scispace - formally typeset
Search or ask a question
Journal ArticleDOI

Persistent outer retinal fluid following non-posturing surgery for idiopathic macular hole

TL;DR: This is the first study of outcomes of OFDs following macular hole surgery in patients who did not posture postoperatively, and OFDs are common but do not adversely affect visual outcomes.
Abstract: Aim To present the anatomical and visual outcomes of patients with hypo-reflective cystic defects in outer fovea (outer foveal defect; OFD) in macular holes repaired with non-posturing vitrectomy and short term gas tamponade. To identify the incidence and risk factors for developing OFD foveal defect. Method A prospective consecutive case series of 58 patients undergoing macular hole surgery was undertaken. OFD detected on 2-week postoperative Optical coherence tomography (OCT) was measured. In these patients OCT was performed monthly until resolution of OCT. Results 27 eyes (46.6%) had an outer defect at 2 weeks, the presence of which was significantly associated with macular holes with larger base diameters preoperatively (p=0.006). All defects closed spontaneously without further intervention, and the final vision was not affected by the presence of an OFD. Visual recovery was only slightly (and not significantly) delayed by the presence of an outer defect. Conclusions This is the first study of outcomes of OFDs following macular hole surgery in patients who did not posture postoperatively. OFDs are common but do not adversely affect visual outcomes.

Summary (1 min read)

Jump to: [Introduction:][Methods:][Results:] and [Discussion:]

Introduction:

  • Macular hole repair with vitrectomy and peeling of internal limiting membrane (ILM) is reported to achieve successful hole closure in 90-98% of cases 1-3 .
  • Optical Coherence Tomography (OCT) has evolved from time domain to spectral domain providing as little as 5 microns of axial resolution of retinal anatomy, thus improving the visualisation of hole architecture.
  • This has led researchers to demonstrate 5 different retinal abnormalities after flat closed macular holes 4 .
  • These include outer foveal hypo-reflective defects, persistent foveal detachment, moderately reflective foveal lesions, epiretinal membranes (ERM) and nerve fibre layer defects (NFL).
  • The incidence is reported to range from 34% to 49% in previous reports 5-8 in relation to posturing macular hole surgery.

Methods:

  • A prospective consecutive case series of 58 eyes from 58 patients undergoing surgery for idiopathic macular hole was performed.
  • Drainage of fluid through the macular hole was not attempted in any of the study patients.
  • Patients noted to have an outer foveal defect at two weeks, underwent serial monthly OCT scanning measuring the maximum horizontal diameter of the OFD until complete resolution of the was observed.
  • Patients were discharged after resolution of the outer retinal fluid and improvement/stabilisation of vision on two consecutive visits.
  • The extent of the correlation between baseline vision and macular hole base diameter was also assessed.

Results:

  • Effect of macular hole base diameter and demographic factors on risk of developing defect A total of 27 patients (46.6%) had developed an OFD; of which 17 were females and 10 were males.
  • Mean time for vision recovery ranged from 1.5 to 10 months (mean 3.74 months) amongst patients who experienced OFD formation.
  • Neither the comorbidities/complications category nor any of the other covariates were significantly associated with time to visual recovery.
  • P-values, odds ratios and associated confidence intervals for analysis of time to vision recovery are summarised in Table 3.

Discussion:

  • Previously it has been shown that excellent success rates can be achieved with non-posturing macular hole surgery using shorter acting gas 3 .
  • In contrast to their results, two earlier studies have shown that outer defects are more likely to occur in patients who have smaller diameter macular hole preoperatively.
  • The presence of a defect did not significantly delay visual recovery in this sample (p=0.054), although there was only one patient in the without-defect group who took longer than 5 months for vision to stabilise (11 months).
  • Without this patient (who had AMD), the difference would have been statistically significant.
  • The presence of an outer foveal defect did not influence the final vision, only preoperative vision affected this.

