Original article
Macular structure on optical coherence tomography after lamellar macular hole surgery and its correlation with visual outcome

https://doi.org/10.1016/j.jcjo.2011.09.011Get rights and content

Abstract

Objective

To report macular structure on optical coherence tomography (OCT) after lamellar macular hole surgery and its relationship with visual outcome.

Design

Retrospective interventional case series; private practice setting.

Participants

Twelve patients diagnosed with a lamellar hole who had undergone vitrectomy and who had OCT scanning before and after surgery and at least 6 months follow-up were included.

Methods

Surgery consisted of 25 g vitrectomy, peeling of epiretinal and internal limiting membrane, fluid/air/gas exchange, and 2 weeks of face-down positioning.

Results

OCT showed an epiretinal membrane in all cases. After a mean follow-up of 16.7 months, VA improved by ≥2 lines in nine patients and remained stable in three. There was a complete closure of the lamellar hole in ten patients; in four a retinal pseudocyst was found during the healing process, resolving spontaneously in two and persisting in the other two after 8 and 9 months, respectively. Two patients developed a full-thickness macular hole that closed successfully after surgical repair. All patients had a VA ≥ 20/32 at the end of follow-up.

Conclusion

Epiretinal membranes appear to have a role in the pathogenesis of lamellar macular holes. Vitrectomy is a useful technique to obtain closure of the lamellar hole and visual improvement. The presence of a retinal pseudocyst is a common feature during the healing process and is compatible with a favorable visual outcome. A full-thickness macular hole is a severe and not uncommon complication of this procedure.

Résumé

Objet

Présentation de la structure maculaire sur tomographie par cohérence optique (TCO) après une chirurgie du trou lamellaire maculaire et son rapport avec le résultat visuel.

Nature

Série rétrospective de cas d'intervention dans un cadre de pratique privée.

Participants

Douze patients qui, ayant subi une vitrectomie pour un trou lamellaire, avaient été examinés par TCO avant et après la chirurgie et eu un suivi d'au moins six mois.

Méthodes

La chirurgie comprenait une vitrectomie 25 g, l'ablation des membranes épirétiniennes et limitante interne, l'échange fluide/air/gaz et deux semaines de position face vers le bas.

Résultats

La TCO a montré une membrane épirétinienne dans tous les cas. Après un suivi de 16,7 mois en moyenne, l'AV s'était améliorée de ≥2 lignes chez neuf patients et était demeurée stable chez trois patients. Il y eut fermeture entière du trou lamellaire chez dix patients; on a observé un pseudokyste rétinien chez quatre patients pendant le processus de guérison, qui s'est résorbé chez deux patients et a persisté chez les deux autres après 8 et 9 mois, respectivement. Deux patients ont développé un trou maculaire pleine épaisseur qui s'est refermé après une chirurgie réparatrice. Tous les patients avaient une AV ≥ 20/32 à la fin du suivi.

Conclusion

Les membranes épirétiniennes semblent jouer un rôle dans la pathogénèse des trous maculaires rétiniens. La vitrectomie est une technique utile pour obtenir la fermeture du trou lamellaire et améliorer la vision. La présence d'un pseudokyste rétinien est un élément commun dans le processus de guérison et il est compatible avec un résultat visuel favorable. Un trou maculaire de pleine épaisseur est une complication grave et plutôt fréquente dans cette procédure.

Section snippets

Methods

The charts of all patients diagnosed with a lamellar hole who had undergone vitrectomy by one of the authors (MSF) were retrospectively evaluated. Patients who had OCT scanning of the macula before and after surgery and who had at least 6 months follow-up were considered for inclusion in the study. Patients who had other ocular pathologies were excluded. The study was approved by our institutional review board and adhered to the tenets of the Declaration of Helsinki.

Preoperatively, all patients

Results

Twelve patients were included in the study; 9 women and 3 men, whose ages ranged between 57 and 82 years. Table 1 shows demographic and pre- and postoperative data.

On OCT, an ERM was preoperatively identified in all cases. These ERMs caused a centrifugal traction, tearing the inner retina and leading to the intraretinal horizontal splits visible in OCT. These splits always occur at the same level: between the outer plexiform layer and the outer nuclear layer (Fig. 1). During surgery, these

Discussion

In recent years, the development of higher definition OCT technology has enabled new insight into the diagnosis and pathogenesis of lamellar macular holes.11 Lamellar holes and macular pseudoholes, which are often difficult to differentiate on clinical examination, have different characteristics on OCT. Lamellar holes have an asymmetric contour and exhibit an intraretinal split, with a separation of the inner from the outer foveal layers. The center of the fovea is often irregular and thinner

Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

References (22)

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      Later, Witkin and associates further refined this description, proposing 4 criteria for the diagnosis of lamellar macular hole with spectral-domain OCT: irregular foveal contour, break in inner fovea, intraretinal split located between the outer plexiform and outer nuclear layers, and intact foveal photoreceptors.1 A number of theories have been proposed to explain the formation of lamellar macular hole, including the union of intraretinal cysts,3 aborted formation of full-thickness macular hole,2,7,8 and centrifugal traction of epiretinal membranes.14 However, none of these hypotheses seem to unify the spectrum of findings observed within the current classification of lamellar macular hole.

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