efficacy of vitrectomy with triamcinolone assistance versus internal limiting membrane peeling...

7/22/2019 EFFICACY OF VITRECTOMY WITH TRIAMCINOLONE ASSISTANCE VERSUS INTERNAL LIMITING MEMBRANE PEELING F

1/7

EFFICACY OF VITRECTOMY WITHTRIAMCINOLONE ASSISTANCE VERSUS

INTERNAL LIMITING MEMBRANEPEELING FOR HIGHLY MYOPICMACULAR HOLE RETINAL DETACHMENT

YONG WEI, MD,* NINGLI WANG, MD, ZHONGQIAO ZU, MD,* CHUNCAO BI, MD,*HUAIZHOU WANG, MD, FENGHUA CHEN, MD, XINGGUANG YANG, MD*

Purpose:To compare the outcomes of pars plana vitrectomy (PPV) with or without the

adjuvant surgical procedures: triamcinolone acetonide (TA) assistance and/or internal

limiting membrane (ILM) peeling for the treatment of highly myopic macular hole retinal

detachment (MHRD).

Design:Casecontrol study.

Methods:Pars plana vitrectomy combined with 2 kinds of adjuvant surgical procedures

were used on 96 highly myopic eyes with MHRD. These eyes were assigned to 4 groups

randomly: Group 1, nonTA-assisted PPV and without ILM peeling; Group 2, nonTA-

assisted PPV with ILM peeling; Group 3, TA-assisted PPV and without ILM peeling; Group

4, TA-assisted PPV with ILM peeling. Anatomical reattachment of the retina, macular hole

closure, and best-corrected visual acuity were measured.

Results:The rates of both retinal reattachment and macular hole closure were higher in

Group 2 (84.0 and 44.0%) and Group 3 (80.8 and 46.2%) than Group 1 (73.9 and 17.4%);

however, there were no differences between Group 2 and Group 3 (P. 0.05). The rates of

macular hole closure were extremely low in Group 1 and also in eyes with extreme long

axial lengths ($29.0 mm), severe chorioretinal atrophy, and posterior staphyloma.

Conclusion: Pars plana vitrectomy with either TA assistance or ILM peeling waseffective for the treatment of highly myopic MHRD. If you peel the ILM, adding TA does not

affect closure rates; and if TA is used to visualize the vitreous, ILM peeling may not be

necessary in MHRD. There was a lower anatomical success rate in MHRD with extreme

long axial lengths, severe chorioretinal atrophy, and posterior staphyloma.

RETINA33:11511157, 2013

Macular holeinduced retinal detachment (MHRD)is a vision-threatening complication to highly

myopic eyes, which is more common in Asian adult

population.

1

An important causative factor of MHRD

might be the tangential traction caused by the premacularvitreous/membrane and the inverse traction caused by

the posterior staphyloma.25 Other theories include

reduced retinal adherence to the choroid because of ret-inal pigment epithelial (RPE) atrophy5 and increased

tangential traction on the macula from the contraction

of the cellular constituents on the surface of the internal

limiting membrane (ILM).6

Complete removal of the posterior hyaloid and

epiretinal membranes is essential for successful retinal

reattachment. Pars plana vitrectomy (PPV) using tri-

amcinolone acetonide (TA) would facilitate removal

of the epiretinal membrane, visualization and helping

separation, and removal of the residual vitreous cortex.

From the *Shaanxi Ophthalmic Medical Center, Xian No.4 Hos-pital, Afliated Guangren Hospital, School of Medicine, Xian Jiao-tong, University, Xian, China; and Beijing Tongren Eye Center,Beijing Tongren Hospital, Ophthalmology and Visual Science KeyLaboratory, Beijing Ophthalmology School, Capital Medical Univer-sity, Beijing, China.

Supported in part by a grant from Society Development, MedicineResearch Foundation, funded by the Xian city government (SF1022[5]).

