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To introduce a novel surgical technique using the human amniotic membrane (hAM) patch technique to address refractory macular holes (MHs). After vitrectomy, the hAM patch was positioned on top of the MH with the chorion side facing downward. Viscoat (Alcon Laboratories) was applied on top of the hAM patch for better fixation. Fluid-air exchange was then performed and 20% SF6 or 10% C3F8 tamponade was administered after the surgery. Five patients with refractory MHs larger than 400 µm underwent the hAM patch technique. After a minimum 2-year follow-up, results showed 100% closure of MHs, 80% improvement in visual acuity, and a notable enhancement in best-corrected logMAR visual acuity from 0.98 to 0.72 ( P = 0.039). Dislocation of hAM patch occurred among 3 out of 5 patients (60%). The hAM patch technique appears to be a promising approach for addressing refractory MHs. [ Ophthalmic Surg Lasers Imaging Retina 2024;55:613-616.] .

Purpose: To report on macular hole repair in macular telangiectasia type 2 (MacTel2)., Design: Global, multicenter, retrospective case series., Participants: Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH)., Methods: Standardized data collection sheet distributed to all surgeons., Main Outcome Measures: Anatomic closure and visual outcomes of MTMH., Results: Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 μm (range, 34-573 μm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 μm (range, 97-697 μm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 μm (range, 132-687 μm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%., Conclusions: Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Müller cells play a critical role in the closure of macular holes, and their proliferation and migration are facilitated by the internal limiting membrane (ILM). Despite the importance of this process, the underlying molecular mechanism remains underexplored. This study investigated the effects of ILM components on the microRNA (miRNA) profile of Müller cells. Rat Müller cells (rMC-1) were cultured with a culture insert and varying concentrations of ILM component coatings, namely, collagen IV, laminin, and fibronectin, and cell migration was assessed by measuring cell-free areas in successive photographs following insert removal. MiRNAs were then extracted from these cells and analyzed. Mimics and inhibitors of miRNA candidates were transfected into Müller cells, and a cell migration assay and additional cell viability assays were performed. The results revealed that the ILM components promoted Müller cell migration ( p < 0.01). Among the miRNA candidates, miR-194-3p was upregulated, whereas miR-125b-1-3p, miR-132-3p, miR-146b-5p, miR-152-3p, miR-196a-5p, miR-542-5p, miR-871-3p, miR-1839-5p, and miR-3573-3p were significantly downregulated ( p < 0.05; fold change > 1.5). Moreover, miR-152-3p and miR-196a-5p reduced cell migration ( p < 0.05) and proliferation ( p < 0.001), and their suppressive effects were reversed by their respective inhibitors. In conclusion, miRNAs were regulated in ILM component-activated Müller cells, with miR-152-3p and miR-196a-5p regulating Müller cell migration and proliferation. These results serve as a basis for understanding the molecular healing process of macular holes and identifying potential new target genes in future research.

Purpose: To report the outcomes of the Peeling and Internal Limiting Membrane Reposition (PAIR) technique in myopic foveoschisis., Methods: A retrospective case series of eyes with myopic foveoschisis that underwent vitrectomy and PAIR. Visual acuity, fundus photographs, and optical coherence tomography measurements were obtained and analyzed. Data are presented as medians (ranges)., Results: A total of seven eyes underwent PAIR and were followed up for 339 days (188-436 days). No intraoperative complications were noted. One eye exhibited postoperative macular hole formation, but the hole was healed through fluid-gas exchange. At the last follow-up, the visual acuity had improved from 20/66 (20/332-20/40) to 20/40 (20/100-20/25), and the central foveal thickness had decreased from 576 µ m to 269 µ m. A repositioned internal limiting membrane (ILM) was observed in six of the eyes, and inner retinal dimples were noted in only two eyes. However, retinal wrinkles under the repositioned or perifoveal ILM were noted in five eyes., Conclusion: The PAIR technique relieved traction, restored the ILM, and achieved functional and morphological improvement in eyes with myopic foveoschisis. Limited occurrence of inner retinal dimples and retinal thinning was noted, but retinal wrinkles occurred, likely due to ILM contracture.