Did you find this useful? Give us your feedback

Content maybe subject to copyright    Report

University of Huddersfield Repository
Rahman, Rubina, Oxley, L. and Stephenson, John
Persistent outer retinal fluid following non-posturing surgery for idiopathic macular hole
Original Citation
Rahman, Rubina, Oxley, L. and Stephenson, John (2013) Persistent outer retinal fluid following
non-posturing surgery for idiopathic macular hole. British Journal of Ophthalmology, 97 (11). pp.
1451-1454. ISSN 0007-1161
This version is available at http://eprints.hud.ac.uk/id/eprint/18240/
The University Repository is a digital collection of the research output of the
University, available on Open Access. Copyright and Moral Rights for the items
on this site are retained by the individual author and/or other copyright owners.
Users may access full items free of charge; copies of full text items generally
can be reproduced, displayed or performed and given to third parties in any
format or medium for personal research or study, educational or not-for-profit
purposes without prior permission or charge, provided:
The authors, title and full bibliographic details is credited in any copy;
A hyperlink and/or URL is included for the original metadata page; and
The content is not changed in any way.
For more information, including our policy and submission procedure, please
contact the Repository Team at: E.mailbox@hud.ac.uk.
http://eprints.hud.ac.uk/

Persistent outer retinal fluid following non-posturing surgery for
idiopathic macular hole
Rahman R
1
, Oxley L
1
, Stephenson J
2
KEYWORDS: macular hole, OCT, non-posturing, outer foveal defect.
Addresses:
1
Ms Rubina Rahman* and Dr. Lucy Oxley, Calderdale Royal Hospital, Salterhebble Hill,
Halifax, HX3 0NJ United Kingdom.
Rubina.Rahman@nhs.net
Tel. 01422 222977. Fax. 01422
222544.
2
Dr John Stephenson PhD CMath MIMA FRSS, Senior Lecturer in Health and Biomedical
Statistics, School of Human and Health Sciences, University of Huddersfield, Queensgate,
Huddersfield HD1 3DH, United Kingdom.
*Corresponding author.
WORD COUNT: 2794 words
This work has no proprietary interest or research funding.
Authorship and contributorship:
1. R Rahman: Conception and design of study, acquisition and analysis of data, revising
the article critically and approval of the version to be published.
2. L Oxley: Collection and analysis of data, drafting and revising the article. Approval of
the published version.
3. J Stephenson: Statistical analysis of the data, revising the article and final approval of
the published version.

Abstract:
Purpose: To present the anatomical and visual outcomes of patients with hypo reflective
cystic defects in outer fovea (OFD) in macular holes repaired with non-posturing vitrectomy
and short term gas tamponade. To identify the incidence and risk factors for developing OFD
foveal defect
Method: A prospective consecutive case series of 58 patients, undergoing macular hole
surgery was undertaken. Any OFD on their two week post-operative OCT was measured, and
in these patients OCT was performed monthly until resolution of OFD was observed.
Results: 27 eyes (46.6%) had an outer defect at 2 weeks, the presence of which was
significantly associated with macular holes with larger base diameters preoperatively
(p=0.006). All defects closed spontaneously without further intervention, and the final vision
was not affected by the presence of an OFD. Visual recovery was only slightly (and not
significantly) delayed by the presence of an outer defect.
Conclusions: This is the first study of outcomes of OFDs following macular hole surgery in
patients who did not posture postoperatively. OFDs are common but do not adversely affect
visual outcomes.

