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Purpose: To describe a new surgical technique involving the use of a human amniotic membrane (hAM) epiretinal patch to treat a primary macular hole retinal detachment (MHRD) in a highly myopic patient., Methods: A 60 years old highly myopic man was referred to our clinic with a diagnosis of MHRD in his right eye. The patient was pseudophakic, with a visual acuity of counting fingers at the baseline evaluation. Pars plana vitrectomy was performed, a small retinotomy was created at the inner margin of the staphyloma, and membrane blue dual was used to obtain an adequate peeling of the inner limiting membrane. Then, a 1.5 mm diameter circular hAM patch was obtained and positioned over the macular hole with the chorion layer settled over the retina. After a complete fluid-air exchange, 20% sulfur hexafluoride gas was used as endotamponade, and the patient was asked to remain face down for three days., Results: Four weeks after surgery, optical coherence tomography (OCT) scan showed the hAM patch, visualized as a distinct hyperreflective layer well integrated with the retina. Nine months after surgery, the macular hole was closed, the retina reattached, the hAM patch was adherent to the retina, and the patient presented a best-corrected visual acuity improved to 0.7 logMar. No postoperative adverse events were registered during the follow-up., Conclusions: Epiretinal hAM implant could represent a novel surgical technique, feasible and easier compared to other current techniques used to treat MHRD in highly myopic patients., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To report our experience using the T-shaped macular buckle (MB) with or without pars plana vitrectomy (PPV) as primary surgery or with a previous failed surgical approach in patients affected by high myopia and macular hole (MH) with or without macular detachment and with or without macular schisis. The primary goal was to evaluate complete closure of the MH and reattachment of the retina., Design: Retrospective case series of 21 consecutive patients who underwent T-shaped MB implant alone or combined with PPV at the Academic Medical Center in Amsterdam, The Netherlands, between January 2013 and November 2014. The mean axial length was 31.22 mm. The mean follow-up period was 7 months., Results: Retinal reattachment was achieved in 100% of cases while MH closure was achieved in 90.5%. No major perioperative complications were observed. Best corrected visual acuity improved in 71.4% of patients., Conclusions: MB combined with PPV should be considered as the preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: The International Vitreomacular Traction Study (IVTS) Group was convened to develop an optical coherence tomography (OCT)-based anatomic classification system for diseases of the vitreomacular interface (VMI)., Design: The IVTS applied their clinical experience, after reviewing the relevant literature, to support the development of a strictly anatomic OCT-based classification system., Participants: A panel of vitreoretinal disease experts was the foundation of the International Classification System., Methods: Before the meeting, panel participants were asked to review 11 articles and to complete 3 questionnaires. The articles were preselected based on searches for comprehensive reviews covering diseases of the VMI. Responses to questionnaires and the group's opinions on definitions specified in the literature were used to guide the discussion., Main Outcome Measures: Optical coherence tomography-based anatomic definitions and classification of vitreomacular adhesion, vitreomacular traction (VMT), and macular hole., Results: Vitreomacular adhesion is defined as perifoveal vitreous separation with remaining vitreomacular attachment and unperturbed foveal morphologic features. It is an OCT finding that is almost always the result of normal vitreous aging, which may lead to pathologic conditions. Vitreomacular traction is characterized by anomalous posterior vitreous detachment accompanied by anatomic distortion of the fovea, which may include pseudocysts, macular schisis, cystoid macular edema, and subretinal fluid. Vitreomacular traction can be subclassified by the diameter of vitreous attachment to the macular surface as measured by OCT, with attachment of 1500 μm or less defined as focal and attachment of more than 1500 μm as broad. When associated with other macular disease, VMT is classified as concurrent. Full-thickness macular hole (FTMH) is defined as a foveal lesion with interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium. Full-thickness macular hole is primary if caused by vitreous traction or secondary if directly the result of pathologic characteristics other than VMT. Full-thickness macular hole is subclassified by size of the hole as determined by OCT and the presence or absence of VMT., Conclusions: This classification system will support systematic diagnosis and management by creating a clinically applicable system that is predictive of therapeutic outcomes and is useful for the execution and analysis of clinical studies., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the incidence and characteristics of iatrogenic retinal breaks in 20-gauge macular surgery with an intensified search strategy., Design: Retrospective, non-comparative interventional case series., Participants: 218 consecutive operations in 209 patients who underwent 20-gauge vitrectomy vitrectomy for idiopathic macular pucker or idiopathic macular hole., Methods: Retrospective review of patient records undergoing 20-gauge vitrectomy with intensified peripheral search for retinal defects., Main Outcome Measures: Incidence of breaks related to the sclerotomies, the incidence of breaks occurring elsewhere, the incidence of lesions suspicious for traction, the location of identified breaks and intraoperative induction of posterior vitreous detachment., Results: Retinal breaks occurred in 24.3% of operations. In 17.4% breaks were related to the sclerotomies and in 9.6% of breaks were found elsewhere. In 6.4% of eyes, only lesions suspicious for traction were detected. Retinal detachment occurred in 1.8% of cases. The occurrence of breaks was significantly related to induction of PVD., Conclusions: With intensified intraoperative search, a much higher incidence of retinal breaks was found than previously reported in the literature. Despite the high incidence of breaks, the incidence of postoperative rhegmatogenous retinal detachment was low. These findings support the rationale that intensive intraoperative search for iatrogenic breaks is crucial for the prevention of postoperative retinal detachments in macular surgery.

