Evolution from macular pseudohole to lamellar macular hole — spectral domain OCT study

PurposeTo discuss the unique morphology and origin of epiretinal proliferation associated with macular hole (EPMH) occasionally observed in full-thickness macular hole (FT-MH) or lamellar hole (LH) and to introduce the perifoveal crown phenomenon encountered when removing this unusual proliferative tissue.MethodsSixteen patients showing EPMH in spectral domain-optical coherence tomography were selected from 212 patients diagnosed with MH, LH, FT-MH, impending MH, macular pseudohole, or epiretinal membrane between January 2013 and December 2014. Of the 212 patients included for clinical analysis, 33, 23, 11, 7, and 190 exhibited LH, FT-MH, impending MH, macular pseudohole, and epiretinal membrane, respectively. We reviewed visual acuity, macular morphology, and clinical course. Surgical specimens were analyzed histologically.ResultsEPMH presented as an amorphous proliferation starting from the defective inner/outer segment (IS/OS) junction covering the inner macula surface. Among the 16 patients with EPMH, 11 underwent vitrectomy, and all exhibited the intraoperative perifoveal crown phenomenon. EPMH tissue was sampled in three patients, one of whom had more tissue removed than intended and showed delayed recovery in visual acuity. Despite hole closure, IS/OS junction integrity was not successfully restored in four of 11 patients. Five patients were followed-up without surgical intervention. Visual acuity slightly decreased in three patients and did not change in one patient, while the remaining patient was lost during follow-up. Among the three perifoveal crown tissues obtained, two were successfully analyzed histologically. Neither tissue showed positivity to synaptophysin or S-100 protein, but one showed positivity to cytokeratin protein immunohistochemical staining.ConclusionsEPMH exhibited a distinct but common configuration in spectral domain-optical coherence tomography. An epithelial proliferation origin is plausible based on its configuration and histological analysis. Perifoveal crown phenomenon was observed when removing EPMH during vitrectomy.

Redefining Lamellar Holes and the Vitreomacular Interface: An Ultrahigh-Resolution Optical Coherence Tomography Study

To investigate morphological variations in the macular area with optical coherence tomography (OCT) after vitrectomy for diabetic fibrovascular proliferation. We reviewed 108 cases using OCT 7-15 months after vitrectomy. Of these, 32 received OCT within 3 months postoperatively. Morphological variations were categorized and correlated with visual outcome. Only 24 cases (21.4%) had no obvious abnormalities. The most frequent findings were epiretinal membrane (52.8%), macular thickening (37.0%) and macular cysts (28.7%). Multivariate regression showed that diffuse macular thickening, loss of foveal depression and diffuse retinal thinning were significantly associated with poor visual acuity. Sequential OCT (< 3 and >or= 7 months) revealed that epiretinal membrane and oedema outside of fovea changed significantly between two examinations. OCT may identify diverse morphological changes in the macular area after diabetic vitrectomy for fibrovascular proliferation. Macular appearance may change over time, and certain types of morphological changes may be associated with poor visual function.

Macular pseudoholes (MPHs) and lamellar macular holes (LMHs) have been recently defined according to spectral domain optical coherence tomography (SD-OCT) criteria. A major feature for differentiating an MPH from an LMH remains the loss of foveal tissue. The anatomy of the foveola is peculiar with the macular pigment (MP) embedded in a very thin layer of tissue underlying the internal limiting membrane and mainly constituted of a specialized group of Müller cells and Henle's fibers. Despite the near microscopic resolution (≈5–7 μm) and the capability to visualize the outer retina in detail, SD-OCT may fail to ascertain whether a very small loss of this foveolar tissue has occurred. Blue-fundus autofluorescence (B-FAF) imaging is useful in this respect because even very small loss of MP can be identified, suggesting a corresponding localized loss of the innermost layers of the foveola. A definition of MP loss would help differentiating an LMH from an MPH where B-FAF imaging will be negative.