The authors declare no conict of interest.Y. Wei and N. Wang contributed equally to this work.Reprint requests: Yong Wei, MD, Department of Ophthalmol-

ogy, Xian NO.4 Hospital, #21 JieFang road, Xian 710004, China;e-mail: [email protected]

1151


2/7

The reoperation rate because of preretinal brosis ineyes by PPV without TA is higher than eyes withTA-assisted PPV.7,8 Otherwise, removing of the ILM

ensures the complete removal of residual prefovealvitreous cortex after posterior vitreous detachment

(PVD). Pars plana vitrectomy with concomitant ILM

peeling also has a high success rate to the surgicaltreatment of MHRD.9,10 In addition, axial length(AXL), extent of chorioretinal atrophy, and presenceof posterior staphyloma are important prognostic fac-

tors associated with the anatomical success of PPV forthe treatment of MHRD.

Little information is currently available on theanatomical outcomes comparing PPV with TA-assistedand/or with concomitant ILM peeling in the treatmentof MHRD, although both techniques can ensure the

complete removal of residual prefoveal vitreous cortexafter PVD. To provide an objective review of these

techniques, we conducted a randomized controlled trialto analyze cases with myopic MHRD treated with oneof these two techniques to determine the prognosticfactors associated with anatomical success in these

cases.

Patients and Methods

Ninety-one consecutive patients (96 eyes) under-went a PPV from October 2008 to May 2011. All ofthese eyes were highly myopic with retinal detach-

ment caused by macular hole (MH). Eyes withproliferative vitreoretinopathy, previous intraocularoperations, idiopathic and traumatic MHs, and post-

operative follow-up of ,6 months were excludedfrom the analysis. Information collected from eachcase record included preoperative refraction, AXL,presence of posterior staphyloma, presence of pre-operative PVD, preoperative lens status, symptomduration, surgical treatments, pre- and postoperativebest-corrected visual acuity, MH closure rate, retinal

reattachment rate, and complications. Our study wascarried out with approval from the appropriate insti-tutional review board and performed in accordancewith the ethical standards laid down in the 1964

Declaration of Helsinki. The possible merits andrisks of the present treatment were explained to thepatients before surgery, and informed consents wereobtained from all patients. The surgeon for each casewas randomly determined.

A PVD was dened as the separation of the

posterior vitreous cortex from the internal limitinglamina of the retina. Diagnosis of PVD was based onslit-lamp biomicroscopy with a 90-diopter lens andB-scan ultrasonography.

Chorioretinal atrophy was considered mild whenthe atrophy (choroidal tessellation) was located in theperipapillary area, with or without a moderate loss ofthe RPE in the macular area. Chorioretinal atrophy wasconsidered severe in the presence of extensive peri-papillary chorioretinal atrophy with, eventually, a local-

ized or more extensive loss of the choroid in the areaincluded between the temporal vascular arcades.11

Eyes were classied as having moderate long AXL(.26.0 mm but,29.0 mm) andextremely long AXL

($29.0 mm) based on B-scan ultrasonography. Staph-ylomas were determined from the B-scan ultrasono-graphic images. Staphyloma depth was measuredaccording to the method described by Steidl andPruett.12 Staphylomas were considered mild when thedepth was 2 mm or less (Grades 0112). Staphylomas

were considered severe when the depth was .2 mm(Grades 2312).13

Anatomical success was dened as complete reat-tachment of the neurosensory retina to the underlyingRPE. Macular hole closure was dened as the absenceof a neurosensory defect over the fovea on optical

coherence tomography (Carl Zeiss Ophthalmic Sys-tems, Inc, Humphrey Division, Dublin, CA).

