Abstract
Purpose: To characterize the change in visual acuity (VA) in eyes treated with vitrectomy using the 2020 international consensus-based optical coherence tomography (OCT) definition of lamellar macular hole (LMH), macular pseudohole (MPH), and epiretinal membrane with foveoschisis (ERMF). Methods: A retrospective chart review was performed from 2000 to 2022 of patients who had vitrectomy for symptomatic decreased VA from LMH, MPH, or ERMF performed by the same surgeon at a community hospital. Preoperative spectral domain (SD-OCT) was reviewed to classify patients using the consensus guidelines. Primary outcomes were the mean change in best-corrected VA at 3 months, 1 year, and the final postoperative examination. Results: Fifty-one patients were included, 30 with LMH, 14 with MPH, and 7 with ERMF. The VA was 20/63 at baseline, 20/62 (P = .79) 3 months postoperatively, 20/40 (P = .003) at 1 year, and 20/52 (P = .10) at the final examination for LMH; 20/64, 20/50 (P = .16), 20/40 (P = .040), and 20/40 (P = .02), respectively, for MPH; and 20/53, 20/50 (P = .42), 20/30 (P = .03), and 20/38 (P = .04), respectively, for ERMF. Subgroup analysis showed that eyes with LMH without ellipsoid zone (EZ) disruption on SD-OCT improved from 20/57 at baseline to 20/39 (P = .01) at the final examination. Conclusions: There was no significant improvement in VA at the final postvitrectomy examination in eyes with LMH, while there was significant improvement in eyes with MPH and ERMF. This supports surgery in selected eyes with MPH and ERMF but possibly not in eyes with LMH, unless OCT shows no EZ disruption.
Keywords: vitrectomy, membrane peel, lamellar macular hole, macular pseudohole, epiretinal membrane with foveoschisis, optical coherence tomography
Introduction
Diseases of the vitreomacular interface, including macular holes (MHs), can cause a decrease in visual acuity (VA) or metamorphopsia. Although these diseases were initially described and staged using slitlamp biomicrosopy, 1 these descriptions included a range of clinical entities that limited scientific investigation of their prognosis and treatment. 2 In recent years, spectral-domain optical coherence tomography (SD-OCT) has allowed for high-resolution cross-sectional imaging of the vitreomacular interface and improved classification of these clinical entities.
An international panel recently created a new consensus-based OCT definition of lamellar MH (LMH), macular pseudohole (MPH), and epiretinal membrane with foveoschisis (ERMF) using specific OCT criteria. 3 OCT allows for more precise differentiation and classification of these diseases according to specific major criteria and minor criteria (Figures 1 and 2). To our knowledge, only 1 small retrospective case series has described the surgical outcomes of LMH, MPH, and ERMF using this consensus definition. 4 Additional studies are needed to establish treatment guidelines and the prognosis.
Figure 1.
Mandatory criteria and minor criteria for lamellar macular holes, macular pseudoholes, and ERM foveoschisis from the new consensus definition. 3
Abbreviation: ERM, epiretinal membrane.
Figure 2.
Examples of LMH (above), MPH (middle), and ERMF (below) on OCT are representative of the new consensus definition.
Abbreviations: ERMF, epiretinal membrane with foveoschisis; LMH, lamellar macular hole; MPH, macular pseudohole; OCT, optical coherence tomography.
The treatment for LMH, MPH, and ERMF requires pars plana vitrectomy (PPV) with membrane peeling, typically with the removal of the internal limiting membrane (ILM) and ERM, if present. The purpose of this study was to characterize the VA outcomes in eyes treated with PPV with membrane peeling based on the disease classification using the new consensus-based OCT definition.
Methods
A retrospective chart review was performed from 2000 to 2022 of patients of the same surgeon at a community hospital. A surgical database was screened for key words including “lamellar macular hole”, “macular pseudohole”, “foveoschisis”, and “macular hole”. The patients included in this initial screening were evaluated for the presence of preoperative and postoperative clinical examinations with OCT imaging. Preoperative OCT imaging was reviewed for each patient to determine the classification of the retinal disease based on the major criteria and minor criteria of the current consensus guidelines; Figure 1 shows the criteria. All patients with an LMH, MPH, or ERMF had preoperative and postoperative OCT and at least 3 months of follow-up; therefore, no patients were excluded from the analysis.
