Methods

This was a retrospective, interventional, observational case series study. We studied the medical records of 21 consecutive patients who had undergone successful vitrectomy for an idiopathic MH at the Teikyo University School of Medicine, University Hospital Mizonokuchi, from August 4, 2011 to March 14, 2013. The procedures used to treat the patients and the examination of their medical records was approved by the Institutional Review Board of the Teikyo University School of Medicine.

Cases with any ocular complications that could affect visual function, such as diabetic retinopathy, macular degeneration, myopic chorioretinal atrophy, rhegmatogenous retinal detachment, cataract >grade III in the Emery-Little scale, and corneal diseases, were excluded. An idiopathic MH was diagnosed and classified as reported by Gass.

Standard 3-port vitrectomy with 23 gauge instruments was performed on 20 eyes and with 25 gauge instruments on 1 eye by a single surgeon to repair the MH. After completion of core vitrectomy, a posterior vitreous detachment was created with active aspiration if one was not present. The ILM was peeled by grasping the ILM with vitreoretinal forceps without the use of dyes to make the ILM more visible, except in 1 eye, in which 0.125% indocyanine green was used. The ILM was grasped at the upper right to the fovea within the vascular arcade and peeled to the edge of the vascular arcade (approximately 2 or 3 disc diameters). After air–fluid exchange, 20% sulfur hexafluoride was used for tamponade. Patients were instructed to maintain a face-down position for 1 day and then allowed to assume any body position except a face-up position until the gas disappeared.

Spectral-domain optical coherence tomography (SD OCT, Spectralis; Heidelberg Engineering, Heidelberg, Germany) was used to evaluate the size and shape of the MH preoperatively and postoperatively. The distance between the temporal margin of the optic disc and an intersection of retinal vessels was measured using the caliper function of the SD OCT preoperatively (A) and 2 weeks and 1, 3, 6, and 12 months postoperatively (B). Fundus autofluorescence (FAF, Figure 1 ) and near-infrared ( Figure 2 ) images were used to measure the distance between the optic disc and the intersection of the retinal vessels. We selected 2 intersections of retinal blood vessels in each eye. One was in the temporal ETDRS subfield and the other was in the nasal ETDRS subfield ( Figure 3 left). The basal diameter and minimum diameter of the MH were measured in the SD OCT images ( Figure 3 right).

Fundus autofluorescence images and spectral-domain optical coherence tomographic images of a 63-year-old woman with a macular hole. (Upper left) Fundus autofluorescence image with a macular hole. The distance from the margin of the optic disc to the intersection of temporal vessels and to the intersection of nasal vessels was measured in fundus autofluorescence images such as this. (Upper right) The temporal and nasal distances were measured 2 weeks postoperatively. The macular hole is closed. (Lower left) Preoperative optical coherence tomographic image. The baseline diameter of the macular hole is 673 μm. (Lower right) Optical coherence tomographic image 2 weeks after vitrectomy with internal limiting membrane peeling.

Near-infrared images and spectral-domain optical coherence tomographic images of a 49-year-old woman with a macular hole. (Upper left) Near-infrared image showing a macular hole. The distance from the optic nerve to the intersection of temporal vessels and the distance from the optic disc to the intersection of nasal vessels were measured in this image. (Upper right) The temporal and nasal distances were measured 2 weeks postoperatively. The macular hole is closed. (Lower left) Preoperative optical coherence tomographic image. The basal macular hole diameter is 722 μm. (Lower right) Optical coherence tomographic image at 2 weeks after surgery.

Identification of intersections of retinal vessels and optical coherence tomographic image used to measure diameter of macular hole. (Left) ETDRS subfield was used to identify nasal and temporal intersections of the retinal blood vessels. (Right) Spectral-domain optical coherence tomography was used to measure basal and minimum sizes of macular hole.

