Patients

Patient data were obtained by retrospective review of the medical records of 49 consecutive patients (52 eyes) who underwent surgery for macular hole at Kyoto University Hospital between February 2006 and July 2008. Candidates for the study were identified by review of the authors’ surgical lists for the study period. The inclusion criteria for this study were as follows: (1) clinical presentation of macular hole, (2) treatment with conventional 20-gauge or 23-gauge 3-port PPV with ILM peeling, and (3) a follow-up period of more than 6 months from the last intraocular surgery. Eyes were excluded from the study if they had pre-existing ocular diseases or a history of ocular surgery, except for cataract surgery. Other exclusion criteria included (1) a history of treatment for peripheral retinal breaks before and after the primary surgery or (2) macular hole with retinal detachment.

All patients had undergone comprehensive ophthalmologic examinations before macular hole surgery, measurements of refractive errors (ARK-700A autorefractor; Nidek, Gamagori, Japan), measurements of uncorrected visual acuity and best-corrected visual acuity (BCVA) using the 5-m Landolt chart, measurement of axial length using A-scan ultrasonography (UD-6000; Tomey Corp., Nagoya, Japan), slit-lamp examinations, measurements of intraocular pressure using a Goldmann applanation tonometer, and dilated indirect slit-lamp biomicroscopy. The size of each macular hole before surgery was measured with reference to the diameter (approximately 150 μm) of the vein on the edge of the optic disc.

Conventional 20-gauge 3-port PPV was performed in 10 eyes and 23-gauge transconjunctival PPV was performed in the other 43 eyes. A posterior vitreous detachment was created, followed by removal of the residual thin premacular posterior cortex. The peripheral vitreous also was excised. Triamcinolone acetonide was used during surgery to facilitate visualization of the vitreous and posterior hyaloid in all of the eyes in this study. All of the eyes underwent ILM peeling (3 to 4 disc diameters in size) with an ILM forceps, after staining with indocyanine green or triamcinolone acetonide. In all eyes, fluid–air exchange was performed, followed by gas tamponade (instillation of 40 mL sulfur hexafluoride, 25%). Patients were instructed to keep the head prone (face downward) for at least 1 week after surgery. In the 46 of 52 eyes (88.5%) that were phakic before macular hole surgery, phacoemulsification was performed before PPV, with implantation of an intraocular lens in all 46 eyes.

Optical Coherence Tomography Examinations

OCT examinations were performed by experienced ophthalmologists using time-domain OCT (Stratus), SD OCT (usually Spectralis HRA+OCT [Heidelberg Engineering, Heidelberg, Germany] or occasionally RTVue-100 [Optovue, Fremont, California, USA]). On preoperative scans of eyes with moderate cataract, time-domain (Stratus) OCT images tended to provide better information than SD OCT scans.

SD OCT was used only after surgery. To determine whether the macular hole closed after surgery, dense serial SD OCT scans were obtained over the macula; scanning usually was horizontal, but sometimes was vertical or radial. Initial anatomic success was defined as no visible open macular hole on any serial SD OCT B-scans during the first month after the first macular hole surgery. To identify possible abnormalities in retinal microanatomic features, so-called speckle-noise–reduced images were generated by averaging 20 to 50 SD OCT B-scans obtained at each location of interest on the retina.

Statistical Analyses

Statistical analyses were performed using SPSS software version 17.0 (SPSS, Inc, Chicago, Illinois, USA). The logarithm of the minimal angle of resolution (logMAR) was used for statistical analyses involving visual acuity. For continuous values, the mean ± standard deviation was calculated for each group, and differences between 2 groups and 3 groups were evaluated for statistical significance by the Mann–Whitney U test and the Kruskal-Wallis H test, followed by the Dunnett rank test, respectively. Differences in categorical variables were evaluated for statistical significance by the Fisher exact test.

Factors Associated with Initial Failure of Macular Hole Surgery

Table 1 shows the preoperative and postoperative characteristics of eyes in which the initial surgery was a success or failure. There were significant preoperative differences between the groups in mean axial length ( P < .0001), refractive error ( P = .031), and whether there was posterior staphyloma ( P = .0060).

Grouping According to Axial Length

Mean axial length for the 52 eyes (24.6 ± 2.4 mm; range, 21.1 to 31.9 mm) was correlated negatively with age ( r = −0.447; P = .001; Figure 1 ), but positively correlated with refractive error ( r = −0.715; P = .0001). Three (60%) of 5 eyes with initial surgical failure were outliers on the linear regression curve ( Figure 1 ). All 3 eyes had axial lengths of 30.0 mm or more. Accordingly, the 52 eyes were divided into 3 groups based on whether they had severely high myopia (group 1), defined as an axial length of 30.0 mm or more; moderately high myopia, defined as an axial length of 26.0 mm or more and less than 30.0 mm (group 2); or mild myopia, emmetropia, or hyperopia (group 3), defined as an axial length of less than 26.0 mm ( Table 2 ). Eyes were statistically significantly different among the 3 groups in mean age at onset of macular holes, mean axial length, and mean preoperative refractive error and in terms of the existence of posterior staphyloma (all P < .0001), but not significantly different in patient gender, laterality, stage or size of macular hole, duration of symptoms, or preoperative logarithm of the minimal angle of resolution BCVA ( Table 2 ).

Scatterplot showing linear regression of axial length in millimeters against age ( r = −0.447; P = .001) for 52 eyes with macular holes treated surgically. White circles = eyes in which the initial surgery was successful; black circles = eyes in which the initial surgery failed to close the hole.