Purpose: To investigate late vitreoretinal complications and visual outcomes in patients with regressed retinopathy of prematurity (ROP) with or without prior treatment., Design: International, multicenter, noncomparative retrospective case series., Participants: We analyzed 264 eyes of 238 patients from 13 centers worldwide who developed vitreoretinal complications (retinal detachment [RD], vitreous hemorrhage [VH], or retinal break) ≥ 2 years after resolution of acute ROP., Methods: Each participant was assigned to 1 of 3 groups (the RD, VH, and retinal break groups) according to their primary diagnosis. The average age at presentation, visual acuities, refractive error, axial length, gestational age, birth weight, acute ROP classification, prior treatments for acute ROP, postoperative visual acuity (VA), and concomitant eye conditions in the 3 groups were documented and compared., Main Outcome Measures: Clinical features and visual outcomes of late vitreoretinal complications in patients with regressed ROP., Results: A total of 264 eyes of 238 patients were included. The prior acute ROP status was comparable among the 3 groups, except that the VH group had a higher proportion of patients with type 1 ROP (P = 0.03) and prior treatment (P < 0.001) than the other groups. The average age at presentation was earlier in the RD (20.3 ± 15.5 years) and VH (21.4 ± 18.9 years) groups than in the retinal break group (31.9 ± 18.2 years; P < 0.001). The retinal break group had the best presenting best-corrected VA, followed by the RD and VH groups (P < 0.001). Surgical intervention improved VA in both the RD and VH groups (both P < 0.05). The overall trend of VA was the most favorable in the retinal break group, followed by that in the VH and RD groups. Cicatricial changes in the fellow retina were observed in > 90% of patients with unilateral involvement., Conclusions: Infants with acute ROP remain at a high risk of vision-threatening complications throughout childhood and adulthood. Continual follow-up of patients with ROP is important. When severe complications, such as RD or VH, are detected, timely surgical intervention is necessary to ensure favorable visual outcomes in these patients., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the outcomes of using an internal limiting membrane (ILM) flap and the conventional ILM peel technique for small- or medium-sized full-thickness macular hole (FTMH) repair., Design: Retrospective, interventional case series., Methods: Eyes with an FTMH ≤400 µm that underwent vitrectomy with a single-layer inverted ILM flap (flap group, 55 eyes) or an ILM peel (peel group, 62 eyes) were enrolled. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) measurements were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively., Results: Primary hole closure was achieved in 54 (98%) and 60 (97%) eyes in the flap and peel groups, respectively. The preoperative and postoperative 12-month BCVA values were comparable between the groups but were significantly better in the flap than in the peel group at 1 month (mean ± SD logMAR: 0.83 ± 0.43 vs 1.14 ± 0.50; P = .001), 3 months (0.58 ± 0.33 vs 0.82 ± 0.43; P = .002), and 6 months (0.56 ± 0.32 vs. 0.72 ± 0.48; P = .028). In the flap group, foveal gliosis was less common than in the peel group at 1 month (P = .030), and restored external limiting membrane and interdigitation zone was more common at 3 months (P = .046 and P < .001, respectively)., Conclusions: The single-layer ILM flap and conventional ILM peel techniques both closed FTMHs and improved vision. ILM flaps were associated with better visual outcomes up to 6 months postoperatively and should be considered in FTMHs ≤400 µm., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: To report the anatomic and functional outcomes of autologous retinal transplantation (ART)., Design: Multicenter, retrospective, interventional, consecutive case series., Participants: One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019., Methods: All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed., Main Outcome Measures: Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT., Results: One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P < 0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n = 35), for refractory MH in 58% of patients (n = 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n = 19). Mean maximum MH diameter was 1470 ± 160 μm, mean minimum diameter was 840 ± 94 μm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P = 0.02) and ANL (P = 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred., Conclusions: In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the outcomes between using a nasal and a temporal inverted internal limiting membrane (ILM) flap both assisted by a novel technique in repairing a full-thickness macular hole (FTMH)., Design: Retrospective interventional case series., Methods: Thirty-nine eyes from 39 patients with a FTMH <600 μm were included from a single institution. All patients underwent vitrectomy using a semicircular single-layered ILM inverted flap assisted by a sub-perfluorocarbon liquid injection of ophthalmic viscoelastic device (OVD) technique. Best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography were used to compare outcomes between nasal (n = 19) and temporal (n = 20) groups., Results: At 6 months postoperatively, all FTMHs closed and BCVA were significantly improved. Overall, 36 eyes (92%) achieved U-shaped closure, and ellipsoid zone restoration was noted in 24 eyes (62%). An ILM flap was present in 29 eyes (74%) and 86% remained single-layered. There were significantly more deep inner retinal dimples in the temporal group (35%) compared with 5% in the nasal group (P = .04), but these were unrelated to BCVA. Significant retinal thinning in the temporal outer sub-field was noted in the temporal group and was negatively correlated with BCVA (rho [ρ]: - .53; P = .03). No significant postoperative retinal displacement was noted in either group., Conclusions: The technique of using sub-perfluorocarbon liquid injection of OVD secured single-layered flaps intraoperatively and postoperatively. Both the nasal and temporal inverted ILM flaps repaired FTMH and improved visual acuity. However, both temporal macular thinning and deep inner retinal dimples were significantly greater in the temporal group., (Copyright © 2020. Published by Elsevier Inc.)