Introduction:
Macular hole repair with vitrectomy and peeling of internal limiting membrane (ILM) is
reported to achieve successful hole closure in 90-98% of cases
1-3
. Clinical hole closure may
be different to anatomical hole closure, especially in the era of increasingly higher definition
imaging of the retinal architecture. Optical Coherence Tomography (OCT) has evolved from
time domain to spectral domain providing as little as 5 microns of axial resolution of retinal
anatomy, thus improving the visualisation of hole architecture. This has led researchers to
demonstrate 5 different retinal abnormalities after flat closed macular holes
4
. These include
outer foveal hypo-reflective defects, persistent foveal detachment, moderately reflective
foveal lesions, epiretinal membranes (ERM) and nerve fibre layer defects (NFL).
An outer foveal defect (OFD) following macular hole surgery is one in which the hole
clinically appears closed. However, on OCT evaluation, there is a hypo-reflective cystic
space in the outer fovea representing persistent outer retinal fluid. The incidence is reported
to range from 34% to 49% in previous reports
5-8
in relation to posturing macular hole
surgery. We aim to determine whether lack of posturing post macular hole surgery influences
the incidence and visual recovery as well as final vision in these patients.
Methods:
A prospective consecutive case series of 58 eyes from 58 patients undergoing surgery for
idiopathic macular hole was performed. Cases were operated by one surgeon (RR) between
May 2009 and November 2011. Only patients in whom the macular hole was closed post-
operatively were included.
Preoperative data included age, gender and best-corrected visual acuity (BCVA). BCVA
refers to pinhole vision, apart from the final vision which was recorded with new distance
prescription. All patients underwent OCT evaluation of macular hole base diameter (BD) and
minimal linear diameter (MLD). OCT scanning was performed using spectral domain SD-
OCT (Optovue RTVue-100 with Version 4.0 software, Freemont, CA, USA). Twelve radial
6mm OCT images (MM6/Radial slice 0.27 sec) through the centre of the macular hole were
obtained by skilled operators.
All patients underwent 23-gauge transconjunctival pars plana vitrectomy, internal limiting
membrane peel with Brilliant Peel (Fluoron, Geuder Germany) and endotamponade with
sulphur hexafluoride (20% SF
6
). Drainage of fluid through the macular hole was not
attempted in any of the study patients. Fifty two patients were phakic and underwent
combined microincision coaxial phacoemulsification with intraocular lens implant at the time
of vitrectomy. The remaining six patients were pseudophakic on presentation after surgery.
Patients were not given any positioning instructions.

As SF
6
had completely resolved in 2 weeks, visual acuity and OCT scans were taken at 2
weeks post-operatively, and the maximum horizontal diameter of any outer foveal defect was
measured using callipers on OCT. Patients noted to have an outer foveal defect at two weeks,
underwent serial monthly OCT scanning measuring the maximum horizontal diameter of the
OFD until complete resolution of the was observed. The pre-operative and post-operative
BCVA was measured using a standard Snellen acuity, and converted to LogMAR scores for
the purposes of statistical analysis. Patients were followed up for a minimum of 3 months or
until their best corrected vision was stable on 2 consecutive visits.
Statistical analyses using SPSS software (Version 18.0) were undertaken on a data set of 58
patients, of which 27 developed an OFD and 31 did not. Patients were discharged after
resolution of the outer retinal fluid and improvement/stabilisation of vision on two
consecutive visits.
A logistic regression analysis was undertaken to assess the effect of macular hole base
diameter, minimum linear diameter (MLD) and demographic factors on risk of developing a
foveal defect. Due to the limited numbers of patients with co-morbidities/complications of
any kind, this data was discretised to compare those with and without either age-related
macular degeneration (AMD) or retinal detachment, without distinguishing between these
conditions.
A Kaplan-Meier non-parametric time-to-event analysis was performed on the data to
compare times to recovery of vision in patients with and without an OFD, with comparisons
facilitated both graphically and using the log-rank statistic.
An analysis of covariance (ANCOVA)-type regression analysis was also undertaken to
investigate the effect of various factors and covariates on change in vision following surgery,
assessed using the linear LogMAR scale. In addition to the baseline vision level, variables
considered included macular hole base diameter, MLD, age, co-morbidities/complications
(defined as in the logistic regression analysis outlined above) and the size of any outer foveal
defect if present. The extent of the correlation between baseline vision and macular hole base
diameter was also assessed.
Results:
The 58 patients comprised 37 females (63.8%) and 21 males (36.2%) spanning an age range
of 47 to 86 years (mean 70.4 years).
Effect of macular hole base diameter and demographic factors on risk of developing defect
A total of 27 patients (46.6%) had developed an OFD; of which 17 were females and 10 were
males. OFDs observed ranged in size up to 754µm (mean 309μm) after 2 weeks and 829µm
(mean 205µm) after 6 weeks.
The means and standard deviation of age, pre-operative base diameters (BD)and, mean linear
diameter (MLD) of macular holes are shown in table 1.

