 0.012, respectively) but was better in tractional LMH/MPH (P = 0.001).ConclusionThe presence of premacular membranes and absence of LMH-associated epiretinal proliferation in all tractional LMH/MPH further distinguishes this from degenerative LMH. Best-corrected visual acuity improved in both subgroups but more so in tractional LMH/MPH. Complete anatomical restoration of foveal microanatomy was rare in degenerative LMH, reflecting significant morphological and pathophysiological differences between the two lesions.

To describe and analyze short-term posterior vitreous abnormalities following intravitreal ocriplasmin in eyes with symptomatic vitreomacular traction syndrome (VMT). In this institutional, prospective and interventional study enrolled patients with symptomatic focal VMT syndrome treated with intravitreal ocriplasmin. In all cases, spectral-domain optical coherence tomography scans were quantitatively and qualitatively analyzed preoperatively and at 1 and 4 weeks postoperatively. Twenty-three patients, of which 5 were males and 18 females, with a mean age of 69.5 ± 8.2 years were included in this study. Postoperatively, VMT resolved in 11 of 23 eyes (47.8%). In 9 out of 11 cases (81.8%), VMT resolved by postoperative week 1, whether in the remaining 2 (18.2%) anatomical restoration, was diagnosed at postoperative week 4. At postoperative week 1, a foveolar detachment was detected in 9 out of 23 eyes (39.1%). The foveolar detachment resolved all but one eye by the end of postoperative week 4. At the end of the follow-up period, the presence of subretinal fluid was detected in 7 out of 9 eyes (77.8%), and it was significantly associated with a shrinkage of the posterior vitreous cortex (p

This case series documents a greater incidence of degenerative lamellar macular holes subtype in advance stages of age-related macular degeneration., Purpose: To investigate whether age-related macular degeneration (AMD) has an influence on the prevalence and anatomical characteristics of lamellar macular holes (LMHs). Methods: Clinical records and spectral-domain optical coherence tomography images of 756 eyes of 423 consecutive patients diagnosed with AMD were reviewed and analyzed. Spectral-domain optical coherence tomography was used to identify degenerative or tractional LMH subtypes and assess their morphology. The clinical and optical coherence tomography findings of AMD eyes with LMH were compared with those of a control group of eyes with LMH without AMD from a previously published report. Results: Lamellar macular holes were identified in 25 eyes of 23 patients (3.3%; 25 of 756). Seventeen of 25 eyes (68%) presented with degenerative LMH and underlying late neovascular AMD. Mean best-corrected visual acuity was worse in eyes with AMD and LMH eyes than in those with AMD and no LMH (20/230 vs. 20/98; P = 0.02). The mean outer diameter was greater in the group with degenerative LMH with concomitant AMD than in the control group of degenerative LMH without AMD (1,323.9 ± 999.1 µm vs. 905.9 ± 356.8 µm, respectively; P = 0.01). Conclusion: The incidence of degenerative LMH increased in advanced forms of AMD, whereas the presence of tractional LMH subtype may be unrelated to AMD evolution.

Purpose We aimed to investigate non-exudative microcystoid macular abnormalities for visual and anatomical outcome in patients with retinal vein occlusion (RVO) with and without glaucomatous optic neuropathy (GON). Methods Medical records of 124 eyes (105 patients) with RVO were reviewed and analyzed. Eyes demonstrating microcystoid macular abnormalities were divided into 2 groups, those with evidence of glaucoma (group A) and those without glaucoma (group B). Best-corrected visual acuity (BCVA), the prevalence and number of microcystoid macular abnormalities, and number of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections were compared at baseline and follow-up. Results Seventy-one out of 105 eyes (67.6%) with RVO displayed microcystoid macular abnormalities. Thirty-eight out of 71 eyes (53.5%) presented with concomitant glaucoma (group A), while the remaining 33 eyes (42.6%) had no history of glaucoma (group B). At the end of the follow-up period, mean BCVA was worse in group A versus group B (20/80 versus 20/40, respectively; p = .003). The mean number of anti-VEGF injections was 10.1 ± 9.2 in group A versus 5.9 ± 6.9 in group B (p = .03). Conclusion Eyes with RVO and concomitant glaucoma exhibited a significantly higher number of microcystoid macular abnormalities and worse BCVA versus eyes with RVO without glaucoma.