This study investigated the effects of growth factors and internal limiting membrane components on Müller cell migration. We studied the effects of epidermal growth factor (EGF), fibroblast growth factor (FGF), somatomedin (IGF-1), platelet derived growth factor (PDGF), and stromal cell-derived factor-1 alpha (SDF-1α) as well as collagen IV, laminin, and fibronectin on the proliferative and migratory activities of rat Müller cells in vitro. A water soluble tetrazolium-1 assay was used to quantify the viability of Müller cells in respective cultures, and analysis was performed using an enzyme-linked immunosorbent assay reader. All the factors examined had significant proliferative effects on cultured Müller cells (p < .05). A two-well Ibidi silicone culture insert was used to assess Müller cell migration. Müller cells cultured in EGF, FGF, IGF-1, collagen IV, and laminin but not in SDF, PDGF, or fibronectin effectively increased the cell migratory activity (p < .001). In addition, combined EGF and collagen IV, combined FGF and collagen IV, and combined IGF-1 and laminin exhibited more significant (p < .001) effects on Müller cell migration compared with culture a single factor. In summary, this study revealed the combinatorial effects of various growth factors and individual internal limiting membrane constituents. This may assist Müller cell migration together with the macular hole healing process., (Copyright © 2020. Published by Elsevier Ltd.)

Purpose: To investigate the long-term surgical outcomes of macular hole retinal detachment (MHRD) following vitrectomy with macular plug in highly myopic eyes., Methods: Thirty-five cases of highly myopic eyes with MHRD in 35 patients who underwent an initially successful vitrectomy with macular plug and were followed up for at least 3 years were reviewed. The anatomical outcomes were evaluated by fundus examination, fundus photographs and optical coherence tomography (OCT). Myopic features after the surgery were differentiated according to recommendations of the Meta-analysis of Pathologic Myopia (META-PM) Study Group. The best-corrected visual acuities (BCVAs) before and after surgery were analysed as the functional outcome. Main outcome measures time-course changes in BCVA and complications., Results: The mean patient age was 61.0 ± 11.4 years. The follow-up was 45.2 ± 8.6 months (ranged from 36 to 71 months). The mean axial length was 29.3 ± 1.2 mm. All eyes demonstrated attached retina, but 2 eyes (5.7%) developed reopened macular holes until the last follow-up. Complications of postoperative rhegmatogenous retinal detachment were detected in 2 eyes (5.7%) within 1 year and retina reattached after the secondary vitrectomy. Three cases (8.6%) of prolonged subretinal fluid lasting more than 1 year were detected but finally absorbed completely. Comparing 1-3 years postoperatively, myopic features showed significant progression of myopic maculopathy category (p = 0.035). Functionally, significantly improved BCVA could be maintained postoperatively between 6 months and 3 years. However, vision of 14 eyes (40.0%) worsened within 1-3 years postoperatively, and visual deterioration was associated with progression of myopic maculopathy (p = 0.004) and pre-existing disease of glaucoma (p = 0.006)., Conclusions: A vitrectomy combined with macular plug provided favourable outcomes in the long term, over the ≥3-year follow-up period., (© 2020 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: To evaluate the feasibility of a surgical technique using a sub-perfluoro-n-octane (PFO) injection of ocular viscoelastic device (OVD) to stabilize inverted internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment (MHRD)., Methods: This study was a retrospective, consecutive, interventional case series. Patients who underwent MHRD surgery with sub-PFO injection of OVD to stabilize inverted ILM flap onto the macular hole (MH) were reviewed. The color fundus and optical coherence tomography (OCT) images were collected and evaluated. The best-corrected visual acuity (BCVA) before and after surgery were compared as the functional outcome., Results: The study included 8 eyes of 8 consecutive patients (mean age: 61.8 ± 7.1 years; mean follow-up period: 9.0 ± 2.5 months). All eyes (100%) achieved successful MH closure; 7 eyes (87.5%) demonstrated complete retinal reattachment, and 1 eye (12.5%) had minimal residual subretinal fluid parafoveally. Of the 8 patients, 7 patients (87.5%) had achieved improvement in BCVA after the primary surgery, whereas 1 eye remained stable. The average BCVA before and after the surgery at the last visit improved from 20/843 (1.63 ± 0.48 logMAR) to 20/200 (1.00 ± 0.39 logMAR) (P = 0.016). Anatomically, near-normal foveal contour was noted in five (62.5%) eyes at the final follow-up., Conclusions: The use of sub-PFO injection of OVD in MHRD surgery could stabilize inverted ILM flaps, achieve good anatomical results and improve postoperative BCVA.