Citations
More filters
Journal ArticleDOI
TL;DR: The presence of OFL appears to have no negative impact on the postoperative VA and it may represent the remodeling of foveal photoreceptors in eyes with large idiopathic macular hole.
Abstract: To explore the evolution of outer foveolar lucency (OFL) after vitrectomy and the correlation between OFL and visual acuity (VA) outcome in eyes with large idiopathic macular hole (IMH). In this retrospective study, 244 eyes of 233 subjects with large IMH (diameter > 400 μm), who underwent vitrectomy, were included. Preoperative clinical data, postoperative optical coherence tomography (OCT) images, and VA at 1-, 4-, and 10-month visits were documented. The prevalence, incidence, and width of OFL and their correlation with postoperative VA were analyzed. The prevalence of OFL was 10.4% (24/231) at 1 month and significantly increased to 30.4% (55/181) at 4 months (P < 0.001) and 34.2% (25/73) at 10 months (P < 0.001). The incidence was 26.1% (40/153) and 22.0% (9/41) at 4 and 10 months, respectively. OFL appeared at 1 month while disappeared at 4 or 10 months in 8 eyes (50.0%). The presence of OFL at 1 month was negatively associated with IMH diameter (Nagelkerke R2 = 0.06; P = 0.02). Eyes with OFL at 4 months had better VA at their 4-month visit than eyes without OFL (P = 0.02). Eyes with early-developed OFLs had better VA at 10 months than those with later-developed ones (P = 0.02). Width of OFL was not associated with postoperative VA at any point. OFL is not rare in eyes with large IMH after surgery. It can occur gradually and remain during the 10-month follow-up. The presence of OFL appears to have no negative impact on the postoperative VA and it may represent the remodeling of foveal photoreceptors.

4 citations

Journal ArticleDOI
TL;DR: In both examples, the objective is to examine whether outcomes naturally fall into two categories, postoperative refractive prediction error or intraocular pressure, which is a common situation in ophthalmic and other clinical fields.
Abstract: Previous notes in this series have been concerned with the common situation in ophthalmic and other clinical fields of describing relationships between one or more ‘predictors’ (explanatory variables) and, usually, one outcome measure (response variable). A classic method used in deriving relationships between outcomes and predictors is linear regression analysis. Linear regression is a member of a family of techniques known as general linear models, which also include analysis of variance and analysis of covariance; the latter of which was covered in a previous Ophthalmic Statistics Note.1 A key feature of all these models is that the outcome measure—for example, postoperative refractive prediction error or intraocular pressure—is continuous. While other notes in the series2 warn of the dangers of unnecessary dichotomisation of variables, sometimes outcomes naturally fall into two categories. In both examples, our objective is to examine …

1 citations

Journal ArticleDOI
TL;DR: Many statistical analyses in ophthalmic and other clinical fields are concerned with describing relationships between one or more ‘predictors’ (explanatory or independent variables) and usually one outcome measure (response or dependent variable), and statistical techniques often make assumptions about data.
Abstract: Many statistical analyses in ophthalmic and other clinical fields are concerned with describing relationships between one or more ‘predictors’ (explanatory or independent variables) and usually one outcome measure (response or dependent variable). Our earlier statistical notes make reference to the fact that statistical techniques often make assumptions about data.1 ,2 Assumptions may relate to the outcome variable, to the predictor variable or indeed both; common assumptions are that data follow normal (Gaussian) distributions and that observations are independent. It is, of course, entirely possible to ignore such assumptions, but doing so is not good statistical practice and in medicine; poor statistical practice can impact negatively upon patients and the public.3 One approach when assumptions are not adhered to is to use alternative tests which place fewer restrictions on the data – non-parametric or so-called distribution free methods.2 A more powerful alternative, however, is to transform your data. While your ‘raw’ (untransformed) data may not satisfy the assumptions needed for a particular test, it is possible that a mathematical function or transformation of the data will. Analyses may then be conducted on the transformed data rather than the raw data. Scenario 1: A study to evaluate the accuracy of intraocular lens power estimation in eyes having phacovitrectomy for rhegmatogenous retinal detachment4 measured the axial length (in mm) of 71 eyes. The raw data (figure 1A) exhibited a fairly strong positive skew (rather than being symmetric there is an extended tail in the histogram to the right); the same data with a logarithmic transformation applied (figure 1B) appears much more normal (less of a …