To describe the natural history, optical coherence tomography characteristics, and proposed biomechanics of macular pseudohole (MPH) evolution and spontaneous resolution. Clinical case report, with longitudinal follow-up documented by fundus photographs and spectral domain optical coherence tomography. A 26-year-old woman presented with visual disturbance secondary to an idiopathic epiretinal membrane. Subsequent formation of an MPH was observed. Spontaneous peeling of the epiretinal membrane occurred in conjunction with posterior vitreous detachment 6.5 years after initial presentation. The MPH resolved, and the patient's vision improved. Spontaneous epiretinal membrane peeling represents a potential mechanism for visual and anatomical improvement in eyes with MPH. This is the first published observation of MPH resolution documented by spectral domain optical coherence tomography.

Optical coherence tomography and focal macular electroretinogram in eyes with epiretinal membrane and macular pseudohole

Purpose To analyze the natural evolution of idiopathic Lamellar Macular Holes (LMH) and Macular Pseudoholes (MPH), in the long‐term, based on Optical Coherence Tomography (OCT) configuration and in Best Corrected Visual Acuity (BCVA) evolution.Methods We prospectively analyzed 68 eyes (41 right eyes and 27 left eyes) of 61 patients (40 female and 21 male), which were diagnosed as having a MPH or a LMH on OCT examination. The following variables were assessed: BCVA, lens status, and hole size (Diameter ‐D, Residual foveal Thickness –RT, and Perifoveal Thickness ‐PT)(software Caliper of Cirrus OCT), at baseline and final examination. Eyes with significant cataract underwent phacoemulsification.Results The mean follow‐up period was 34.33 ± 15.02 (12‐78) months. Mean BCVA (logMAR notation) in the total group at baseline was 0.40 ± 0.25 and at final was 0.36 ± 0.13 (p=0,082). PAM showed slightly better BCVA than LMH (p&lt;0.05). BCVA improved in those eyes who underwent cataract surgery and remained unchanged in the rest of the eyes. No statistically significant differences regarding D, RT and PT were observed during the follow‐up period (p=0,125).Conclusion Most of idiopathic LMH and MPH do not progress anatomically and do not contribute to a significant diminution of visual acuity during the follow‐up period. We must take into account that the diminishment in visual acuity in most LMH and MPH can be due to the presence of an opacified crystalline and not to the lamellar hole itself.

AIMSThe reliability of scanning laser ophthalmoscope (SLO) microperimetry in differentiating full thickness macular holes from macular pseudoholes and impending macular holes was evaluated.METHODS106 eyes with the clinical diagnosis of full...

PurposeThis study aims to report a case of idiopathic epiretinal membrane (ERM) spontaneously separated from the retinal surface even in eyes with a macular pseudohole, which was immediately followed by resolution of visual deterioration and morphological findings.Case ReportA 66-year-old man presented with visual deterioration and metamorphopsia in the right eye. An ERM with a macular pseudohole in the right eye was shown by fundus examinations and optical coherence tomography (OCT) images. We intended to perform vitrectomy to remove the ERM, but within 2 months after the initial visit, the ERM spontaneously separated from the retina. Fundus photograph showed that the ERM and the macular pseudohole were absent and the fundus looked almost normal, and OCT image showed no ERM and an almost normal appearance of the retina without remaining undulations. After the ERM separation, his vision improved to 20/15.ConclusionCases with an ERM-associated macular pseudohole should be carefully monitored for the possibility of a spontaneous separation of the ERM from the retina.