Purpose: To evaluate a surgical technique using a perfluoro-n-octane (PFO)-assisted autologous internal limiting membrane (ILM) plug for refractory macular holes (MHs)., Methods: This study was a retrospective, consecutive, interventional case series. Patients with refractory MHs following PFO-assisted autologous ILM plugs were reviewed between October 1, 2017, and February 28, 2018. The anatomical results of MH preoperatively and postoperatively were evaluated by fundus examination and optical coherence tomography (OCT). The best-corrected visual acuities (BCVAs) before and after surgery were compared as the functional outcome., Results: Six eyes of six consecutive patients with refractory MH were enrolled in this study. Successful MH closure and BCVA improvement after the surgeries were obtained in all eyes. There were four male and two female patients, and the mean age was 63.7 ± 11.1 years. Intraoperatively, the average number of autologous ILM grafts we harvested was 2.2 ± 0.4. The mean follow-up was 6.0 ± 1.7 months. The averaged BCVA before and after the surgery at the last visit improved from 20/356 to 20/153. The ILM graft tissue was still visible, as shown by OCT, in all 6 of 6 (100%) eyes during the follow-up period., Conclusions: This surgical technique using PFO-assisted autologous ILM plug may provide an option for the treatment of refractory MH.

Background: To evaluate the surgical technique using autologous retinal graft (ARG) and autologous blood clot (ABC) for the management of refractory macular holes (MHs)., Methods: This study was a retrospective, consecutive, interventional case series. Six eyes of 6 patients who underwent vitrectomy combined with ARG and ABC for the treatment of refractory MH were reviewed. Visual and anatomic outcomes were evaluated., Results: The mean age was 59.0 ± 9.9 years. All cases had multiple vitreoretinal procedures including vitrectomy and gas fluid exchange before patient presentation. The average numbers of vitrectomies were 2.3 ± 0.5, and those of gas fluid exchange were 3 ± 1.7. Closure of the macular hole was achieved in four (66.7%) cases at last follow-up. The mean follow-up time was 25.2 ± 15.6 months. The averaged BCVA before and after 12 months of the surgery improved from 20/591 to 20/244., Conclusions: This surgical technique using ARG and ABC provide an option for the treatment of refractory MHs.

Purpose: To evaluate the differences in anatomical and visual function changes after macular hole (MH) surgery using the International Vitreomacular Traction Study classification., Methods: Patients who underwent vitrectomy and blood-assisted internal limiting membrane peeling because of MHs were enrolled in the present study. The patients were divided into three groups according to the sizes of their MHs (small: ≤250 μm, medium: >250 μm and ≤400 μm, and large: >400 μm). The effect of vitreomacular traction on the outcome was also analyzed. All the patients were followed for at least 12 months. The changes in best-corrected visual acuity and the outer retina at the foveal area were monitored using spectral-domain optical coherence tomography., Results: A total of 146 eyes of 146 patients were enrolled. The patients with small MHs showed significantly better mean final visual acuity (mean: 20/58) than patients with large MHs (20/178, P < 0.05). There was no significant difference between patients with small- and medium-sized MHs (20/69). Longitudinal analysis showed that the presence of vitreomacular traction was related to a better restoration of the outer retinal structure and visual acuity., Conclusion: Patients with smaller MHs and vitreomacular adhesion had superior final visual acuity and better restoration of the outer retinal structure after MH surgery.