This study aims to describe vessel density differences in tractional versus exudative macular oedema with the aid of novel custom imaging analysis techniques. In this retrospective study, patients with exudative and tractional macular oedema were imaged with optical coherence tomography (OCT), en-face OCT, OCT-angiography and fluorescein angiography. A novel image processing algorithm was developed to extrapolate data from the vessel density maps. Forty-one eyes of 36 patients were included. A total of 30 control eyes comprised the control group. At the deep capillary plexus (DCP), exudative eyes presented with a vessel density of 62.12 ± 5.7, significantly higher if compared to both tractional lamellar macular hole (57.6 ± 4.6, p = 0.004) and controls (52.07 ± 2.3, p

Introduction: To compare visual outcomes and complication rates of giant retinal tear-associated retinal detachment (GRT-RD) cases treated with short-term perfluorodecalin (PFD) tamponade versus silicone oil (SiO). Methods: Database analysis of patients with GRT-RD operated on in the period from 1 January 2014 to 31 December 2019. Results: Forty-five patients were operated for GRT-RD using PFD or SiO during this period. Two children, 7 patients receiving gas tamponade, and 2 lost to follow-up were excluded. Eighteen eyes (40%) received PFD and 27 (60%) received SiO. There were 15/18 (83%) macula-sparing cases in the PFD group and 18/27 (67%) in the SiO group (p = 0.13). The mean duration of oil tamponade was 91 days for SiO and 7.6 days for PFD (p < 0.0001). The mean length of follow-up was 274.5 days for PFD and 668.9 days for SiO. The mean BCVA was 6/18 (63.4 ± 26.0 ETDRS letters) for SiO and 6/12 (72.9 ± 12.7 ETDRS letters) for PFD (p = 0.42). Analysing macula-sparing pseudophakic eyes, the BCVA was 6/12 (67.4 ± 25.9 letters, n = 18) for SiO eyes and 6/9 (76.8 ± 9.9 letters, n = 11) for PFD eyes (p = 0.54). The recurrence rate was 22% (6/27) for SiO and 6% (1/18) for PFD (p = 0.12). The rate of cystoid macular oedema (CMO) was 22% for SiO and 22% for PFD. Epiretinal membrane (ERM) was found in 26% of SiO cases and 22% of PFD cases. Loss of vision after oil removal was not observed. Seven eyes (26%) receiving SiO and none receiving PFD developed chronic ocular hypertension (OHT) (p = 0.02). Conclusions: Short-term tamponade with PFD for GRT-RD appears similar to tamponade with SiO in terms of the visual outcomes and complication rates.

To report two cases of spontaneous closure of lamellar macular holes with epiretinal proliferation (ERP).Observational cases report.Two patients affected with lamellar macular hole showed progressive and spontaneous closure of the hole associated with ERP development. At presentation, both patients presented with irregular foveal contour, and foveal cavitation with apparent loss of retinal tissue. In both cases, ERP, also called "lamellar hole-associated epiretinal proliferation", was present and increased in size over time. This proliferation progressively developed across the hole with apparent restoration of the foveal contour and preservation of visual acuity.This report describes two cases of lamellar macular hole in which ERP increased over time, resulting in lamellar macular hole closure. Such observations may suggest a spontaneous healing process driven by glial cell proliferation.

BackgroundTo explore the role of foveal and parafoveal Müller cells in the morphology and pathophysiology of tractional macular disorders with a mathematical model of mechanical force transmission.MethodsIn this retrospective observational study, spectral-domain optical coherence tomography images of tractional lamellar macular holes and patients with myopic foveoschisis were reviewed and analysed with a mathematical model of force transmission. Parafoveal z-shaped Müller cells were modelled as a structure composed of three rigid rods, named R1, R2 and R3. The angle formed between the rods was referred to as θ . R1, R2 and R3 lengths as well as the variation of the angle θ were measured and correlated with best corrected visual acuity (BCVA).ResultsIn tractional lamellar macular holes, there was a significant reduction of the angle θ towards the foveal centre (pConclusionParafoveal Müller cells in the Henle fibre layer may guarantee structural stability of the parafovea by increasing retinal compliance and resistance to mechanical stress. Small values of the angle θ were related to worse BCVA possibly due to damage to Müller cell processes and photoreceptor’s axons.