14

Pars plana vitrectomy was performed in all patientsusing a 20-gauge 3-port system. If lens opacityobscured the view of the fundus, phacoemulsication

was performed before the PPV. After vitreous removalby vitrectomy, a dose of 0.1 mL/4 mg TA aqueous

suspension (40 mg/1.0 mL suspension; Lab.It.Bio-

chim.Farm.co Lisapharma S.P.A., Via Licinio, Como,Italy) was injected to the posterior pole in some eyesfor visualizing the residual cortical vitreous, after

removal of the solvent through a 0.2-mm microporelter (Millex-GS 0.22 mg, Merck Millipore, Billerica,MA). If a PVD was not present, the posterior hyaloidface was separated from the optic disk and removedusing controlled suction of up to 150 mmHg with thevitreous cutter applied close to the optic disk or inci-

sion and elevation the posterior hyaloid face near theoptic disk using a membrane pick. Airuid exchangewas performed while draining the subretinal uid witha soft tipped cannula over the MH. Indocyanine green(ICG) (0.5%) staining of the ILM was done in somepatients using 0.2 mL of the solution for 60 seconds.The ILM could be peeled using a diamond-dusted ILM

scraper to create an initial ap, and forceps allowed fordirect gripping and subsequent removal of the three tofour disk diameter ILM around the MH in a concentricmanner. Intraocular air was exchanged with a 14%

C3F8/air mixture. All patients were asked to remainin the prone position for 2 weeks after surgery.

We performed PPV using 4 different surgicalprocedures: nonTA-assisted PPV and without ILM

1152 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2013 VOLUME 33 NUMBER 6


3/7

peeling (Group 1: TA, ILM), nonTA-assisted PPVwith ILM peeling (Group 2: TA, ILM+), TA-assistedPPV and without ILM peeling (Group 3: TA+, ILM),

and TA-assisted PPV with ILM peeling (Group 4:TA+, ILM+). Triamcinolone acetonide was used to

visualize the posterior cortical vitreous, and diluted

ICG was used to stain the ILM for peeling.Statistical analysis was performed by SPSS statisti-

cal software (version 11.5; SPSS, Chicago, IL). Con-tinuous variables are expressed as mean SD, and

categorical variables are expressed as individual countsand proportions. The Snellen best-corrected visual acu-ity was converted into logarithm of minimum angle ofresolution units for analysis.15 Univariate analyses todetermine the association between baseline demo-graphics, surgical treatments, and anatomical success

after different surgical procedures were performedusing one-way analysis of variance, chi-square test,

and the Fisher exact test, as appropriate. In addition,logistic regression analysis was performed to estab-lish the determinants of MH closure rate as the depen-dent variable and AXL, chorioretinal atrophic,

posterior staphyloma, concomitant ILM peeling, con-comitant TA assistance as independent variables. Thecritical value of signicance was set atP , 0.05 forall tests.

Results

One hundred and three patients (108 eyes) wererecruited in this study. After randomization, 26 eyeswere assigned to Group 1, 27 eyes to Group 2, 30 eyes

to Group 3, and 25 eyes to Group 4. After the12-month follow-up, 91 enrolled patients (96 eyes,88.89%) completed the study.

No statistically signicant differences were foundamong 4 groups for variants, such as gender, age,symptom duration, preoperative visual acuity, pre-operative refraction, preoperative lens status, extent of

retinal detachment, AXL, and presence of chorioreti-nal atrophy and posterior staphyloma among 4 groups(Table 1).

Subgroup analysis of the anatomical success rate

was performed at 12 months after surgery. The ratesof retinal reattachment and MH closure were higherin Group 2 (84.0 and 44.0%), Group 3 (80.8 and46.2%), and Group 4 (81.8 and 50.0%) than Group 1.No difference was found for rates of retinal reattach-ment and MH closure in Group 2 versus Group 3

(P = 1.000 and P = 0.877), Group 2 versus Group 4(P= 1.000 and P= 0.681), and Group 3 versus Group4 (P = 1.000 and P = 0.790). For Group 1, retinalreattachment rates were lower (73.9%), especially