Purpose: To investigate the surgical results of macular hole retinal detachment (MHRD) repaired using vitrectomy combined with inverted internal limiting membrane repositioning (ILMR) and autologous blood clot (ABC) in highly myopic eyes., Design: Retrospective, interventional case series., Participants: Twenty-seven cases of MHRD., Methods: Twenty-seven cases of highly myopic eyes with MHRD in 27 patients who underwent a vitrectomy combined with ILMR and ABC and were followed up over 6 months were reviewed. The anatomic outcomes of MHRD were evaluated by fundus examinations and optical coherence tomography. The preoperative and postoperative best-corrected visual acuities (BCVAs) were compared as the functional outcome., Main Outcome Measures: Retinal reattachment, macular hole (MH) closure, and BCVA before and after surgery., Results: In total, women accounted for 85% (23/27) of the MHRD patients. The mean age was 59.1±10.6 years. The mean axial length was 29.37±1.92 mm. Type 1 MHRD was present in 9 eyes, and type 2 MHRD was present in 18 eyes. After a single surgery, the retina was attached and the hole was closed in 26 eyes (96%), and 100% retinal attachment was achieved by another vitrectomy for rhegmatogenous retinal detachment that occurred 3 months after the initial surgery. A parafoveal unclosed hole was found in 1 eye (4%) during the follow-up period, and the patient did not undergo further treatment. Three eyes with a closed hole showed persistent subretinal fluid (SRF) after gas absorption. In 2 of these cases, the fluid absorbed completely during the follow-up period, but 1 eye exhibited persistent SRF, which was resolved progressively during the 12 months of follow-up. The surgery significantly improved the BCVAs {from 1.8±0.7 logarithm of the minimum angle of resolution units to 1.3±0.7 logarithm of the minimum angle of resolution units (P = 0.001)} at 3 and 6 months and at the last visit after surgery. Seven patients underwent cataract surgery during the follow-up period., Conclusions: A vitrectomy combined with ILMR and ABC is effective for closing MHs and reattaching the retina and significantly improves the postoperative BCVA in MHRD patients., (Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the surgical outcomes of macular hole (MH) repair by vitrectomy and internal limiting membrane peeling in highly myopic eyes., Methods: In this retrospective interventional case series, 30 highly myopic eyes with MH in 29 consecutive patients who underwent vitrectomy and internal limiting membrane peeling to repair MH were studied. The mean follow-up time was 36.4 months. The anatomical outcomes of the MH were evaluated by optical coherence tomography. The best-corrected visual acuities before and after surgery were compared as the functional outcome., Results: Women accounted for 69% of MH in highly myopic eyes. The mean age was 49 years. The mean refraction error and mean axial length were -9.80 (± 2.93) diopter and 28.13 (± 2.41) mm, respectively. Myopic foveoschisis was observed in 3 eyes (10%). The MHs were closed by a single surgery in 26 eyes (87%), and the final closure rate was 97% (29/30 eyes). Macular hole surgery significantly improved best-corrected visual acuity from 1.20 ± 0.70 to 0.77 ± 0.51 logarithm of the minimum angle of resolution (P = 0.003). However, rhegmatogenous retinal detachment developed in 3 eyes (10%) during the follow-up., Conclusion: Vitrectomy with internal limiting membrane peeling is effective to repair MH in highly myopic eyes in terms of anatomical and functional outcomes, although visual acuity may continue to improve slowly until 3 years after successful MH-closing surgery. In addition, a small proportion of MH cases were associated with myopic foveoschisis. Delayed hole closure and rhegmatogenous retinal detachment may occur in these highly myopic eyes after surgery.

Purpose: To report the efficacy and safety of outpatient fluid-gas exchange for open macular hole after primary vitrectomy., Design: Retrospective interventional case series., Methods: setting: Institutional. patients: Thirty-six patients with primary failed closure or reopened holes after primary vitrectomy. intervention: Fluid-gas excahnge with 15% perfluoropropane (C3F8) or 20% sulfur hexafluoride (SF6) was performed to reclose the hole under topical anesthesia. main outcome measures: The hole closure rate and type, pre- and postexchange best-corrected visual acuity (BCVA), and complication rates were assessed., Results: Thirty-two eyes (89%) achieved anatomic success from 1-3 weeks after the fluid-gas exchange. Twenty-two eyes (61%) achieved type 1 closure, 10 eyes (28%) achieved type 2 closure, and 4 eyes (11%) did not achieve closure. The BCVA for type 1 closure improved significantly from logarithm of the minimal angle of resolution (logMAR) 1.66 ± 0.41 to 0.84 ± 0.41, with a P value <.001. The BCVA for type 2 closure improved from logMAR 1.77 ± 0.41 to 1.52 ± 0.41, with a P value of .05. All patients with an unclosed hole after fluid-gas exchange had a stage IV macular hole before the primary vitrectomy and a hole size larger than 1000 μm. The complication related to fluid-gas exchange procedure was transient high intraocular pressure, which responded well to topical antiglaucoma medications. There were 2 retinal detachment cases following the exchange; surgery to reattach the retina was performed, with visual acuity recovery., Conclusion: Outpatient fluid-gas exchange is an effective treatment option for eyes with open holes following vitrectomy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the efficacy and safety of using diluted autologous blood clumps to assist in vitrectomy and internal limiting membrane (ILM) peeling for macular hole (MH) repair., Methods: Twenty-six patients with MHs who underwent ILM peeling were enrolled. The blood clump solution was prepared by mixing autologous whole blood with 5% glucose water. This solution was introduced to identify the posterior vitreous and was then used to coat the surface of the ILM in the macular area. The blood clump-coated ILM was removed with forceps in a circular fashion. The MH closure rate, the pre- and postoperative best-corrected visual acuity change, and retinal changes were evaluated., Results: The blood clump-assisted procedure effectively labeled the posterior vitreous and coated the ILM, enhancing the visibility of ILM and, thus, facilitating MH repair. The MHs were closed by a single surgery in 24 eyes (92%), and the other 2 holes were closed after a second gas-fluid exchange. The pre- and postoperative mean best-corrected visual acuities were 0.96 ± 0.3 and 0.38 ± 0.3 (logarithm of the minimum angle of resolution visual acuity ± SD, P < 0.001), respectively. No toxic fundus changes were observed during the follow-up period., Conclusion: This novel blood clump-assisted procedure effectively labeled the posterior vitreous and coated the ILM, enhancing the visibility of ILM and thereby facilitating MH repair.