Patients who had PPV with membrane peeling for LMH, MPH, or ERMF in at least 1 eye and had preoperative and postoperative SD-OCT imaging and at least 3 months of follow-up were included. Only patients with symptomatic visual loss, metamorphopsia, or both were offered vitrectomy. The primary outcome measures were the mean change in best-corrected VA (logMAR) from baseline to postoperatively at 3 months, 1 year, and the final examination. At each time interval, other patient characteristics were measured, including intraocular pressure and lens status. For all patients, follow-up duration, age, sex, laterality, and ocular history, including previous surgery, were noted (Table 1). Surgical notes were reviewed for the presence of intraoperative complications and ILM stain used. Table 2 shows the presence of minor consensus definition criteria.
Table 1.
Patient Characteristics.
| Characteristic | All (N = 51) |
LMH (n = 30) |
MPH (n = 14) |
ERMF (n = 7) |
P Value |
|---|---|---|---|---|---|
| Mean age (y) ± SD | 71.4 ± 9.3 | 72.3 ± 10.6 | 71.4 ± 7.7 | 68.1 ± 5.6 | .58 |
| Mean follow-up (mo) ± SD | 34.6 ± 31.8 | 44.4 ± 38.0 | 28.8 ± 25.4 | 41.3 ± 37.9 | .48 |
| Women, n (%) | 29 (57) | 12 (40) | 8 (57) | 6 (86) | .08 |
| Pseudophakic, n (%) | 26 (51) | 17 (57) | 7 (50) | 1 (14) | .13 |
| Pseudophakic by final exam, n (%) | 46 (90) | 27 (90) | 14 (100) | 5 (71) | .12 |
| Right eye, n (%) | 23 (45) | 14 (47) | 6 (43) | 3 (43) | .97 |
| ILM staining and removal at time of surgery, n (%) | 49 (96) | 29 (97) | 13 (93) | 7 (100) | .73 |
| Had ILM removal with ICG staining, n (%) a | 41 (80) | 24 (83) | 11 (85) | 6 (86) | .98 |
Abbreviations: BBG, brilliant blue G; ERMF, epiretinal membrane with foveoschisis; ICG, indocyanine green; ILM, internal limiting membrane; LMH, lamellar macular hole; MPH, macular pseudohole.
Otherwise BBG was used.
Table 2.
Presence of Minor Consensus Definition Criteria.
| Condition/Minor Criteria | Number (%) |
|---|---|
| LMH | |
| Epiretinal proliferation | 29 (97) |
| Foveal bump | 6 (20) |
| Ellipsoid zone disruptions | 15 (50) |
| MPH | |
| Microcystoid spaces in inner nuclear layer | 8 (57) |
| Near normal retinal thickness | 5 (36) |
| ERMF | |
| Microcystoid spaces in inner nuclear layer | 4 (57) |
| Retinal thickening | 3 (43) |
| Retinal wrinkling | 7 (100) |
Abbreviations: ERMF, epiretinal membrane with foveoschisis; LMH, lamellar macular hole; MPH, macular pseudohole.
Statistical analysis was conducted with Excel software (Microsoft Corp) with paired t tests or unpaired t tests assuming equal variances and 2-tailed analysis. A P value < .05 was considered statistically significant. Mean values are ± SD.
Results
Of the 51 patients who met the inclusion criteria, 30 had LMH, 14 had MPH, and 7 had ERMF. The mean follow-up time at the final examination for all patients was 34.6 ± 31.8 months. The mean follow-up time at the final examination was 28.8 ± 25.4 months, 44.4 ± 38.0 months, and 41.4 ± 37.9 months for LMH, MPH, and ERMF, respectively.
The mean preoperative VA of all patients was 20/62. The mean postoperative VA at 3 months, 1 year, and the time of final follow-up was 20/52, 20/40, and 20/38, respectively. There was no significant improvement in VA in patients with LMH from preoperatively to the final postoperative visit; however, there was significant improvement in patients with MPH (P = .04) and ERMF (P = .02). Although there was a significant improvement in the LMH group at 1 year (P = .003), the improvement was no longer significant by the final examination (P = .10). Table 3 and Figure 3 show the VA results by group.