Optical Coherence Tomography (OCT) is part of the routine examination of all vitreomacular disorders. Spectral domain technology has provided images with better resolution, which are also easier to interpret reliably. In most of these pathologic cases, it is now possible to visualize the status of the posterior hyaloid, its connection to the retinal surface, and its thickness and reflectivity. OCT plays an essential role in the diagnosis and preoperative assessment of macular holes. In impending macular holes, it shows minute irregularities of the foveal curvature, and/or tiny intrafoveal tractional retinal cysts. In full thickness macular holes, OCT clearly shows defects in the retinal tissue and allows full thickness macular holes to be distinguished from macular lamellar holes or pseudoholes. The quality of the OCT scan profiles also allows accurate measurement of macular hole diameter, which is a major indicator of the chances of successful surgery and may affect the choice of surgical technique. Furthermore, OCT allows assessment of the quality of macular hole closure. Although the presence of epiretinal membranes may also be diagnosed on red-free and blue reflectance photographs, OCT has the advantage of showing the degree of retinal thickening in the fovea, as well as the presence of any intrafoveal cysts or vitreomacular traction. Diagnosis of the vitreomacular traction syndrome has also been greatly facilitated by the use of OCT, which shows, more clearly than ultra sound or biomicroscopy, the elevation of the foveal surface due to the focal traction of a thick and hyper-reflective posterior hyaloid. Finally, OCT has allowed the identification of myopic foveoschisis, a hitherto unknown but relatively common complication related to myopic staphyloma. This vision - threatening complication may benefit from surgery, depending on its OCT characteristics. In conclusion, although OCT is still a technique in evolution, but it already provides invaluable information on vitreomacular disorders and plays an essential part in their diagnosis and management.

Purpose Myofibroblasts play a major role in the production of retractile phenomena causing contraction or shrinkage of the epiretinal membranes (ERM) in proliferative vitreoretinopathy and diabetic retinopathy. The purpose of our study was to evaluate the expression of myofibroblasts on epiretinal tissues in eyes with epiretinal membranes, diabetic macular edema (DME) or macular holes.Methods Samples of ERM and ILMs (internal limiting membranes) following macular epiretinal membrane removal in eyes with diabetic maculopathy, refractory to conservative treatment, idiopathic epiretinal membrane and macular holes, were collected. Double immunofluorescence staining, with antibodies recognizing a smooth muscle actin (a‐SMA) and fibronectin (ED‐A FN) or vimentin in myofibroblasts, followed by confocal and electronic microscopy was performed.Results a‐SMA in association with either ED‐A FN or vimentin were detected in all ERM specimens. a‐SMA and ED‐A FN were also detected in ILMs removed in cases of stage IV macular holes. ED‐A FN was expressed in close relation to a‐SMA–positive myofibroblasts, predominately located close to the border of the macular hole area. In all idiopathic ERMs, ED‐A FN was expressed in close relation to a‐SMA–positive myofibroblasts. In those cases, no a‐SMA staining was observed in ILM specimens.Conclusion Scanning electron microscopy indicated that active contraction mechanisms are always expressed in epiretinal macular membrane and underling ILM tissues in eyes with diabetic maculopathy and late stages of macular hole.ILM folding seems to be myofibroblast‐independent in idiopathic epiretinal membrane cases.

Background/Objectives: Spontaneous macular hole closure is a rare phenomenon, with lamellar hole epiretinal proliferation (LHEP) frequently implicated as a potential mechanism. This study aims to analyze the presence of LHEP in patients with full-thickness macular holes (FTMHs) or lamellar macular holes (LMHs) that closed spontaneously without intervention. Methods: A retrospective longitudinal analysis of optical coherence tomography (OCT) scans was conducted for 73 patients diagnosed with FTMH or LMH in a single institution. Patients with documented spontaneous hole closure were further analyzed for the presence of LHEP, other OCT findings, and clinical characteristics. Results: Of the 73 patients, eight (11%) exhibited spontaneous closure of their macular holes. LHEP was identified in all cases, regardless of hole type (FTMH or LMH). Associated OCT features on diagnosis included VMT in one eye (13%), partial or complete posterior vitreous detachment in seven eyes (88%) and epiretinal membrane in eight eyes (100%). During hole closure, an outer nuclear layer bridge was noted in six eyes (75%). Various extents of outer retinal recovery were noted following closure. After closure, five holes (63%) remained closed without further intervention, while three (38%) reopened and required surgical intervention. Conclusions: Spontaneous macular hole closure is strongly associated with the presence of LHEP, highlighting its potential role in retinal repair mechanisms. While in most patients the spontaneous closure is permanent, surgical intervention may be necessary in cases of hole recurrence.