Statistical analyses were performed using Excel (Microsoft, Washington, DC, USA) with add-in statistical software (SSRI, Tokyo, Japan). The descriptive data are presented as the means ± standard deviations. The best-corrected visual acuity (BCVA) was measured with a Landolt C chart in decimal units and then converted to logarithm of the minimal angle of resolution (logMAR) units. Paired t tests were used to determine whether differences over time were significant. The correlations between the MH size and distances of the retinal displacement were determined by Spearman rank correlations. A P value < .05 was considered significant.

Results

The medical records of 21 eyes of 21 patients (9 men, mean age, 64.6 ± 8.4 years) with MH were studied. Ten eyes (47.6%) had stage 2 MH, 9 eyes (42.9%) had stage 3 MH, and 2 eyes (9.5%) had stage 4 MH. The average basal diameter of the MHs was 662.1 ± 238.1 μm with a range of 281–1116 μm. The minimum diameter of the MH was 271.8 ± 111.3 μm with a range of 63–459 μm. The mean postoperative follow-up period was 11.0 ± 5.6 months with a range of 3-19 months. The preoperative refractive error (spherical equivalent) was −1.5 ± 3.0 diopters (D). The clinical demographics of all of the participants are summarized in the Table .

Table

Clinical Characteristics of the 21 Cases of Macular Hole Undergoing Vitrectomy With Internal Limiting Membrane Peeling

Case No	Age	Sex	Stage	DT (μm)		DN (μm)		Migration Length at 2 Weeks After Surgery (μm)		Best-Corrected Visual Acuity (logMAR)		Basal Diameter (μm)	Minimum Diameter (μm)
				Baseline	2 Weeks	Baseline	2 Weeks	Temporal	Nasal	Preoperative	Best Postoperative
1	76	M	2	4739	4353	2982	2822	−386	−160	0.699	0.155	606	251
2	71	F	2	5140	4916	3219	3146	−224	−73	0.699	0.155	811	275
3	63	M	2	4999	4680	2151	2027	−319	−124	1.046	0.097	983	459
4	62	F	2	5217	5110	3189	3159	−107	−30	0.523	0	374	181
5	65	M	3	4875	4665	2589	2590	−210	1	1	0	690	232
6	49	F	3	5035	4667	2981	2936	−368	−45	0.699	0.145	722	255
7	56	F	4	4369	3886	1795	1752	−483	−43	0.523	0.097	894	387
8	65	M	2	4679	4414	2367	2314	−265	−53	1	0.301	951	114
9	62	F	2	5289	5109	3201	3141	−180	−60	0.699	0.145	587	378
10	75	M	3	4353	4062	2462	2406	−291	−56	1.097	0.155	902	346
11	71	F	3	5000	4714	2305	2256	−286	−49	1	0.523	1116	443
12	65	F	2	4717	4501	2977	2882	−216	−95	0.398	0.155	344	168
13	62	F	3	4863	4632	2920	2862	−231	−58	1.097	0.097	701	368
14	73	M	3	4347	4277	2738	2754	−70	16	0.398	0.398	281	112
15	76	F	2	4937	4619	2790	2474	−318	−316	0.398	0.046	403	63
16	65	M	3	4045	3951	2732	2706	−94	−26	0.699	0.301	725	315
17	75	M	2	4786	4855	2193	2187	69	−6	0.699	0.046	447	244
18	46	F	3	4674	4066	2458	2155	−608	−303	0.523	−0.079	703	306
19	59	M	2	5403	5047	2987	2793	−356	−194	0.824	0.398	707	390
20	57	F	4	5911	5659	3005	2865	−252	−140	0.398	0.155	285	169
21	63	F	3	4874	4592	2808	2709	−282	−99	1	0.301	673	252
Mean	64.6			4869.1	4608.3	2707.1	2616	−260.8	−91.1	0.733	0.171	662.1	271.8
± SD	8.4			412.1	432.9	388	389.4	145.8	89.7	0.251	0.15	238.1	111.3

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