Table 3.
Mean VA Before and After Vitrectomy by Group.
| Group | Preop | POM3 | POY1 | Final |
|---|---|---|---|---|
| LMH | ||||
| Snellen | 20/63 | 20/62 | 20/43 | 20/52 |
| P value | — | .79 | .003 | .10 |
| MPH | ||||
| Snellen | 20/64 | 20/50 | 20/40 | 20/40 |
| P value | — | .16 | .04 | .02 |
| ERMF | ||||
| Snellen | 20/53 | 20/50 | 20/30 | 20/38 |
| P value | — | .42 | .03 | .04 |
Abbreviations: ERMF, epiretinal membrane with foveoschisis; LMH, lamellar macular hole; MPH, macular pseudohole; POM, postoperative month; POY, postoperative year; VA, visual acuity.
Figure 3.
Preoperative and postoperative visual acuity for patients who had pars plana vitrectomy for LMH, EMRF, or MPH. Asterisks denote a statistically significant change from baseline. Error bars show the standard error of the mean. The first bar in each group is the preoperative VA; the second bar, the POM3 VA; the third bar, the POY1 VA; and the last bar, the final VA.
Abbreviations: ERMF, epiretinal membrane with foveoschisis; LMH, lamellar macular hole; MPH, macular pseudohole; OCT, optical coherence tomography; POM, postoperative month; POY, postoperative year.
Postoperative complications were infrequent after PPV. Three patients developed cystoid macular edema (CME), which was treated with topical nonsteroidal anti-inflammatory drugs. No patient developed retinal tears, retinal detachments, or full-thickness MHs (FTMHs).
Subgroup analysis for patients with LMH showed a weak positive correlation between the preoperative foveal thickness and postoperative VA (R2 = 0.27) and no association with the preoperative VA (R2 = 0.03) (Figure 4). In addition, there was a statistically significant difference in postoperative VA in patients with ellipsoid zone (EZ) disruption and those without EZ disruption at the initial evaluation for LMH. Fifteen patients with EZ disruption had a baseline VA of 20/69 and a final postoperative VA of 20/69 (P = .99). Fifteen patients without EZ disruption had a baseline VA of 20/57 and a final postoperative VA of 20/39 (P = .01). There was no statistically significant difference in the baseline VA between these 2 groups (P = .19). The follow-up duration was 37.6 months for patients with EZ disruption and 21.1 months for patients without EZ disruption; the difference was not statistically significant (P = .09).
Figure 4.
Scatterplot with linear regression showing the association between preoperative and postoperative VA and the thinnest measured point in the fovea in patients with a lamellar macular hole.
Abbreviation: VA, visual acuity.
Subgroup analysis was performed for patients with LMH and MPH who were pseudophakic before PPV; however, it could not be performed for patients with ERMF because the sample size was insufficient. In the LMH group, when the analysis was limited to patients who were pseudophakic before PPV, the mean VA was 20/62 preoperatively and 20/55 at the final postoperative follow-up; the difference was not significant (P = .43). In patients with MPH who were pseudophakic before PPV, the mean VA was 20/69 preoperatively and 20/39 postoperatively, a significant improvement (P = .01).
Conclusions
This study highlights the utility of the consensus OCT-based classification of LMH, MPH, and ERMF in stratifying surgical outcomes and identifying patients with decreased VA whose vision would improve after PPV with membrane peeling. A similar consensus OCT definition has been established for the classification of vitreomacular traction and FTMH, 5 with the same purpose of aiding in a consistent diagnosis and standardization for clinical research.