MH closure (17.4%). Compared with Groups 2 and3, the rates of MH closure in Group 1 were signi-cantly lower (Group 1 vs. Group 2, P = 0.047; Group 1vs. Group 3, P = 0.032), while there were no differ-ences in the rates of retinal reattachment in Group 1versus Group 2 (P= 0.487) and Group 1 versus Group

3 (P = 0.566) (Table 2).Of 96 eyes with MHRD, 57 eyes had a consistent

moderate long AXL, mild chorioretinal atrophy, andposterior staphyloma (Group A) and 25 eyes had

a consistent extremely long AXL, severe chorioretinalatrophy, and posterior staphyloma (Group B). Therates of retinal reattachment and MH closure werehigher in Group A compared with Group B (P= 0.005and P = 0.001) (Table 3). The functional outcome wasmuch better in those eyes with myopic MH closurethan those without in Group A (P = 0.011, Table 4).

Logistic regression showed that the method of

operation was strongly associated with MH closurerate in highly myopic MH retinal detachment. Parsplana vitrectomy concomitant TA assistance is the rstfactor that inuenced the rate of MH closure (Waldchi-square = 4.876, P = 0.027), and concomitant ILM

peeling is the second factor that inuenced it (Waldchi-square = 4.767, P = 0.029) in these eyes. Otherfactors such as AXL, presence of chorioretinal atro-phy, and posterior staphyloma were found by logistic

regression to have no correlation with MH closure rate(Table 5).

Intraoperative complications included iatrogenic

retinal breaks in 3 eyes of 96 eyes. Submaculardeposition of TA crystals was found in 3 eyes of 48eyes, and it spontaneously disappeared after 2 weeks.Postoperatively, 10 eyes developed epiretinal mem-

branes in 96 eyes. Four eyes suffered from MHreopened after initial closure (from 4 weeks to3 months). Of the 52 eyes with lens preservation aftersurgery, 13 eyes (25.0%) developed visually detri-mental cataracts during the course of the follow-up andlater required cataract surgery (follow-up 6 months to

1 year, mean 8.6 months). Fifteen eyes of 96 eyes(15.6%) developed increased intraocular pressurerequiring more than 1 antiglaucomatous medicationduring the rst 2 weeks of the postoperative period(Table 2).

Seventeen eyes of 19 eyes in which primary PPVfailed underwent reoperation. Thirteen were treated

with silicone oilair exchange and 4 were treated againwith C3F8uid exchange concomitant with endolaserphotocoagulation of the MH rim. Anatomical success

was achieved in 6 of 13 silicone oil tamponade eyesafter silicone oil removal. In 7 of 13 silicone oil tam-ponade eyes with extremely long AXL, severe chorior-etinal atrophy, and posterior staphyloma, the oil was

TRIAMCINOLONE ASSISTANCE VERSUS ILM PEELING WEI ET AL 1153


4/7

left in place and there were no complications related tosilicone oil use. In 2 of 4 C3F8 tamponade eyes con-comitant with endolaser photocoagulation of theMH rim, retina failed reattachment again, and nally,

eyes were tamponade with silicone oil.

Discussion

Tangential traction caused by the premacular vitre-ous/membrane is a critical causative factor for MHRD.One of the principal goals of PPV is to completelyremove the premacular vitreous/membrane from the

retina. Extremely thin translucent sheets of epiretinaltissue around the hole are always harvested intra-operatively, despite the absence of detectable tissue onpreoperative examinations. The premacular vitreous/

membrane forms the posterior wall of aposterior pre-cortical vitreous pocket that progressively enlargesbecause of extensive liquefaction of the vitreous,which is characteristic of highly myopic eyes.16 The

thin premacular vitreous/membranes are friable inmany highly myopic eyes and rmly adherent to theretina, and this makes it difcult to grasp and removefrom the retina as a single sheet. In addition, manypatients who are initially thought to have a PVD arefound to have plaques of cortical vitreous adhering to

the retina.17,18

These plaques cannot be visualized andare not apparent based on the sh-strike sign.19

