Purpose
To evaluate the anatomic and visual outcomes in patients with initially closed macular holes after vitreoretinal surgery and with 1 to 7 years of follow-up.
Design
Retrospective, noncomparative, consecutive case series.
Methods
Eighty-seven consecutive eyes of 79 patients with previous closure of the macular holes and with at least 1 year of follow-up were reviewed in this retrospective clinical study. Main outcome measures included the rate of macular hole reopening and visual acuity outcomes.
Results
The mean age of enrolled patients was 63.1 ± 6.2 years (range, 49 to 74 years); the mean duration of macular hole was 5.6 ± 9.7 months (range, 0.25 to 60 months); and the mean follow-up interval was 38.4 ± 19.7 months (range, 12 to 86 months). All eyes underwent internal limiting membrane peeling during the vitrectomy, and 64 (73.6%) of 87 eyes underwent cataract extraction. No reopening of initially closed macular holes was observed in any eyes. Slight perifoveal epiretinal membranes were observed by optical coherence tomography in 32.2% of cases (28/87). The final best-corrected visual acuity improved to 0.47 ± 0.39 logarithm of the minimal angle of resolution units, which was significantly higher than preoperative visual acuity of 1.01 ± 0.36 logarithm of the minimal angle of resolution units ( t = −12.532; P = .000). Multiple linear regression analysis demonstrated that the final best-corrected visual acuity was affected by the macular hole stage, preoperative best-corrected visual acuity, and cataract exaction ( F = 19.858; P = .000).
Conclusions
The stable closure of macular holes is achieved after vitrectomy with internal limiting membrane peeling. Phacoemulsification cataract surgery with intraocular lens implantation for improvement of visual function is not responsible for the reopening of previously closed macular holes.
Since the first publication of vitreous surgery for idiopathic macular holes (IMH) was described by Kelly and Wendel in 1991, there has been a great focus on increasing closure rates and visual outcomes. In recent years, peeling of the internal limiting membrane (ILM) has been used as a supplementary treatment to reduce the tangential tractional forces and to induce hole closure in macular hole surgery, and thus the anatomic success rate has increased to more than 90%. However, despite these high rates of surgical success, the reopening of initially closed macular holes also has been observed from the first month to several years after surgery.
Because a progressive nuclear sclerosis cataract develops in approximately 45% to 95% of phakic patients after macular hole surgery, requiring combined or subsequent cataract extraction to improve visual acuity, cataract extraction has become a potential factor in causing macular hole reopening, although this is still under debate. Recently, Bhatnagar and associates reported that in 20% of cases (17 of 86 eyes), there was reopening of a previously closed macular hole after cataract extraction, whereas Haritoglou and associates reported contrary results: none of the closed macular holes in 73 eyes with subsequent cataract surgery reopened. The purpose of this study was to describe the long-term anatomic and visual outcomes in patients who had initial anatomic success with macular hole surgery and who had postoperative follow-up of one year or more.
Methods
Eighty-seven consecutive eyes of 79 patients who had anatomically successful macular hole surgery were recruited in this retrospective clinical review from January 2003 through April 2009 at the Zhongshan Ophthalmic Center of Sun Yat-sen University, Guangzhou, China. The diagnosis of a macular hole was made by the presence of a full-thickness neurosensory defect confirmed by optical coherence tomography (OCT). Macular hole closure was defined as the reattachment of the edge of the hole to the retinal pigment epithelium or connection of the edge from side to side. Inclusion criteria were the successful closure of a macular hole after initial vitreoretinal surgery and a follow-up of at least 1 year. Exclusion criteria were posttraumatic holes, myopic macular holes, macular holes associated with a rhegmatogenous retinal detachment, and eyes with silicone oil tamponade.
Preoperative and postoperative examinations consisted of ophthalmologic and general medical history, best-corrected visual acuity (BCVA) recorded in decimal, intraocular pressure, slit-lamp biomicroscopy, direct and indirect ophthalmoscopy, fundus photography, and OCT. All patient charts were reviewed for age, macular hole stage (using the Gass classification ), macular hole duration, epiretinal membrane (ERM) of macula presence, ILM peeling, preoperative and postoperative visual acuity, rate of macular hole reopening, cataract extraction, and length of follow-up after vitrectomy.