Objective: To compare indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling with and without autologous whole blood (WB) protection during macular hole repair surgery., Material and Methods: We retrospectively reviewed 50 eyes with an idiopathic macular hole. Group 1 contained 22 eyes that underwent ILM peeling with WB protection and group 2 contained 28 eyes that underwent ILM peeling without WB. Anatomic and visual results were compared., Results: After surgery, macular hole closure was achieved in 96% of the group 1 eyes and in 93% of the group 2 eyes. The preoperative mean best-corrected visual acuity (BCVA) was logarithm of the minimum angle of resolution (logMAR) 0.95 in group 1 and logMAR 0.89 in group 2 (p = .544). The postoperative mean BCVA was logMAR 0.57 in group 1 and logMAR 0.92 in group 2 (p = .017)., Conclusion: Macular hole surgery protected with WB facilitates improved visual recovery in ICG-assisted ILM peeling.

Purpose: To evaluate the efficacy of autologous heparinized whole blood in assisting internal limiting membrane (ILM) peeling by coating the ILM for macular hole (MH) repair., Design: Prospective, interventional case series., Participants: Twenty-nine patients (32 eyes) who underwent blood-assisted ILM peeling for MH repair., Methods: Patients in whom stage 2-4 idiopathic MHs had developed and who desired surgery were enrolled in this study. After core vitrectomy, autologous heparinized whole blood was applied to cover the macula and to coat the surface of the macular area in the fluid-filled vitreous cavity. The redundant blood was removed and only a very thin film of blood was left on the macular area. The blood-coated ILM was removed by forceps in a circular fashion. To confirm the removed membrane was the ILM, the first 10 specimens were examined by electron microscopy (EM)., Main Outcome Measures: The MH closure rate, the interval mean visual acuity (before and after surgery), retinal changes, and the EM results of the ILM specimens., Results: All 32 eyes in 29 patients completed 12 months of follow-up. The ILM were coated by autologous heparinized whole blood, removed without difficulty, and confirmed by EM. The whole blood highlighted the contrast of the coated and noncoated areas during the ILM peeling procedure. The MHs were closed in all surgical eyes with a single surgery (100%). Compared with study entry, the mean logMAR best-corrected visual acuity 12 months after surgery improved significantly (1.02 and 0.53, respectively; P<0.001). At 12 months of follow-up, 31 eyes (96.9%) had stable or improved vision. No toxic fundus changes were observed during follow-up., Conclusions: Autologous heparinized whole blood coated the ILM and facilitated visibility during ILM peeling. Autologous heparinized whole blood is a cost-effective and useful tool for assisting MH surgery.

Objective: To prevent trypan blue (TB) retention and its potential toxicity by selectively staining the internal limiting membrane (ILM) with the aid of whole blood., Methods: Twenty-four consecutive patients with macular holes who underwent TB-assisted ILM peeling were enrolled. In the surgeries, autologous whole blood was applied to cover the macular hole, and only the area selectively used for TB staining was exposed. Trypan blue solution (0.75 mg/mL, after being diluted with 5% glucose) was used to stain the exposed macular area in the fluid-filled vitreous cavity. The stained ILM was then completely removed., Results: Twenty-four macular holes were studied. The ILMs were selectively stained by trypan blue and then removed completely. No visible dye remained on the retina after peeling. The macular holes were closed in 22 eyes (92%) after a single surgery. The mean best-corrected visual acuity improved from 20/140 to 20/62 after surgery. In addition, no fundus changes were observed during the follow-up period., Conclusion: Selective staining of ILM during TB-assisted membrane peeling could be achieved with whole blood as the adjuvant. Complete removal of stained membranes can prevent TB retention and may further reduce toxicity on retinal pigment epithelium and retina.