One patient with past ocular history of full thickness macular hole surgically closed in the right eye was followed with diagnostic of lamellar macular hole in the left eye since 2000. After uncomplicated cataract surgery in the left eye in March 2008, the lamellar hole spontaneously progressed to full thickness macular hole. The patient underwent pars plana vitrectomy, membrane peel and gas bubble injection, with successful closure of the macular hole and improvement in the visual acuity. Optical coherence tomography (OCT) scans through the macula were performed at the initial and follow-up visits. To the best of our knowledge, this is the first description of a long-standing stable lamellar macular hole progressing into a full thickness macular hole. The causative factors for this progression remain unclear.

Purpose:To report the use of intraoperative spectral domain optical coherence tomography (SD-OCT) for detecting anatomical changes during macular surgery.Methods:In a consecutive case series, 32 eyes of 32 patients undergoing concurrent pars plana vitrectomy and intraoperative SD-OCT for macular hole (MH), epiretinal membrane (ERM) and vitreomacular traction (VMT) were enrolled. Intraoperative changes in retinal thickness and dimensions of the macular hole were measured in patients with ERM and VMT following surgical manipulation using a hand-held SD-OCT device (iVue, Optovue Inc., Fremont, CA, USA).Results:SD-OCT images of sixteen eyes with macular hole were subjected to quantitative and qualitative analysis. All MH dimensions remained stable during consecutive stages of surgery except for MH apex diameter, which showed a significant decrease after internal limiting membrane (ILM) peeling (P=0.025). Quantitative analysis of ten patients with ERM showed a significant decrease in retinal thickness after membrane removal (P=0.018) which did not remain significant until the end of the procedure (P=0.8). In three cases, subretinal fluid was formed after ILM peeling. Quantitative analysis of five patients with VMT showed a decrease in retinal thickness during consecutive steps of the surgery, although these changes were not significant. In two cases, subretinal fluid was formed after ILM peeling.Conclusion:Intraoperative SD-OCT is a useful imaging technique which provides vitreoretinal surgeons with rapid awareness of changes in macular anatomy during surgery and may therefore result in better anatomical and visual outcomes.

To evaluate clinical features and visual outcomes in macular pseudohole (MPH) and to investigate associations between visual acuity and optical coherence tomography (OCT) parameters in patients with MPH. We retrospectively reviewed consecutive patients with MPH who underwent vitrectomy and were followed for at least 6 months after surgery. MPH was diagnosed based on spectral-domain OCT findings. Analysed factors included axial length, spherical equivalent, overlapping cases of epiretinal membrane foveoschisis (ERM-FS) and lamellar macular hole (LMH), presence of glaucoma, preoperative and postoperative best-corrected visual acuity (BCVA), presence of inner and outer retinal cysts, epiretinal proliferation (EP) and ellipsoid zone (EZ) disruption. This study enrolled 76 eyes of 75 patients, with overlapping cases that included MPH+ERM FS (17 eyes), MPH+LMH (18 eyes) and MPH+ERM FS + LMH (3 eyes). BCVA significantly improved from 0.29±0.25 preoperatively to 0.06±0.17 postoperatively (p<0.001). Preoperative BCVA and the presence of EP exhibited significant associations with worse postoperative BCVA (p<0.0005 and p<0.05, respectively). Presence of EZ disruption at 3 and 6 months postoperatively was associated with worse postoperative BCVA (p<0.001 and p<0.01, respectively). There was significant improvement in patients with MPH after undergoing surgery. Current results suggest preoperative poor visual acuity, preoperative presence of EP and postoperative EZ disruption are negative prognostic factors for visual outcomes.