1 citations

25 Aug 2017
TL;DR: Agarwal et al. as discussed by the authors determined the incidencia of liquido subretiniano luego de cirugia exitosa de agujero macular and its impact on the agudeza visual final.
Abstract: Objetivo: Determinar la incidencia de liquido subretiniano luego de cirugia exitosa de agujero macular y su impacto sobre la agudeza visual final. Diseno del estudio: Estudio retrospectivo y descriptivo. Metodos: Se analizaron 32 ojos de 32 pacientes con diagnostico de agujero macular tratado con vitrectomia mas pelaje de la membrana limitante interna; se calculo la incidencia de liquido subretiniano segun los hallazgos de la tomografia de coherencia optica del postoperatorio y se realizo comparacion de variables entre los subgrupos con y sin presencia de liquido. Resultados: Se obtuvo una incidencia de liquido subretiniano de 15.6%, sin evidenciarse una diferencia estadisticamente significativa entre los subgrupos con y sin liquido para las variables de edad, genero, estado del cristalino, diametro del agujero, posicion postquirurgica, agudeza visual mejor corregida prequirurgica y postquirurgica a los a los 3 y a los 6 meses. Se identifico menor cronicidad en los agujeros con presencia de liquido subretiniano que en aquellos que no lo presentaban. Conclusiones: Los resultados obtenidos en este estudio, apoyan la teoria que sugiere que la presencia de liquido subretiniano no influye sobre la agudeza visual final alcanzada luego de vitrectomia mas pelaje de la membrana limitante interna para el tratamiento de agujero macular. Ademas, se documento una incidencia de liquido subretiniano inferior a la reportada previamente en la literatura, lo cual podria estar relacionado con la tecnica quirurgica utilizada.
References
More filters
Journal ArticleDOI
TL;DR: With improved visualization of fine retinal architectural features, ultrahigh-resolution OCT can visualize persistent retinal abnormalities despite anatomically successful macular hole surgery.
Abstract: Objective To evaluate retinal anatomy using ultrahigh-resolution optical coherence tomography (OCT) in eyes after successful surgical repair of full-thickness macular hole Methods Twenty-two eyes of 22 patients were diagnosed as having macular hole, underwent pars plana vitrectomy, and had flat/closed macular anatomy after surgery, as confirmed with biomicroscopic and OCT examination findings An ultrahigh-resolution–OCT system developed for retinal imaging, with the capability to achieve approximately 3-μm axial resolution, was used to evaluate retinal anatomy after hole repair Results Despite successful closure of the macular hole, all 22 eyes had macular abnormalities on ultrahigh-resolution–OCT images after surgery These abnormalities were separated into the following 5 categories: (1) outer foveal defects in 14 eyes (64%), (2) persistent foveal detachment in 4 (18%), (3) moderately reflective foveal lesions in 12 (55%), (4) epiretinal membranes in 14 (64%), and (5) nerve fiber layer defects in 3 (14%) Conclusions With improved visualization of fine retinal architectural features, ultrahigh-resolution OCT can visualize persistent retinal abnormalities despite anatomically successful macular hole surgery Outer foveal hyporeflective disruptions of the junction between the inner and outer segments of the photoreceptors likely represent areas of foveal photoreceptor degeneration Moderately reflective lesions likely represent glial cell proliferation at the site of hole reapproximation Thin epiretinal membranes do not seem to decrease visual acuity and may play a role in reestablishing foveal anatomy after surgery

123 citations

Journal ArticleDOI
TL;DR: An outer retinal defect by OCT may occur in the early postoperative period after macular hole surgery, and despite this defect, good visual acuity is possible.