Pars plana vitrectomy has been reported to increase the risk of ocular hypertension and open-angle glaucoma. The authors conducted a systematic review of randomized and nonrandomized studies to compare the incidence of open-angle glaucoma and ocular hypertension in vitrectomized versus nonvitrectomized eyes.A literature search was performed using MEDLINE and EMBASE until August 2016. Data on ocular hypertension and open-angle glaucoma incidence and mean intraocular pressure after at least 1 year were pooled using random-effects metaanalysis models. Because only nonrandomized studies were retrieved, ROBINS-I tool was used to assess risk of bias in the review.Seven included studies had a paired design to compare the outcomes of vitrectomized versus fellow eyes, with mean follow-up of least 12 months. Four studies (851 patients) provided data on open-angle glaucoma: incidence in vitrectomized versus non-vitrectomized eyes was 7.8% and 4.8%, respectively, yielding a metaanalytic odds ratio of 1.67 (95% CI: 1.08-2.57). Six studies (1,060 patients) reported on the occurrence of ocular hypertension, which was 5.8% in vitrectomized eyes versus 3.1% in fellow eyes (odds ratio: 2.03, 95% CI: 0.97-4.22), without significant differences in the mean postoperative intraocular pressure (mean difference 0.31 mmHg, 95% CI: -0.26 to 0.89).Although the review found increased risk of open-angle glaucoma with pars plana vitrectomy, the studies were heterogenous or inconsistent regarding ocular hypertension and intraocular pressure increase. Larger studies should be conducted in homogenous cohorts of patients undergoing macular surgery, excluding complex conditions such as retinal detachment or diabetic retinopathy.

Purpose To investigate the tractional alterations of the central bouquet (CB) in idiopathic epiretinal membranes (ERMs). Design Retrospective, consecutive, observational case series. Methods ERMs were classified according to a 4-stage grading system. The CB was defined as a circular area of approximately 100 μm composed of densely packed cones (and Muller cells) in the central fovea. Tractional abnormalities of the CB were identified with spectral-domain optical coherence tomography. Ex vivo histopathologic analysis was performed. Results In this study 263 eyes with ERMs were included. Mean follow-up was 21.2 ± 16.7 months. At baseline, tractional abnormalities of the CB were diagnosed in 58 out of 263 eyes (22%) and divided into 3 categories: cotton ball sign (defined as a fuzzy hyperreflective area between the ellipsoid zone and the interdigitation zone in the central fovea), foveolar detachment, and acquired vitelliform lesion. The presence of ectopic inner foveal layers was negatively correlated with the presence of CB tractional abnormalities ( P = .002). Visual acuity was highest in association with the cotton ball sign and lowest in the acquired vitelliform lesion group. Sequential morphologic progression was identified in 7 eyes. Ex vivo histopathologic analysis illustrated characteristic staining patterns supporting a potential mechanism of traction by Muller cells in the CB. Conclusions The cotton ball sign, foveolar detachment, and acquired vitelliform lesion may comprise a continuum in the same clinical spectrum and may represent subsequent stages of CB abnormalities. Foveal Muller cells may play an integral role in the transmission of mechanical forces to the central foveal cones.

Purpose To describe the clinical and surgical significance of microcystoid macular changes in the inner nuclear layer in patients with idiopathic epiretinal membranes, with and without glaucomatous optic neuropathy. Design Retrospective case series. Methods Clinical charts and spectral-domain optical coherence tomography images of 264 eyes of 234 consecutive patients diagnosed with idiopathic epiretinal membranes were reviewed and analyzed. Surgical data were analyzed in a subgroup of eyes with microcystoid macular changes treated with pars plana vitrectomy and epiretinal and internal limiting membrane peel. In surgical cases, postoperative functional and anatomic results at 1 and 6 months were compared between glaucomatous and nonglaucomatous eyes. Associations of microcystoid macular changes with visual acuity and other morphometric parameters were assessed by means of linear or multiple logistic regressions. Results Microcystoid macular changes in the inner nuclear layer were diagnosed in 52 out of 264 eyes with epiretinal membranes (19.7%), of which 28 (55.0%) had concomitant glaucoma. The likelihood to develop microcystoid macular changes increased at advanced glaucoma and epiretinal membrane stages. The morphology of microcystoid macular changes was similar between glaucomatous and nonglaucomatous eyes. Forty-four out of 52 eyes (84.6%) with microcystoid macular changes, of which 20 were with glaucoma and 24 without glaucoma, underwent surgery with pars plana vitrectomy and epiretinal and internal limiting membrane peel. At 1 and 6 months after surgery the mean number of microcysts decreased significantly from baseline in nonglaucomatous eyes ( P = .003 and P = .002, respectively) and remained unchanged in glaucomatous eyes ( P = .400 and P = .700, respectively). Conclusions This study reports a high frequency of microcystoid macular changes in the inner nuclear layer in eyes with concomitant epiretinal membrane and glaucomatous optic neuropathy. In glaucomatous eyes, pars plana vitrectomy with epiretinal and internal limiting membrane peel was ineffective in the treatment of microcystoid macular changes.