Using TA as an aid to visualize the vitreous and assistin separation of the posterior hyaloid during PPV was

described by Peyman et al.17

The white suspension isdispersed in the vitreous cavity and trapped in the gelstructure of the residual epiretinal tissue, and it can be

Table 1. Preoperative Clinical Characteristics in Different Surgical Procedure Groups

Group 1 (23 Eyes) Group 2 (25 Eyes) Group 3 (26 Eyes) Group 4 (22 Eyes) P

Age, years 0.600Range 45 to 68 45 to 71 45 to 65 45 to 71Mean 55.7 6.5 57.3 6.1 56.2 5.4 58.0 6.9

Gender 0.707

Men 5 6 9 5Women 18 19 17 17

Visual acuity (logMAR units) 1.8 0.2 1.9 0.5 1.7 0.3 1.8 0.2 0.240Myopia, D 0.827

Range 7 to22 7 to24 7 to22 7 to24Mean 12.1 4.3 12.9 4.3 12.3 4.2 12.6 4.0

Lens status (eyes) 0.727Pseudophakic 2 3 4 3Aphakic 1 0 1 2Phakic 20 22 21 17

PVD (eyes) 0.999Yes 17 18 19 16No 6 7 7 6

AXL (eyes) 0.929,29.0 mm 16 17 16 14$29.0 mm 7 8 10 8

Chorioretinal atrophic (eyes) 0.967Mild 15 18 18 15Severe 8 7 8 7

Posterior staphyloma 0.924Mild 16 18 17 14Severe 7 7 9 8

Duration of symptoms, months 0.323Range 1 to 4 1 to 4 1 to 4 1 to 4Mean 1.7 0.8 1.7 0.9 1.9 0.9 1.7 0.9

Extent of the RD (eyes) 0.990PR 5 7 6 6PR-1Q 7 6 8 6PR-2Q 5 6 5 3

PR-3Q 3 4 3 4TD 3 2 4 3

Group 1: TA, ILM; Group 2: TA, ILM+; Group 3: TA+, ILM; Group 4: TA+, ILM+. TA, nonTA-assisted PPV; ILM, without ILMpeeling; TA+, TA-assisted PPV; ILM+, with ILM peeling.

logMAR, logarithm of the minimum angle of resolution; PR, posterior retina; Q, quadrant; RD, retinal detachment; TD, total detachmentof the retina.



5/7

seen on the retina as either a diffuse membrane or

small islands. This allows for clear visualization ofthe residual epiretinal tissue, which can then be

removed using a membrane pick, surgical forceps, ora silicone-tipped needle.7,17,18

The ILM represents the structural boundary betweenthe retina and the vitreous. It has a smooth vitreal

surface and an irregular retinal surface in closeapposition with the plasma membrane of the Mllercells.20 Macular holes develop from contraction of the

prefoveal vitreous and enlarge by contraction of themyobroblasts on the inner surface of the ILM.9,10

Removing the ILM ensures complete removal of theadherent areas of the vitreous and relieves the tangen-

tial traction of the residual prefoveal vitreous afterPVD by default. Additionally, ILM removal mayinduce the contraction of epiretinal cellular constitu-ents, resulting in closure of the MH.6,10

The ILM may have an important function duringearly embryogenesis,21 and although to date there are

no obvious detrimental effects of its removal, the ben-ets or detriments of ILM removal in the aged human

eye remain unclear. Furthermore, the ILM is thin, fri-able, and rmly adherent to the thin highly myopic

retina. Internal limiting membrane peeling may be

more difcult and prone to induce retinal break inhighly myopic retina. Indocyanine green toxicity to

atrophic RPE may exist in highly myopic eyes withthe use of ICG staining, because potentially ICG fallsthrough the hole on the RPE even when airuidexchange was performed. Using TA to visualize the

vitreous and assist in the separation of the posteriorhyaloids is easier than ILM peeling in highly myopicMHRD. In our study, ICG was used under air, and