50 citations

Journal ArticleDOI
TL;DR: Outer foveolar defects were detected predominantly after surgery for small MHs, and the defect decreases gradually in size and eventually disappears completely approximately 6 months after surgery.

39 citations

Journal ArticleDOI
TL;DR: Vitrectomy with internal limiting membrane peeling and gas tamponade with SF6 followed by short-duration 3-day face-down positioning is a successful surgical intervention for Stage 2 and Stage 3 idiopathic MHs and offered significant improvement in visual acuity.
Abstract: PURPOSE The role of face-down posturing after macular hole (MH) surgery remains unclear and controversial. We evaluated the anatomical and visual outcomes of MH repair using a short duration (3 days) of prone positioning. METHODS Prospective series of 50 consecutive eyes in 50 patients with Stage 2 or Stage 3 idiopathic MHs. All eyes underwent vitrectomy MH surgery with internal limiting membrane peeling and 20% sulfur hexafluoride (SF6) gas tamponade. The procedure was combined with phacoemulsification cataract surgery in phakic eyes. Surgical outcomes, MH closure rates, complications, and postoperative visual acuity were investigated. RESULTS Anatomical closure of MHs was achieved in 49 (98%) of 50 eyes by 1 surgery. Postoperative logarithm of the minimum angle of resolution visual acuity decreased (i.e., improved) by 0.271 (95% confidence interval, 0.101-0.441 [P = 0.0024]). One complication of intraocular lens pupillary capture and one case of chronic cystoid macular edema were observed. There were no complications attributed to intraocular pressure fluctuations. CONCLUSION Vitrectomy with internal limiting membrane peeling and gas tamponade with SF6 followed by short-duration 3-day face-down positioning is a successful surgical intervention for Stage 2 and Stage 3 idiopathic MHs. This method possessed minimal complications and offered significant improvement in visual acuity.

39 citations

Journal ArticleDOI
TL;DR: Macular-hole surgery with SF6 gas achieves similar results to C2F6 and is absorbed faster, allowing quicker visual rehabilitation for the patient.
Abstract: Aim To compare the outcomes of non-posturing macular-hole surgery using sulfur hexafluoride (SF 6 ) gas versus perfluoroethane (C 2 F 6 ) for idiopathic macular hole repair. Design Interventional, comparative cohort study. Methods 39 eyes of 38 patients undergoing macular-hole surgery with SF 6 were compared with another consecutive group of 39 eyes (39 patients) in whom C 2 F 6 was used. All patients were operated on by a single surgeon and underwent 23G transconjunctival phakovitrectomy with no prone posturing in the postoperative period. The best-corrected Snellen9s visual acuity (VA) was converted to the logarithm of minimal angle of resolution (logmar) visual acuity for analysis. Optical coherence tomography documentation of anatomical closure and complications of surgery were recorded. Results Primary hole closure was achieved in 89.75% in the C 2 F 6 group and 87.2% in the SF 6 group. Secondary closure after non-posturing redo surgery with heavy oil (Oxane-HD) was 100% in both groups. The mean preoperative VA in the C 2 F 6 group and SF 6 group was 0.81 logMAR and 0.78 respectively. 2 weeks after surgey, SF 6 was completely absorbed in all cases, and the mean VA improved to 0.5 logMAR; however, it remained 1.9 logMAR in the C 2 F 6 group. The final mean VA at 6 months was 0.44 (range 0–0.78) and 0.38 (range 0–1) in the C 2 F 6 and SF 6 group respectively. There were no instances of pupillary capture in the SF 6 group, whereas there were four in the C 2 F 6 group. Conclusion Macular-hole surgery with SF 6 gas achieves similar results to C 2 F 6 and is absorbed faster, allowing quicker visual rehabilitation for the patient.

35 citations

Frequently Asked Questions (1)
Q1. What are the contributions mentioned in the paper "Persistent outer retinal fluid following non-posturing surgery for idiopathic macular hole" ?

This is the first study of outcomes of OFDs following macular hole surgery in patients who did not posture postoperatively.