Purpose To describe the presence of continuous ectopic inner foveal layers associated with epiretinal membranes (ERMs) and to present a new optical coherence tomography (OCT) staging system of ERMs. Design Retrospective multicenter observational case series. Methods Clinical charts and spectral-domain OCT images of 194 eyes of 172 consecutive patients diagnosed with ERMs were reviewed and analyzed. Results The presence of continuous ectopic inner foveal layers was identified in 63 out of 194 eyes (32.5%) and this morphology was significantly associated with lower visual acuity. ERMs were divided into 4 stages. Stage 1 (43 out of 194 eyes, 22.1%) ERMs were mild and thin and a foveal depression was present. Stage 2 (88 out of 194 eyes, 45.4%) ERMs were associated with widening of the outer nuclear layer and loss of the foveal depression. Stage 3 (51 out of 194 eyes, 26.3%) ERMs were associated with continuous ectopic inner foveal layers crossing the entire foveal area. In stages 1, 2, and 3 all retinal layers were clearly defined on OCT. Stage 4 ERMs (12 out of 194 eyes, 6.2%) were thick and associated with continuous ectopic inner foveal layers. In addition, retinal layers were disrupted. Visual acuity progressively declined from stage 1 through stage 4 ( P Conclusions The presence of continuous ectopic inner foveal layers in ERMs is a newly described OCT finding associated with significant vision loss and is an essential element of a novel OCT-based grading scheme of ERMs that may influence visual prognosis.

BackgroundTo describe the clinical presentation and characteristic imaging features of deep retinal haemorrhages primarily located in the Henle fibre layer (HFL) of the macula. The spectrum of aetiologies and a comprehensive theory of pathogenesis are presented.MethodsThis is a retrospective, multicentre case series evaluating eyes with retinal haemorrhage in HFL. Clinical features, underlying aetiology, systemic and ocular risk factors, visual acuity, and multimodal imaging including fundus photography and cross-sectional and en face optical coherence tomography (OCT) are presented.ResultsRetinal haemorrhages localised to HFL in 33 eyes from 23 patients were secondary to acute blunt trauma to the head (n=2), eye (n=1) and trunk (n=1), ruptured intracranial aneurysm (Terson’s syndrome, n=3), general anaesthesia (n=1), epidural anaesthesia (n=1), hypertension with anaemia (n=1), decompression retinopathy (n=1), postvitrectomy with intraocular gas (n=1), retinal vein occlusion (n=7), myopic degeneration (n=2), macular telangiectasia type 2 (n=1), and polypoidal choroidal vasculopathy (n=1). Defining clinical features included deep retinal haemorrhage with feathery margin and petaloid pattern radiating from the fovea. OCT demonstrated characteristic hyper-reflectivity from the haemorrhage delineated by obliquely oriented fibres in the Henle layer. Spontaneous resolution of HFL haemorrhage occurred after 3 months in 15 patients with follow-up.ConclusionThe characteristic petaloid-shaped, deep intraretinal haemorrhage with a feathery margin localised to HFL is associated with various disorders. The terminology ‘Henle fiber layer hemorrhage (HH)’ is proposed to describe the clinical and OCT findings, which may result from abnormal retinal venous pressure from systemic or local retinovascular disorders affecting the deep capillary plexus or from choroidal vascular abnormalities.