after a uidair exchange, the dye was applied onlyover the desired area, preventing the access of ICGinto the subretinal space and also limiting theunwanted staining of the lens capsule and anterior

vitreous. Therefore, it may reduce the inuence tothe outcomes when ICG is used in ILM peeling. Tri-amcinolone acetonide crystals were rinsed througha Millipore lter in an attempt to remove the vehicleand yield a suspension of TA with none or a lowamount of vehicle to reduce the intraocular toxicity

of TA containing preservatives.In our study, the MH closure rate was lower in ILM-

preserved eyes without TA-assisted PPV. Without theuse of TA assistance and without ILM peeling, the

Table 3. Postoperative Clinical Characteristics in Eyes with Different AXL, Extent of Chorioretinal Atrophy, and PosteriorStaphyloma

Group A (57 Eyes) Group B (25 Eyes) P

MH closure rate 54.4% (31 eyes) 16.0% (4 eyes) 0.001Retinal reattachment rate 89.5% (51eyes) 60.0% (15 eyes) 0.005

Group A: eyes with consistent moderate long AXL, mild chorioretinal atrophy, and posterior staphyloma. Group B: eyes withconsistent extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma.

Table 2. Postoperative Clinical Characteristics in Different Surgical Procedure Groups

Group 1 (23 Eyes) Group 2 (25 Eyes) Group 3 (26 Eyes) Group 4 (22 Eyes)

MH closure rate 17.4% (4 eyes) 44.0% (11 eyes) 46.2% (12 eyes) 50.0% (11 eyes)Retinal reattachment rate 73.9% (17 eyes) 84.0% (21 eyes) 80.8% (21 eyes) 81.8% (18 eyes)Combined phacoemulsication (eyes)

Performed 7 7 8 6

Not performed 13 15 13 11Intraoperative complications (eyes)

Retinal breaks 1 1 0 1Postoperative complications (eyes)

Epiretinal membrane 5 2 1 2MH reopen 3 1 0 0Cataract 4 2 3 4Glaucoma 3 4 5 3

Final BCVA (eyes)Improvement 9 15 13 12Unchanged 10 8 10 8Worsened 4 2 3 2

Group 1: TA, ILM; Group 2: TA, ILM+; Group 3: TA+, ILM; Group 4: TA+, ILM+. TA, nonTA-assisted PPV; ILM, without ILMpeeling; TA+, TA-assisted PPV; ILM+, with ILM peeling.

BCVA, best-corrected visual acuity.



6/7

remaining vitreous during PPV may act as a scaffoldfor the epiretinal membrane, thereby exerting tractionon both the MH and retina in the posterior pole, thuslimiting MH closure or even promoting reopening.Myobroblasts may be a prominent feature only in

cases of long-standing wide-ranging retinal detach-ment threatening to progress to proliferative vitror-etinopathy rather than in our study, so better resultsmay be achieved if the vitreous is completely removedin the posterior pole, whether the ILM is peeled orpreserved during PPV. Of course, removing the ILMalso ensures complete removal of the prefoveal

vitreous by default. So, the surgical approach forTA-assisted PPV without ILM peeling or PPV withILM peeling without using TA assistance based onthese features seems logical, and may help the surgeon

to achieve better results for the patients. In our study,the anatomical success rate was higher both in ILM-preserved eyes with TA-assisted PPV and in ILM-peeled eyes without TA-assisted PPV and there was no

signicant difference between the results.It is generally believed that it is more difcult to

obtain retinal reattachment in eyes with severe highmyopia.

2224 One reason is that AXL elongation con-tributed signicantly to MH enlargement, which mayprohibit sealing of the MH. Another reason is that theposterior staphyloma shape, choroidal atrophic changes,or both of them vary widely in highly myopic patients.