Surgical Technique
Standard 3-port vitrectomy was performed under local retrobulbar anesthesia by one experienced vitreoretinal surgeon (S.Z.). After the removal of the posterior cortical vitreous, the ILM was peeled off in all eyes. The area of removal of the ILM was intended to be 3 disc diameters surrounding the macular hole. ERMs were removed, and peripheral retinal degenerations were supported by laser photocoagulation if present. Fluid–air exchange was performed, and approximately 15% perfluoropropane (C 3 F 8 ) subsequently was injected in the vitreous cavity. All patients were encouraged to maintain a face-down position for 10 days after surgery. No other agents, such as indocyanine green or autologous platelets, were used during the surgery.
Statistical Analysis
All visual acuity values were converted to the logarithm of the minimal angle of resolution (logMAR) and were compared by a 2-tailed t test. Results were expressed as mean ± standard deviation. Multiple linear regression analysis was used to assess the relationship between final visual acuity and multiple variables. All data were analyzed using the SPSS statistical software system version 16.0 (SPSS, Inc, Chicago, Illinois, USA). A P value of less than .05 was considered statistically significant.
Results
Eighty-seven eyes (81 phakic eyes and 6 pseudophakic eyes) after anatomic success with macular hole surgery and with 1 to 7 years of postoperative follow-up information were investigated. There were 16 males and 63 females among the 79 patients. The mean age at the first macular hole was 63.1 ± 6.2 years (range, 49 to 74 years). The mean follow-up interval was 38.4 ± 19.7 months (range, 12 to 86 months). The duration of the IMH, which was estimated from the patient’s history of visual symptoms, was 5.6 ± 9.7 months (range, 0.25 to 60 months). The macular hole was less than 6 months in duration in 66 (75.9%) eyes and was 6 months or more in duration in 21 (24.1%) eyes, including 5 years in 2 eyes. Ten (11.5%) eyes had a stage 2 macular hole, 53 (60.9%) eyes had a stage 3 hole, and 24 (27.6%) eyes had a stage 4 hole. At baseline, 7 (8.0%) eyes were coupled with ERM of the macula. All eyes underwent ILM peeling during the vitrectomy. Fifty-four (62.1%) eyes underwent a vitrectomy for the macular hole followed by phacoemulsification cataract surgery with intraocular lens (IOL) implantation at a later date, whereas 4 (4.6%) eyes underwent a combined vitrectomy and cataract extraction. Neodymium:yttrium–aluminum–garnet laser posterior capsulotomy was performed in 13 (14.9%) eyes with obvious posterior capsular opacification after surgery. The baseline characteristics of these patients and eyes are shown in Table 1 .
| Characteristics | Patients and Eyes |
|---|---|
| Mean age (range), yrs | 63.1 ± 6.2 (49 to 74) |
| Gender, no. of patients (%) | |
| Male | 16 (20.3%) |
| Female | 63 (79.7%) |
| Bilateral macular hole, no. of patients (%) | 8 (10.1%) |
| Mean follow-up, mos (range) | 38.4 ± 19.7 (12 to 86) |
| Preoperative lens status, no. of eyes (%) | |
| Phakic | 81 (93.1%) |
| IOL | 6 (6.9%) |
| Macular hole duration, mos | |
| Mean (range) | 5.6 ± 9.7 (0.25 to 60) |
| Fewer than 6, no. of eyes (%) | 66 (75.9%) |
| 6 or more, no. of eyes (%) | 21 (24.1%) |
| Macular hole stage, no. of eyes (%) | |
| Stage 2 | 10 (11.5%) |
| Stage 3 | 53 (60.9%) |
| Stage 4 | 24 (27.6%) |
| ILM peeling, no. of eyes (%) | 87 (100%) |
| CE | |
| Prior CE | 6 (6.9%) |
| PPV and CE combined | 4 (4.6%) |
| PPV followed by CE | 54 (62.1%) |
| No CE | 23 (26.4%) |
| Mean duration of PPV to phacoemulsification, mos (range) | 13.6 ± 6.3 (3 to 24) |
| Nd:YAG laser posterior capsulotomy, no. of eyes (%) | 13 (14.9%) |
Anatomic Outcomes
In our study, macular holes that were clinically closed at the 3-month benchmark but found to be open at a later examination were deemed to have reopened. After this long-term period of review, no reopening of previously closed macular holes was observed in any eyes involved in the study. Ocular complications that developed subsequent to macular hole surgery, such as retinal detachment, glaucoma, clinically apparent choroidal neovascular membrane, and cystoids macular edema (CME), were not observed, except for cataract formation. Although clinically visible cellular proliferation in the macular area was not noted in any of our patients, OCT confirmed that in 28 (32.2%) of 87 eyes, slight perifoveal ERMs developed.