Purpose To investigate whether lamellar macular holes can be divided into different subgroups. Design Retrospective observational case series. Methods In this institutional study, clinical charts and spectral-domain optical coherence tomography (OCT) images of 102 eyes of 90 consecutive patients diagnosed with lamellar macular hole were reviewed. In OCT imaging, the presence of lamellar macular hole was defined according to the following findings: presence of irregular foveal contour, separation of the layers of the neurosensory retina, and the absence of full-thickness macular defect. Mean outcome was the morphologic and functional characterization of different subtypes of macular hole. Results Two different subtypes of lamellar macular hole were identified: tractional and degenerative. The first type, tractional, was diagnosed in 43 eyes, and was characterized by the schitic separation of neurosensory retina between outer plexiform and outer nuclear layers. It often presented with an intact ellipsoid layer and was associated with tractional epiretinal membranes and/or vitreomacular traction. The second type, degenerative, was diagnosed in 48 eyes, and its distinctive traits included the presence of intraretinal cavitation that could affect all retinal layers. It was often associated with nontractional epiretinal proliferation and a retinal "bump." Moreover, it often presented with early ellipsoidal zone defect and its pathogenesis, although chronic and progressive, remains poorly understood. Eleven eyes shared common features with both tractional and degenerative lamellar macular holes and were classified as mixed lesions. Conclusions Degenerative and tractional lamellar macular holes may be 2 distinct clinical entities. A revision of the current concept of lamellar macular holes is needed.

Purpose To report a case of branch retinal artery wall rupture and subsequent branch retinal artery occlusion occurring during a routine pars plana vitrectomy with epiretinal membrane and internal limiting membrane peeling. Methods Case report. Multimodal imaging including fluorescein angiography, spectral domain optical coherence tomography (OCT), en face OCT, and OCT angiography were performed. Results An 86-year-old woman presented with a symptomatic epiretinal membrane in the right eye. Pars plana vitrectomy with epiretinal membrane and internal limiting membrane peel was performed. During the peel, spontaneous preretinal and intraretinal hemorrhage emanating from an adjacent branch retinal artery developed. At postoperative Week 1, OCT showed retinal thinning and hyperreflectivity suggestive of vascular accident. At postoperative Year 1, OCT imaging revealed retinal atrophy while fluorescein angiography demonstrated the arterial occlusion, and OCT angiography illustrated reduction in retinal perfusion in the region of the branch retinal artery occlusion. Conclusion The authors report an unusual case of retinal arterial wall rupture and hemorrhaging during routine pars plana vitrectomy with membrane peel resulting in a branch retinal artery occlusion and subsequent retinal atrophy. Surgeons must limit stress on the underlying retina during membrane peel to avoid this surgical complication.

PurposeTo describe the sequential evolution of outer retinal tubulations (ORTs) in patients diagnosed with choroidal neovascularization and/or retinal pigment epithelium atrophy.MethodsRetrospective evaluation of spectral domain optical coherence tomography of a consecutive cohort of patients with various retinal conditions.ResultsWe reviewed the clinical findings of 238 eyes of 119 consecutive patients (54 men and 65 women) with a mean age of 76.2 ± 14.2 years (range: 57-90) and a mean follow-up of 3 ± 1.6 years (range 1-7). Over the follow-up period, ORTs were diagnosed in 67 of 238 eyes (28.1%), 9 of which were imaged with sequential, eye-tracked spectral domain optical coherence tomography dating from the beginning of ORT formation. The presence of geographic atrophy and subretinal hyperreflective material at baseline were found to be risk factors for ORT development (P < 0.001 and P < 0.001, respectively). Outer retinal tubulations were divided into forming versus formed morphologies. The latter was comprised open and closed ORTs of which the open subtype was the most common. The formation of ORTs was significantly associated with microcystic macular lesions in the inner nuclear layer and the downward displacement of the outer plexiform layer, referred to as the outer plexiform layer subsidence sign (P < 0.001).ConclusionOuter retinal tubulation is a frequent optical coherence tomography finding in eyes with choroidal neovascularization and geographic atrophy. Open ORTs with progressive scrolled edges and shortened diameter were significantly associated with microcystic macular lesions in the inner nuclear layer and the outer plexiform layer subsidence sign.