When posterior staphyloma is present, the retina mustbe reattached not only along the normal contour of theglobe but also along the curvature of the posteriorstaphyloma. Posterior prolapse and stretching of the

sclera could lead to a disparity in the length of thesclera and retina. Retinal adhesion can be overcome

by inverse traction produced by this disparity of theenlarged posterior staphyloma.5 Absence of the RPEin areas of chorioretinal atrophy could lead to reducednatural retinal adhesion.25 In these cases, PPV, evenconcomitant with endolaser photocoagulation and/or

ILM peeling, and together with the injection of along-acting gas such as C3F8 for tamponade, is insuf-cient to achieve MH closure and retinal reattachment.Silicone oil in this particular situation is especiallyadvantageous for maintaining the retinal reattach-ment and may counteract the centrifugal stretching

force caused by posterior staphyloma and contributeto retinal reattachment. The success rate using C3F8tamponade is lower than that using silicone oil tam-ponade.25,26 In the present study, there was a lowerrate of retinal reattachment and MH closure in

MHRD with an extremely long AXL, severe chorior-etinal atrophy, and posterior staphyloma than thoseeyes with a moderate long AXL, mild chorioretinalatrophy, and posterior staphyloma.

In summary, PPV with either TA or ILM peelingwas effective for the treatment of highly myopic

MHRD. If you peel the ILM, adding TA does notseem to affect closure rates; however, if you do notpeel the ILM, then using TA improves closure rates,probably because of better visualization of the vitre-ous, hence a more complete vitrectomy and separationof the posterior hyaloid. So ILM peeling might notbe necessary in TA-assisted PPV eyes. In addition to

the various surgical options, the anatomical character-istics of the eyes also contribute to the postoperativeoutcome. There was a higher rate of retinal reattach-

ment and MH closure in MHRD with a moderatelong AXL, mild chorioretinal atrophy, and posterior

Table 4. Postoperative Clinical Characteristics of Eyes with Moderate Long AXL, Mild Chorioretinal Atrophy, andPosterior Staphyloma

MH Closure (32 Eyes) MH Nonclosure (25 Eyes) P

Final BCVA (eyes) 0.011Improvement 24 10Unchanged 8 9

Worsened 0 5Retinal reattachment rate 100% (32 eyes) 76.0% (19 eyes)

BCVA, best-corrected visual acuity.

Table 5. Logistic Regression Model Summary for MH Closure After Primary PPV

Dependent Variable Independent Variable Wald P

MH closure after primary PPV AXL 0.885 0.347Chorioretinal atrophic 0.062 0.804Posterior staphyloma 0.923 0.337Concomitant ILM peeling 4.767 0.029Concomitant TA assistance 4.876 0.027



7/7

staphyloma than eyes with a extremely long AXL,severe chorioretinal atrophy, and posterior staphylo-ma, and the functional outcomes were better in eyes

with myopic MH closure than in those without.Currently, there is no established optimal surgical

technique for eyes with an extremely long AXL,

severe chorioretinal atrophy, and posterior staphylo-ma. Further studies are needed to examine thesealternative surgical techniques in patients with poorprognostic factors.

Key words: highly myopic, macular hole, retinaldetachment, internal limiting membrane peeling, tri-

amcinolone acetonide.

References

1. Zhang CF, Hu C. High incidence of retinal detachment sec-

ondary to macular hole in a Chinese population. Am J Oph-

thalmol 1982;94:817819.

2. Oshima Y, Ikuno Y, Motokura M, et al. Complete epiretinal

membrane separation in highly myopic eyes with retinal

detachment resulting from a macular hole. Am J Ophthalmol

1998;126:669676.

3. Stirpe M, Michels RG. Retinal detachment in highly myopic

eyes due to macular holes and epiretinal traction. Retina 1990;

10:113114.

4. Seike C, Kusaka S, Sakagami K, et al. Reopening of macular

holes in highly myopic eyes with retinal detachments. Retina

1997;17:26.

5. Morita H, Ideta H, Ito K, et al. Causative factors of retinal

detachment in macular holes. Retina 1991;11:281284.