Visual Acuity Outcomes
Functional outcomes with preoperative and postoperative visual acuity are summarized in Table 2 . The mean preoperative BCVA of all eyes was 1.01 ± 0.36 logMAR units (range, 0.02 to 0.6 decimal units). After successful macular hole closure (approximately 3 months after vitrectomy), the mean BCVA for all eyes improved to 0.65 ± 0.38 logMAR units (range, 0.02 to 0.7 decimal units). Of the 87 eyes, the BCVA improved in 78 (89.7%) eyes, remained unchanged in 7 (8.0%) eyes, and decreased in 2 (2.3%) eyes. Eighteen (20.7%) eyes had a visual acuity of 0.5 decimal units or better.
| BCVA | Eyes |
|---|---|
| Mean preoperative BCVA of PPV (range decimal), logMAR | 1.01 ± 0.36 (0.02 to 0.6) |
| Postoperative BCVA of PPV (approximately 3 mos after vitrectomy) | |
| Mean (range decimal), logMAR | 0.65 ± 0.38 (0.02 to 0.7) |
| ≥ 0.5 (decimal), no. of eyes (%) | 18 (20.7%) |
| Improved, no. of eyes (%) | 78 (89.7%) |
| Unchanged, no. of eyes (%) | 7 (8.0%) |
| Decreased, no. of eyes (%) | 2 (2.3%) |
| Final BCVA | |
| Mean (range decimal), logMAR | 0.47 ± 0.39 (0.02 to 1.2) |
| ≥ 0.5 (decimal), no. of eyes (%) | 35 (40.2%) |
| Improved, no. of eyes (%) | 77 (88.5%) |
| Unchanged, no. of eyes (%) | 6 (6.9%) |
| Decreased, no. of eyes (%) | 4 (4.6%) |
At the last follow-up examination, the mean final BCVA of all eyes was 0.47 ± 0.39 logMAR units (range, 0.02 to 1.2 decimal units), which was significantly higher than the preoperative BCVA ( t = −12.532; P = .000). Thirty-five (40.2%) eyes had a visual acuity of 0.5 decimal units or better, and 77 eyes (88.5%) had an improvement in BCVA. Of the 64 eyes with vitrectomy, phacoemulsification cataract surgery, and IOL implantation, the mean final BCVA was 0.28 ± 0.26 logMAR units (range, 0.2 to 1.2 decimal units). Thirty-six (56.3%) eyes had a visual acuity of 0.5 decimal units or better, and 58 (90.6%) eyes had an improvement in BCVA.
To describe the linear association between the final BCVA and a set of exploratory variables—including the macular hole stage, the duration of a macular hole, the preoperative BCVA, ERM, and cataract exaction—a multiple linear regression model was developed by a stepwise method. Our result demonstrated that the final BCVA was affected by the macular hole stage, the preoperative BCVA, and cataract exaction ( F = 19.858; P = .000); however, the result failed to show a relationship between macular hole duration or ERM and final visual acuity.
Results
Eighty-seven eyes (81 phakic eyes and 6 pseudophakic eyes) after anatomic success with macular hole surgery and with 1 to 7 years of postoperative follow-up information were investigated. There were 16 males and 63 females among the 79 patients. The mean age at the first macular hole was 63.1 ± 6.2 years (range, 49 to 74 years). The mean follow-up interval was 38.4 ± 19.7 months (range, 12 to 86 months). The duration of the IMH, which was estimated from the patient’s history of visual symptoms, was 5.6 ± 9.7 months (range, 0.25 to 60 months). The macular hole was less than 6 months in duration in 66 (75.9%) eyes and was 6 months or more in duration in 21 (24.1%) eyes, including 5 years in 2 eyes. Ten (11.5%) eyes had a stage 2 macular hole, 53 (60.9%) eyes had a stage 3 hole, and 24 (27.6%) eyes had a stage 4 hole. At baseline, 7 (8.0%) eyes were coupled with ERM of the macula. All eyes underwent ILM peeling during the vitrectomy. Fifty-four (62.1%) eyes underwent a vitrectomy for the macular hole followed by phacoemulsification cataract surgery with intraocular lens (IOL) implantation at a later date, whereas 4 (4.6%) eyes underwent a combined vitrectomy and cataract extraction. Neodymium:yttrium–aluminum–garnet laser posterior capsulotomy was performed in 13 (14.9%) eyes with obvious posterior capsular opacification after surgery. The baseline characteristics of these patients and eyes are shown in Table 1 .