Author(s): Chen, Cheng-Wei; Chen, Cheng-Wei; Lee, Yu-Hsiu; Gerber, Matthew J; Cheng, Harrison; Yang, Yan-Chao; Govetto, Andrea; Francone, Anibal Andres; Soatto, Stefano; Grundfest, Warren S; Hubschman, Jean-Pierre; Tsao, Tsu-Chin | Abstract: BackgroundWith the development of laser-assisted platforms, the outcomes of cataract surgery have been improved by automating several procedures. The cataract-extraction step continues to be manually performed, but due to deficiencies in sensing capabilities, surgical complications such as posterior capsule rupture and incomplete cataract removal remain.MethodsAn optical coherence tomography (OCT) system is integrated into our intraocular robotic interventional surgical system (IRISS) robot. The OCT images are used for preoperative planning and intraoperative intervention in a series of automated procedures. Real-time intervention allows surgeons to evaluate the progress and override the operation.ResultsThe developed system was validated by performing lens extraction on 30 postmortem pig eyes. Complete lens extraction was achieved on 25 eyes, and "almost complete" extraction was achieved on the remainder due to an inability to image small lens particles behind the iris. No capsule rupture was found.ConclusionThe IRISS successfully demonstrated semiautomated OCT-guided lens removal with real-time supervision and intervention.

Purpose To investigate the short-term safety and efficacy of autologous platelet-rich plasma (a-PRP) as adjuvant to pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in the treatment of highly myopic macular holes (MH). Methods This was a prospective, nonrandomized interventional case series. Patients with MH associated with high myopia, with or without previous PPV, were included. All patients underwent 23-G PPV with the use of a-PRP. Anatomical and functional results of surgery were recorded. Results We included 7 eyes of 6 patients with highly myopic MH. Primary anatomical success was achieved in 7 out of 7 eyes. Mean best-corrected visual acuity improved by more than 1 line from baseline (0.66 ± 0.36 LogMAR) to final visit (0.52 ± 0.25 logMAR), but with no statistically significant difference (p = 0.246, Wilcoxon test). No surgical-related complications were noticed. Conclusions The use of a-PRP as adjuvant to PPV with ILM peeling is effective in the treatment of highly myopic MH. This approach may represent a valid alternative to the inverted ILM flap technique, with comparable visual and anatomical results and the advantage of a simpler procedure. Further studies are necessary to confirm its usefulness in the management of high myopic MH.

To assess the frequency of pseudoexfoliation syndrome (PXF) in patients scheduled for cataract surgery and to evaluate its association with pupil dilation, lens nucleus hardness, intraocular pressure (IOP), glaucoma, age, and sex.Ourense University Hospital, Ourense, Spain.Cross-sectional study.This study evaluated eyes scheduled for cataract surgery between January 2013 and July 2013. Pseudoexfoliation was diagnosed in phakic eyes that showed central and/or peripheral white deposits on the lens surface, pupillary margin, or both. Dilated pupils were evaluated with a portable pupil chart. Nucleus hardness was assessed according to the Lens Opacities Classification System III. Diagnosis of glaucoma was based on International Society Geographical and Epidemiological Ophthalmology criteria.Of the 1763 eyes (1093 patients) evaluated, 381 (21.6%) were diagnosed with PXF. The frequency of PXF increased with age from 6.0% in people between 50 year and 60 years to 31.66% in those older than 80 years. In PXF eyes, nuclear cataracts were significantly harder than in non-PXF eyes (P.001). The mean IOP was significantly higher in PXF eyes than in non-PXF eyes (P = .002). The frequency of glaucoma was higher in PXF eyes (17.4%) than in non-PXF eyes (9.4%), with a statistically significant difference (P.001). In PXF eyes, the pupil was significantly smaller than in non-PXF eyes (P.001).The frequency of PXF was high in the study population and increased with age. Eyes with PXF were associated with significantly harder nuclear cataracts, smaller pupils, and glaucoma.No author has a financial or proprietary interest in any material or method mentioned.