6. Yooh HS, Brooks HL, Capone A, et al. Ultrastructural features

of tissue removed during idiopathic macular hole surgery.

Am J Ophthalmol 1996;122:6775.7. EnaidaH, Hata Y,UenoA, et al. Possible benets of triamcinolone-

assisted pars plana vitrectomy for retinal diseases. Retina 2003;

23:764770.

8. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinolone-

assisted pars plana vitrectomy improves the surgical proce-

dures and decreases the postoperative blood-ocular barrier

breakdown. Graefes Arch Clin Exp Ophthalmol 2002;240:

423429.

9. Kadonosono K, Yazama F, Itoh N, et al. Treatment of retinal

detachment resulting from myopic macular hole with internal lim-

iting membrane removal. Am J Ophthalmol 2001;131:203207.

10. Uemoto R, Yamamoto S, Tsukahara I, et al. Efcacy of inter-

nal limiting membrane removal for retinal detachments result-

ing from a myopic macular hole. Retina 2004;24:560566.

11. Ripandelli G, Coppe AM, Parisi V, et al. Fellow eye ndings

of highly myopic subjects operated for retinal detachment asso-

ciated with a macular hole. Ophthalmology 2008;115:1489

1493.

12. Steidl SM, Pruett RC. Macular complications associated with

posterior staphyloma. Am J Ophthalmol 1997;123:181187.

13. Hsiang HW, Ohno-Matsui K, Shimada N, et al. Clinical char-

acteristics of posterior staphyloma in eyes with pathologicmyopia. Am J Ophthalmol 2008;146:102110.

14. Kang SW, Ahn K, Ham DI. Types of macular hole closure and

their clinical implications. Br J Ophthalmol 2003;87:1015

1019.

15. Holladay JT. Proper method for calculating average visual

acuity. J Refract Surg 1997;13:388391.

16. Spaide RF. Measurement of the posterior precortical vitreous

pocket in fellow eyes with posterior vitreous detachment and

macular holes. Retina 2003;23:481485.

17. Peyman GA, Cheema R, Conway MD, et al. Triamcinolone

acetonide as an aid to visualization of the vitreous and the

posterior hyaloid during pars plana vitrectomy. Retina 2000;

20:554555.

18. Sonoda KH, Sakamoto T, Enaida H, et al. Residual vitreous

cortex after surgical posterior vitreous separation visualized byintravitreous triamcinolone acetonide. Ophthalmology 2004;

111:226230.

19. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular

holes. Results of a pilot study. Arch Ophthalmol 1991;109:

654659.

20. Fine BS. Limiting membranes of the sensory retina and pig-

ment epithelium. An electron microscopic study. Arch Oph-

thalmol 1961;66:847860.

21. Halfter W, Willem M, Mayer U. Basement membrane-dependent

survival of retinal ganglion cells. Invest Ophthalmol Vis Sci

2005;46:10001009.

22. Sayanagi K, Ikuno Y, Tano Y. Macular hole diameter after

vitrectomy for macular hole and retinal detachment. Retina

2005;25:608611.23. Wolfensberger TJ, Gonvers M. Surgical treatment of retinal

detachment owing to macular hole. Semin Ophthalmol 2000;

15:122127.

24. Ripandelli G, Parisi V, Friberg TR, et al. Retinal detachment

associated with macular hole in high myopia: using the vitre-

ous anatomy to optimize the surgical approach. Ophthalmol-

ogy 2004;111:726731.

25. Wolfensberger TJ, Gonvers M. Long-term follow-up of retinal

detachment due to macular hole in myopic eyes treated by

temporary silicone oil tamponade and laser photocoagulation.

Ophthalmology 1999;106:17861791.

26. Scholda C, Wirtitsch M, Biowski R, et al. Primary silicone oil

tamponade without retinopexy in highly myopic eyes with

central macular hole detachments. Retina 2005;25:141146.


efficacy of vitrectomy with triamcinolone assistance versus internal limiting membrane peeling...

Documents