Purpose: To elucidate the relationship between the severity of vitreous haemorrhage (VH) and visual outcome in primary rhegmatogenous retinal detachment (RRD) without previous vitreoretinal surgery., Methods: We carried out a retrospective review of patients presenting with RRD and VH between January 1993 and December 2002. Diabetic retinopathy, retinal vessel occlusion and open-globe injury patients were excluded. Study patients were separated into group 1 (eyes with mild to moderate VH) and group 2 (eyes with severe VH)., Results: Our sample included 71 eyes of 71 patients (mean age 48.0 years, range 7-78 years) (median follow-up period 19 months, range 12-140 months), of which 21 had mild, 17 had moderate and 33 had severe VH. The mean visual acuity (VA) in logMAR (logarithm of minimum angle of resolution) of the 38 eyes in group 1 improved from 1.90 (Snellen equivalent [SE] 20/1589) to 0.68 (SE 20/96). In the 33 eyes in group 2, mean logMAR VA improved from 2.42 (SE 20/5261) to 1.63 (SE 20/853). Group 2 patients were significantly older (p = 0.002), had longer duration of preoperative haemorrhage (p = 0.004), lower presenting VA (p < 0.001), worse final VA (p < 0.001), and a higher incidence of severe (grade C) proliferative vitreoretinopathy (PVR) (p = 0.002). More eyes in group 2 required silicone oil tamponade, although this was not statistically significant (p = 0.133). The overall recurrence rate of retinal detachment after primary surgery was around 21% in both groups., Conclusions: Rhegmatogenous retinal detachment with severe VH is associated with longer duration of preoperative haemorrhage, a higher incidence of severe PVR and worse visual outcome. Close follow-up and aggressive surgical interventions are suggested in these patients.

Purpose: To prevent triamcinolone acetonide (TA) deposition in the macular hole by use of whole blood during TA-assisted internal limiting membrane (ILM) peeling., Methods: The prospective, interventional case series study included 18 consecutive idiopathic macular holes (18 patients) that underwent TA-assisted internal limiting membrane (ILM) peeling for macular hole treatment. After core vitrectomy, autologous whole blood was applied to cover the macular hole. Pre-prepared TA solution was gently injected onto the macular area. Residual TA particles were removed after ILM peeling. Closure rate of macular hole, preoperative and postoperative median visual acuity, and retinal changes were evaluated., Results: Autologous whole blood prevented the deposition of TA particles in the macular hole. The ILM could be recognized after TA-assisted visualization for removal. Average follow-up time was 8.6 months. The hole was closed with one surgery in 17 eyes (94%); visual acuity improved in 15 eyes (83%). Preoperative median best-corrected visual acuity was 20/100 (range = 20/400-20/50). Postoperative median best-corrected visual acuity was 20/40 (range = counting fingers-20/20)., Conclusions: Whole blood can prevent TA particle deposition in the macular hole. Potential toxicity of TA on retinal pigment epithelium and retina also may be reduced.

Purpose: To evaluate the surgical outcome of retinal detachment resulting from a posterior staphyloma-associated macular hole in highly myopic eyes., Methods: Fifty-seven consecutive highly myopic eyes with retinal detachment resulting from a posterior staphyloma-associated macular hole diagnosed between January 1993 and June 2003 were retrospectively studied. Anatomical reattachment of the retina and best-corrected visual acuity were measured., Results: Six different operative methods were used to treat this condition with diverse retinal reattachment rates: long-acting gas tamponade only (12.5%); pars plana vitrectomy (PPV) with long-acting gas tamponade (42.8%); PPV with epiretinal membrane (ERM) peeling and long-acting gas tamponade (50.0%); encircling scleral buckling combined with PPV and long-acting gas tamponade (57.1%); encircling scleral buckling combined with PPV, ERM peeling, and long-acting gas tamponade (40.0%); and encircling scleral buckling combined with PPV and silicone oil tamponade (75.0%). Overall, successful retinal reattachment was achieved in 25 (43.9%) of 57 eyes after the first surgery. However, the ultimate success rate of retinal reattachment was 77.2% (44 of 57 eyes) after subsequent surgery. The mean preoperative visual acuity +/- SEM (in logarithm of the minimal angle of resolution units) was 2.08 +/- 0.55, and the mean postoperative visual acuity +/- SEM was significantly increased to 1.87 +/- 0.54 at the last follow-up (P = 0.038). The major cause of recurrent retinal detachment in the long-acting gas tamponade group was nonclosure of the macular hole. For vitrectomized eyes, the major cause was reopening of the macular hole, even with ERM formation and proliferative vitreoretinopathy. There was no obvious correlation between the extent of the detachment or lens status and the reattachment rate., Conclusions: The major causes of recurrent retinal detachment in the long-acting gas tamponade and vitrectomized groups were nonclosure of the macular hole and reopening of the macular hole, respectively. Furthermore, a lesser extent of retinal detachment was not associated with a higher anatomical success rate. More aggressive treatment such as silicone oil tamponade may need to be performed to overcome reduced natural adhesion due to posterior staphyloma with marked chorioretinal atrophy. Failure to initiate aggressive treatment can result in an unsatisfactory outcome and repeated surgery.