Purpose: Intraocular dyes facilitate the identification of the inner limiting membrane (ILM) during surgery. Appropriate dyes should be safe, provide adequate staining, and be easy to use. Heavy Trypan blue eliminates the need for an air-fluid exchange (AFX) and appears to have little retinal toxicity. This study refers to a prospective, consecutive trial with heavy Trypan blue in macular hole surgery., Patients and Methods: A consecutive group of 20 patients with full thickness macular holes was recruited in a single institution study. Patients were operated using conventional methods. Heavy Trypan blue was prepared by mixing isovolumetrically glucose 10% with MembraneBlue (DORC, Zuidland, The Netherlands). Patients were assessed for ease of surgery and post-operatively at 3 and 6 months (vision and ocular coherence tomography) for hole closure and vision., Results: Twenty eyes were included in the study. Reapplication of dye was used in 75% of the cases, leading to improved contrast further facilitating the ILM peel. In no case was an AFX necessary to obtain sufficient staining. Macular hole closure was achieved in 19 of 20 patients with one surgery. No retinal detachment or other complication was observed in the follow-up period., Conclusion: Heavy Trypan blue can be delivered efficiently to the retinal surface without the need for an AFX. Staining was sufficient to help visualise and peel the ILM. Repeat applications were easily performed. The macular hole closure rate was similar to that of other series with a comparable visual improvement.

Purpose: Vitreomacular adhesion causing vitreomacular traction is a common indication for vitrectomy. It may be avoided by using enzymatic vitreolysis. The MIVI-IIT (traction) study evaluated the ability of a single or repeated injection of microplasmin to release vitreomacular traction., Methods: This randomized, double-masked, Phase II trial with control sham injection enrolled 60 patients. Patients in each of the 4 cohorts were randomized (4:1) to active treatment or sham injection. In the first 3 cohorts, increasing doses of microplasmin (75, 125, and 175 microg) were administered. In the fourth cohort, an initial injection of 125 microg microplasmin or sham was administered followed 1 month later by an injection of 125 microg microplasmin if no release of adhesion occurred. A third dose was injected 4 weeks later if there was still no release of adhesion., Results: Within 28 days of sham, 75, 125, and 175 microg microplasmin administration, nonsurgical resolution of vitreomacular adhesion was observed in 8, 25, 44, and 27% of the patients, respectively. When the 125 microg dose was repeated up to 3 times, adhesion release was observed in 58% of patients 28 days after the final injection., Conclusion: These results provide support for the potential of microplasmin as a nonsurgical treatment for vitreomacular adhesion.

Purpose: To describe the incidence and characteristics of iatrogenic retinal breaks in 25-gauge macular surgery., Design: Retrospective, noncomparative, interventional case series., Methods: We included 177 consecutive operations in 171 patients who underwent 25-gauge vitrectomy for idiopathic macular pucker or idiopathic macular hole. Main outcome measures were the incidence of breaks related to the sclerotomies, the incidence of breaks occurring elsewhere, the incidence of lesions suspicious for traction, the location of identified breaks, and intraoperative induction of posterior vitreous detachment (PVD)., Results: Retinal breaks occurred in 15.8% of operations. In 6.2%, breaks were related to the sclerotomies, and in 10.7%, breaks were found elsewhere. In 8.5% of eyes, only lesions suspicious for traction were detected. Breaks or suspicious lesions were treated with external cryocoagulation in a total of 24.3% of cases. A statistically significant relation between PVD induction and presence of breaks elsewhere was identified. No correlation with lens status, initial diagnosis, or preoperative refraction was found. Retinal detachment occurred in 1.7% of cases., Conclusions: We report an incidence of retinal breaks that is higher than previously found for 20- or 25-gauge surgery. Despite the high incidence of breaks, the incidence of postoperative retinal detachment was low. A specific characteristic was the relatively high incidence of breaks elsewhere and their relation to PVD induction. Our findings underscore the importance of scrupulous full 360-degree internal search at the end of each procedure to identify and treat all breaks and suspicious lesions optimally.

Objective: To investigate the expression of the profibrotic connective tissue growth factor (CTGF) in relation to severity of intraocular fibrosis and neovascularization in human vitreoretinal disorders for the identification of potential therapeutic targets to prevent fibrosis., Methods: Concentrations of CTGF were measured by enzyme-linked immunosorbent assay in 119 vitreous samples from patients with proliferative diabetic retinopathy, proliferative vitreoretinopathy, epiretinal membrane, and macular hole. Clinical data, including degree of intraocular fibrosis and neovascularization, were collected using standardized forms., Results: Multifactorial analysis revealed that only CTGF levels correlated highly significantly with degree of fibrosis in the various vitreoretinal disorders studied (P<.001; R2= 47.7%). Likewise, variation in degree of fibrosis was best predicted by CTGF levels (P<.001)., Conclusion: The strong correlation between CTGF levels and degree of fibrosis in vitreoretinal disorders suggests that CTGF is an important factor in ocular fibrosis, similar to its role in pathologic fibrosis in other organs., Clinical Relevance: Connective tissue growth factor may be a therapeutic target for prevention of sight-threatening vitreoretinal scarring in the eye.