PurposeTo investigate the incidence, clinical features and risk factors of premacular membrane (PMM) formation after primary rhegmatogenous retinal detachment (RRD) repair with scleral buckling (SB) alone.MethodsThis institutional, prospective and consecutive case series included phakic eyes with RRD, treated with SB alone within 7 days from the occurrence of symptoms, with a follow-up of 6 months. Spectral-domain optical coherence tomography images were reviewed. The association of PMM development and morphology with preoperative and intraoperative RRD features was analysed.ResultsNinety-two patients with a mean age of 56±13 years completed the 6 months follow-up period. Postoperatively, eyes with any PMM stage were 30 out of 92 (32.6%) at 1 month and 47 out of 92 (51,1%) at both 3 months and 6 months. Over the follow-up period, 17 out of 47 PMMs (36.2%) progressed to later stages. Progression of PMMs to later stages were observed only in RRDs involving the macular region (17 out of 35 eyes, 48.5%), while none of the PMMs in macula-sparing detachments progressed to later stages (p=0.020). The risk factors significantly associated with postoperative new onset of PMM were preoperative RRDs involving the macular region (p=0.001), cryopexy time (p=0.045), presence of horseshoe tears (p=0.003), worse preoperative visual acuity (p=0.004) and subretinal fluid drainage (p=0.047).ConclusionThe incidence of postoperative PMM formation after RRD repair with SB alone was high. In retinal detachments involving the macular region PMM were more severe, tending to anatomical progression and functional deterioration. Activation of foveal Müller cell in detachments involving the macula may be a key factor in PMM progression.

Author(s): Govetto, Andrea; Virgili, Gianni; Rodriguez, Francisco J; Figueroa, Marta S; Sarraf, David; Hubschman, Jean Pierre | Abstract: PURPOSE:To describe the functional and anatomical outcomes of pars plana vitrectomy with epiretinal membrane and internal limiting membrane peel in eyes with and without ectopic inner foveal layers (EIFLs). METHODS:In this retrospective multicenter study, patients diagnosed with idiopathic epiretinal membranes who underwent pars plana vitrectomy with epiretinal membrane and internal limiting membrane peel were enrolled, with a minimum follow-up of 12 months. Preoperative and postoperative spectral domain optical coherence tomography scans were qualitatively and quantitatively evaluated. The association of the EIFL and other spectral domain optical coherence tomography parameters with preoperative and postoperative best-corrected visual acuity (BCVA) was analyzed. RESULTS:One hundred eleven eyes of 107 patients were included. Preoperatively, the EIFLs were present in 56 of 111 eyes (50.4%). The presence of EIFL was significantly associated with lower preoperative and postoperative BCVA (P l 0.001). Ectopic inner foveal layer thickness was negatively correlated with preoperative BCVA (r = 0.58, P l 0.001). Postoperatively, the EIFL persisted in 51 of 56 eyes (91%) with Stage 3 and 4 epiretinal membranes. Ectopic inner foveal layer thickness decreased significantly after surgery (P l 0.001), but postoperative EIFL thinning had no direct effect on postoperative change in BCVA. At 12 months from surgery, EIFL thickness maintained a significant negative correlation with BCVA (r = 0.55, P l 0.001). CONCLUSION:The presence of EIFL should be considered a negative prognostic factor for postoperative anatomical and functional recovery.

To describe the sequential evolution of outer retinal tubulations (ORTs) in patients diagnosed with choroidal neovascularization and/or retinal pigment epithelium atrophy.Retrospective evaluation of spectral domain optical coherence tomography of a consecutive cohort of patients with various retinal conditions.We reviewed the clinical findings of 238 eyes of 119 consecutive patients (54 men and 65 women) with a mean age of 76.2 ± 14.2 years (range: 57-90) and a mean follow-up of 3 ± 1.6 years (range 1-7). Over the follow-up period, ORTs were diagnosed in 67 of 238 eyes (28.1%), 9 of which were imaged with sequential, eye-tracked spectral domain optical coherence tomography dating from the beginning of ORT formation. The presence of geographic atrophy and subretinal hyperreflective material at baseline were found to be risk factors for ORT development (P0.001 and P0.001, respectively). Outer retinal tubulations were divided into forming versus formed morphologies. The latter was comprised open and closed ORTs of which the open subtype was the most common. The formation of ORTs was significantly associated with microcystic macular lesions in the inner nuclear layer and the downward displacement of the outer plexiform layer, referred to as the outer plexiform layer subsidence sign (P0.001).Outer retinal tubulation is a frequent optical coherence tomography finding in eyes with choroidal neovascularization and geographic atrophy. Open ORTs with progressive scrolled edges and shortened diameter were significantly associated with microcystic macular lesions in the inner nuclear layer and the outer plexiform layer subsidence sign.