Purpose: To examine whether whole blood prevents indocyanine green (ICG) toxicity on in vitro retinal pigment epithelium (RPE) and prevents RPE staining in ICG-assisted macular hole (MH) surgery., Design: In vitro study and prospective case series., Participants: In vitro study and 20 patients who underwent ICG-assisted MH surgery (20 eyes)., Methods: In the in vitro study, cultured human RPE cells were covered with balanced saline solution (BSS), heparinized whole blood, plasma, or packed red blood cells, then exposed to various concentrations of ICG. One cohort was incubated in the dark; the other cohort was exposed to light. Indocyanine green toxicity was evaluated by mitochondrial dehydrogenase assay. In the clinical study, a prospective noncomparative review of 20 consecutive patients (20 eyes) with stage 3 to stage 4 MH who underwent surgery with ICG to stain the internal limiting membrane (ILM) was performed. Indocyanine green solution (0.5 mg/ml) was used to stain the ILM after autologous whole blood covered the macular hole area. Postoperative staining of ICG on RPE was detected by an infrared-sensitive camera., Main Outcome Measures: Cultured human RPE cell viability, macular hole closure rate, median visual acuity preoperatively and postoperatively, postoperative ICG staining, and retinal changes., Results: Cultured human RPE cells covered by whole blood or plasma showed no decrease of mitochondrial dehydrogenase even in 5.0 mg/ml concentration of ICG for 20 minutes with or without light exposure. Conversely, those exposed to ICG and covered with BSS demonstrated a significant decrease of mitochondrial dehydrogenase after incubation in 5, 2.5, and 1.0 mg/ml for 20 minutes in the dark and in 5 to 0.05 mg/ml with light. Clinically, no postoperative staining on RPE was detected. No atrophic RPE changes or other retinal changes were observed in the previous MH area that was covered by autologous whole blood in all 20 eyes on average follow-up of 10.6 months. The hole closed in 19 eyes (95%) on first surgery. Visual acuity improved in 17 eyes (85%) on most recent follow-up., Conclusions: Whole blood prevents ICG toxicity in RPE cell culture and prevents staining of RPE in surgery of MH when the ILM is stained with ICG.

Purpose: To investigate the clinical characteristics and surgical outcome of traumatic macular hole-related retinal detachment., Design: Retrospective, interventional case series., Methods: Eight eyes of eight patients with traumatic macular hole-related retinal detachment underwent vitrectomy combined with gas tamponade, either initially or subsequently. Anatomic re-attachment of the retina, closure of traumatic macular hole, and visual outcome were measured., Results: Successful retinal re-attachment was achieved in seven eyes (87.5%), and the macular hole was successfully closed in all eyes (100%). Improved vision after the surgery was noted in five eyes (62.5%), whereas three eyes (37.5%) displayed no change., Conclusions: Vitrectomy combined with gas tamponade appears to give an effective anatomic re-attachment rate for traumatic macular hole-related retinal detachment. The presence of peripheral retinal breaks, vitreous hemorrhage, or the extent of retinal detachment has no discernible significant influence on closure rate of macular hole and retinal re-attachment rate.

Background: To evaluate the efficacy of internal limiting membrane (ILM) peeling in the treatment of a macular hole., Methods: The ocular evaluation included Snellen visual acuity, a slit-lamp examination, indirect ophthalmoscopy, and contact lens biomicroscopy. The macular holes were confirmed using a Watzke-Allen slit beam test. Surgery consisted of a standard 3-port vitrectomy under local anesthesia. The vitreous was removed, and the macular ILM was peeled by creating a small opening and a tear in the ILM with a bent 22-gauge needle around the inner margin of the vascular arcade. The ILM flap was then grasped with end-gripping forceps, and a circular capsulorrhesis maneuver was initiated. Next, gas-fluid exchange and internal tamponade with 10% C3F8 were performed, followed by postoperative face-down positioning., Results: Thirty-six eyes in 36 patients with idiopathic macular holes from stages 2 to 4 were included. The average follow-up time was 8.9 months. The holes were completely closed in 33 eyes (92%), and visual acuity was improved in 26 eyes (72%). Ten eyes were pseudophakic, 24 of the 26 phakic eyes had an increased density of the cataract after surgery, which was not detected in 2 cases. One of the patients had vitreous hemorrhage and hyphema; no retinal detachment or retinal tear was found in this study., Conclusion: Surgery for macular holes using ILM peeling has a high anatomical and functional success rate.