Anatomic and Functional Success According to Axial Length

The overall initial and final anatomic success rates of the macular hole surgeries were both 92.3% (48 of 52 eyes; Table 2 ). The median final BCVA (Snellen equivalent) was 20/32 (range, 20/500 to 20/12.5). In eyes with axial lengths of less than 26.0 mm, the initial and final success rates were both 100.0% (37 of 37 eyes), and in highly myopic eyes with axial lengths of 26.0 mm or more, the initial and final success rates were both 73.3% (11 of 15 eyes); this difference was significantly different (both P = .0050). In highly myopic eyes with axial lengths of 30.0 mm or more, the initial and overall success rates were both 0% (0 of 3 eyes), whereas in highly myopic eyes with axial lengths of 26.0 mm or more and less than 30.0 mm, the initial and final success rates were both 91.7% (11 of 12 eyes). The initial and final success rates in eyes with axial lengths of 30.0 mm or more were significantly lower than those in eyes with axial lengths 26.0 mm or more and less than 30.0 mm and in eyes with axial lengths of less than 26.0 mm ( P < .0001 for both; Table 2 ). At 6 months after the last surgery, the mean change in logarithm of the minimal angle of resolution BCVA in eyes with axial lengths of 30.0 mm or more also was significantly smaller than those in eyes with axial lengths of 26.0 mm or more and less than 30.0 mm ( P = .015) and in eyes with axial lengths less than 26.0 mm ( P = .020; Table 2 ).

Spectral-Domain Optical Coherence Tomography Findings

On SD OCT images obtained before surgery, almost all eyes with all stages of macular holes (2, 3, or 4) had centrifugal elevation of the retina limited to the fovea and cystoid spaces in the Henle nerve fiber layer and sometimes in the inner nuclear layer, in the fovea, or just outside the fovea ( Figure 2 ).

(Left column, top to bottom) Abnormal features in horizontal 9-mm long B-scan images obtained by speckle noise-reduced (averaging multiple B-scans at the same location) spectral-domain optical coherence tomography in eyes with full-thickness macular holes and axial lengths of less than 26.0 mm. (Right column, top to bottom) Color fundus photographs showing, by green arrows, the direction of scanning to obtain images in the left column, from top to bottom, respectively. (Top) Stage 2 macular hole in the left eye of a 68-year-old man. (Middle) Stage 3 macular hole in the left eye of a 63-year-old woman. (Bottom) Stage 4 macular hole in the left eye of a 65-year-old woman. Abnormal features, shown by asterisks and white arrows, were cystoid spaces in the Henle nerve fiber layer and the inner nuclear layer, respectively, that were seen only in the vicinity of the fovea in all scans and retinal thickening, also limited to the vicinity of the fovea (Left column, top to bottom).

However, on preoperative SD OCT images of 6 (11.5%) of the 52 eyes, a retinoschisis-like feature was seen consisting of widespread thickening of the retina in the extrafoveal as well as the foveal region ( Figures 3 and 4 ). The thickening appeared to be located in the outer retina. The retinoschisis-like feature was seen in 3 (6.3%) of 48 eyes with initial success and in 3 (75.0%) of 4 eyes with initial failure of macular hole surgery; this difference was statistically significant ( Table 1 ; P = .0030). This retinoschisis-like feature was found to be associated with axial lengths ( Table 2 ). In eyes with axial lengths of 26.0 mm or more, the retinoschisis-like feature was seen in 3 (75%) of the 4 eyes with initial failure, compared with only 1 (9.1%) of 11 eyes with initial success ( Table 3 ); this difference was statistically different ( P = .033).

Images of the right eye of a 63-year-old woman with macular hole. Best-corrected visual acuity before surgery was 20/333 and axial length was 26.7 mm. (Top row, left) (Upper) Horizontal time-domain optical coherence tomography (OCT) B-scan obtained at the initial visit and (Lower) horizontal speckle-noise–reduced spectral-domain OCT images obtained 1 month after the first operation. The top row, left upper image is blurred because of cataract, but shows a stage 4 full-thickness macular hole with apparent retinal thickening, mainly in the outer retina, that extends widely extrafoveally. (Top right) Color fundus photograph obtained 1 month after the first operation. The green (6-mm long) and white (9-mm long) arrows indicate the scan lines in Top left, Second row, and Third row, respectively. (Second and third rows) Horizontal speckle noise-reduced spectral-domain OCT images obtained (Second row) 1 year after the first operation and (Third row) 1 month after the second surgery. One month after the first operation, the macular hole remained open, but its edge was not elevated. At 1 year after the operation, the edge of the macular hole was lifted up and the retina was thickened over much of the macula. A second operation therefore was performed. One month after the second operation, the macular hole remained open and thickening of the retina in the macula persisted. (Bottom left and right) Magnified (×2) views of areas outlined by red dashed lines in the B-scan images in the Second and Third rows, respectively. Where the retina was thickened, columnar structures are seen in the retinoschisis-like separation between the outer plexiform layer and the outer nuclear layer. The extent of the retinoschisis-like feature is indicated by white double-headed arrows.

Images of the right eye of a 58-year-old woman with macular hole and posterior staphyloma. Best-corrected visual acuity before surgery was 20/125 and axial length was 31.89 mm. (Left) Horizontal 9-mm long speckle-noise-reduced spectral-domain optical coherence tomography images. (Right) Color fundus photographs. (Top) Four months before the first operation, retinal thickening was limited to the nasal retina. (Second row) Two months before the first operation, retinal thickening extended widely in the macula and a retinoschisis-like feature became evident in the macular region (white double-headed arrows). (Third row) One month after the first operation, the macular hole and retinoschisis-like feature (white double-headed arrows) were still present and the retinal detachment appeared to have extended. (Bottom) Two months after the second operation, the macular hole was larger, the nasal retina appeared to have shrunk, and the temporal retinal detachment had enlarged, but the retinoschisis-like feature had disappeared.

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