Previous OCT studies have suggested different subtypes of LMH with distinct clinical profiles. 2 OCT has been used to describe features such as epiretinal proliferation, 6 which has been shown to have an effect on VA outcomes after vitrectomy for lamellar holes in previous studies, including 1 meta-analysis that reported an improvement in VA of 0.17 logMAR.7,8 Even before the current OCT definition, however, such studies on LMH were limited. A recent Cochrane review only found 1 randomized clinical trial including 36 patients that compared observation alone with surgery for LMH. In this study, the patient who had PPV for LMH had an improvement in VA of 0.27 logMAR.9,10 Other studies report different results, with most patients in the original study of LMH diagnosed on OCT as having no visual improvement. 1 OCT has also been used to differentiate between LMH and MPH, finding that MPH responds more favorably to surgery, with results similar to those of PPV with membrane peeling for ERM. 11
The current study did not include patients who were managed with observation alone because the screening database included only patients who had surgery. Some studies suggest that in some cases, the LMH may progress to an FTMH 12 ; however, this did not occur in the current series. There have been, however, a few reports of spontaneous resolution. 13 Other studies have suggested stability in anatomic and visual outcomes for both LMH and MPH observed over 5 years. 14 Ultimately, randomized prospective trials are needed to compare surgical outcomes with those of observation alone.
Improved classification on OCT has been used to aid in the understanding the pathogenesis and different types of FTMH based on mechanism and appearance. 15 Findings in similar studies comparing LMH and ERMF suggest that LMH has a unique pathogenesis, including more bilateral findings. 16 Other imaging modalities, such as fluorescein angiography, have been used to compare ERMF with LMH but did not show specific differences that would assist in the diagnosis or selection of surgical patients. 17
The percentage of patients with ERMF noted to have foveoschisis on OCT is small. Although these patients have visual outcomes similar to those of patients with ERMF without foveoschisis, the reported rate of macular edema is higher; however postoperatively, residual foveoschisis may be difficult to distinguish from CME. 18 Studies of vitrectomy for ERMF have shown that the surgery can improve VA 19 ; however, comparative studies found no benefit for LMH. Eyes with MPH have been shown to benefit from PPV since the late 1990s. 20 Similar to its use in LMH and ERMF, OCT has been performed in recent years to identify characteristics of MPH to predict surgical outcomes, with a recent study showing an average improvement in VA of 0.22 logMAR after PPV. 21
Although some of these studies were randomized controlled trials, they used differing, and in some cases conflicting, definitions of LMH, ERMF, and MPH. Only 1 study, a retrospective review that included 11 patients with LMH only and excluded patients with ERMF and MPH, has been performed using the new consensus definition. 4 The study reported an improvement in VA of 0.28 logMAR in patients with LMH, suggesting that some eyes with LMH benefit from this surgery. In our study, eyes with LMH and no EZ disruption responded favorably, with a significant improvement in VA. The status of the EZ might be helpful in the future in selecting eyes that are most likely to benefit from vitrectomy. The patients with EZ disruption in our study tended to have a longer follow-up, while more patients without EZ disruption were lost to follow-up sooner. Although the difference was not statistically significant, it is possible there is gradual deterioration in the OCT morphology and VA after vitrectomy for LMH that results in less gain of VA by the final examination. We initially thought this deterioration might be an effect of cataract progression in eyes with LMH; however, an analysis of pseudophakic eyes did not confirm this premise. To our knowledge, ours is the only study to compare LMH, ERMF, and MPH using the new consensus definition.
Limitations of this study include the sample size, which also limited subgroup analysis. The retrospective design, which included only patients who had surgery, could also have introduced selection bias. Further studies are needed, and a larger multicenter study with a randomized prospective design would help provide more definitive answers about which eyes might benefit from vitrectomy and which eyes should be monitored with observation alone.
In conclusion, using the new consensus OCT-based definitions, we found that overall, patients with LMH did not have a significant improvement in VA after PPV with membrane peeling, although some eyes did have improved VA. This lack of improvement remained even when including pseudophakic patients only. However, in a subgroup of patients with LMH but without EZ disruption, there was a significant improvement in VA. Patients with MPH or ERMF had a significant improvement in VA after PPV with membrane peeling. The results support surgery in symptomatic eyes with MPH and ERMF with decreased VA; however, such benefits in eyes with LMH might only occur when there is no EZ disruption.
Footnotes
Ethical Approval: This study was conducted in accordance with the Declaration of Helsinki. The collection and evaluation of all protected patient health information were performed in a US Health Insurance Portability and Accountability Act–compliant manner. The Institutional Review Board, Greater Baltimore Medical Center, approved this study.
Statement of Informed Consent: Informed consent was not required as part of this retrospective study.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
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