Background Endophthalmitis is a rare but severe complication of vitrectomy. Clinical Relevance Post-surgical endophthalmitis is suspected to be more frequent after microincisional (23- and 25-gauge) compared with standard (20-gauge) vitrectomy. Methods We conducted a systematic review of studies that compared microincisional and standard vitrectomy by searching MEDLINE and EMBASE up to November 2012. We used the Bayesian meta-analysis method to compute the odds ratio (OR) of endophthalmitis. We conducted subgroup analyses to compare the effect of different incision types and use of perioperative antibiotics. Results We identified 3 small randomized and 18 nonrandomized studies that reported 68 cases of endophthalmitis in 148 643 participants. The overall OR of endophthalmitis for microincisional versus standard vitrectomy was 2.3 (95% credible interval [CrI], 0.8–5.8). We found an increased risk of endophthalmitis using a microincisional straight approach compared with standard vitrectomy (OR, 15.1; 95% CrI, 2.01–179), but not for a beveled approach (OR, 0.82; 95% CrI, 0.23–2.28). The OR of studies that reported on mixed microincision was between these 2 values (OR, 4.4; 95% CrI, 1.32–14.3). We estimated that the overall rate of endophthalmitis with 20-gauge vitrectomy was 3 cases in 10 000 procedures, and the probability that a beveled microincision increases the rate of endophthalmitis to more than 6 or 9 events was small (no more than 5% or 1%, respectively). Conclusions We did not find an increased risk of endophthalmitis for microincisional vitrectomy compared with standard vitrectomy. The beveled approach seems to be safer than a straight approach, supporting the current recommendation of its adoption in microincisional vitrectomy. However, these findings must be interpreted cautiously because of the small number of endophthalmitis events reported from included studies. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose To investigate the possible differences in choroidal thickness (CT) between non-neovascular (NNV) and neovascular (NV) age-related macular degeneration (AMD). Methods A retrospective, observational chart review of consecutive patients diagnosed with NNV AMD in one eye and with NV AMD in the fellow eye was carried out. NNV AMD was classified into four subgroups according to the Beckman Initiative for Macular Research AMD Classification Committee Meeting. CT was manually assessed using enhanced depth imaging optical coherence tomography from 1500 µm nasal to 1500 µm temporal to the fovea. Parametric and non-parametric tests were used to compare quantitative variables, a χ 2 test was used to compare categorical variables and logistic regression was used to evaluate associations of CT with other variables of interest. Results In this study, 322 eyes from 161 patients were included and 102 (63.35%) were female and 59 (36.65%) were male, with a mean age of 80.80±8.45 years (range 58–99 years). Mean follow-up was 11.2±10.8 months (range 1–38 months). In NNV AMD eyes, the choroid was significantly thicker in the subfoveal and temporal regions of the macula, if compared with NV AMD fellow eyes. Differences in CT between NNV AMD and NV AMD fellow eyes were higher at earlier stages of NNV AMD. Conclusions Subfoveal and temporal choroid was significantly thicker in NNV AMD compared with NV AMD fellow eyes. There was a significant choroidal thinning at advanced stages of NNV AMD.

The objective of this work was to assess the activation of the stabilization muscles used to keep one lower limb raised from a supine position, in healthy subjects and in subjects with multiple sclerosis (MS) in two different conditions. The test required subjects to keep the right lower limb at 45° from the supine position on a horizontal bed plane, with the knee extended. The position was reached in two ways: by raising the right limb (A), and by resting the left lower limb on the bed after both limbs had been raised (B). During the test, pelvis and hip kinematics and the surface electromyographic (sEMG) activity were acquired. Fourteen healthy subjects and 14 subjects with multiple sclerosis were included in the study. Results showed that in the A condition, healthy subjects had a greater activation of the biceps femoris than the abdominal muscles, while in the B condition the difference between the two muscles decreased. In the MS group there was no difference in muscular activation for the two conditions. The data show that in the MS subjects there is an alteration of the stabilization muscles with regard the quality of the activation. Starting from these data new exercises of motor rehabilitation in subjects with multiple sclerosis could be recommended.