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      Meta-Analysis of Chromovitrectomy with Indocyanine Green in Macular Hole Surgery

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          Purpose: To report a meta-analysis of the literature comparing internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) staining in macular hole (MH) treatment. Methods: A Pubmed search was conducted from January 1999 to June 2004. Manuscripts describing the anatomical and functional outcomes of vitrectomy plus ILM peeling with and without ICG application in MH surgery were reviewed. A statistical meta-analysis was performed including studies which defined anatomical outcomes as closure of the MH and disappearance of the fluid cuff and functional outcomes as improvement of 2 or more Snellen lines. A secondary outcome was to investigate the incidence of retinal pigment epithelium (RPE) alterations with and without ICG staining in MH surgery. Results: Results including all types of MHs in 837 eyes indicated the same anatomical success but worse functional outcomes in the group with ICG application (p = 0.0008; odds ratio = 0.587, 95% confidence interval = 0.427–0.808). A higher incidence of RPE alterations in the ICG injection group was observed. The incidence of RPE alterations was found to be 1.98%, whereas RPE changes were noted in 13.83% of 201 patients with ICG application (odds ratio = 7.998). Conclusion: This meta-analysis of previous reports comparing ILM peeling with and without intravitreal ICG application in the treatment of MHs demonstrated statistically worse functional outcomes when ICG was applied (p = 0.0008). A higher number of RPE alterations were observed in the ICG-stained group.

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          Most cited references 41

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          Macular hole surgery with and without internal limiting membrane peeling.

          To compare results of surgery for idiopathic macular hole with and without internal limiting membrane (ILM) peeling in a series of consecutive patients over a 5-year period. A retrospective, nonrandomized, comparative trial with concurrent control group. Forty-four eyes with macular holes of less than or equal to 6 months duration without ILM peeling were compared to 116 eyes with ILM peeling and the same hole duration. A third group of 65 eyes with ILM peeling and duration greater than 6 months was also evaluated. All eyes underwent pars plana vitrectomy with or without ILM peeling, intravitreous gas, and positioning face down. No adjunctive therapies were used in any group. Comparing the closure and/or reopening rate, prognosis, visual acuity, and complications for macular holes with and without ILM peeling. All patients had postsurgical follow-up of 18 months or greater. Primary closure was significantly improved with ILM peeling with 116 of 116 eyes (100%) showing no reopenings versus 36 of 44 holes (82%) primarily closed, 9 of which (25%) reopened without ILM peeling (P: < 0.00001) in holes less than or equal to 6 months. The 27 eyes without ILM peeling that had successful surgery displayed a mean postoperative vision of 20/40, which is the same as the successful eyes with ILM peeling (P: = 0.6). The 52 stage II eyes with ILM peeling had a mean postoperative vision of 20/30, and 48 of the 52 eyes (92%) were 20/40 or better. Stage III eyes (greater than 400-microm holes) without ILM peeling had a poor prognosis, with 6 of the 25 eyes (24%) having initial surgery fail and an additional 4 of 25 eyes (16%) reopening. Without ILM peeling, holes less than 300 microm had only one reopen, whereas holes greater than or equal to 300 microm had 16 of the 17 (94%) primary failures and/or reopenings (P: < 0.001). All 12 holes that reopened and/or primarily failed were repaired with ILM peeling with excellent visual recovery. Macular holes with a duration greater than 6 months were treated with ILM peeling, and 63 of 65 holes (97%) were closed primarily and 65% had an increase in vision by two or more Snellen lines. ILM peeling significantly improves visual and anatomic success in all stages of recent and chronic macular holes and reopened and failed holes, while eliminating reopening for holes greater than 300 microm.
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            Macular hole surgery with internal-limiting membrane peeling and intravitreous air.

            To examine the results of macular hole surgery using pars plana vitrectomy, internal-limiting membrane peeling, and intravitreous air in a series of consecutive patients. A retrospective, interventional, noncomparative case series. Fifty consecutive patients (58 eyes) with full-thickness macular holes. All eyes underwent a pars plana vitrectomy with internal-limiting membrane peeling and intravitreous air, and patients were asked to position face-down for only 4 days. Status of macular holes, visual acuity, and associated findings and complications. All patients had postsurgical follow-up of 6 months or greater. Eight eyes (14%) presented with stage-2 macular holes, 48 eyes (83%) with stage-3 macular holes, and 2 eyes (3%) with stage-4 macular holes. Only 26 eyes (45%) had a macular epiretinal membrane seen before surgery. Fifty-three (91 %) of the 58 macular holes were closed with 1 operation, and 55 (95%) had closure of the macular holes with subsequent operations. Five (9%) of 58 eyes had an initial visual acuity of 20/50 or better, and 31 eyes (53%) had a final visual acuity of 20/50 or better. Of the 45 eyes with symptoms of less than 6 months' duration, 44 (98%) had macular holes that were closed with 1 operation and 27 (60%) had a final visual acuity of 20/50 or better. Of the 13 eyes with symptoms of 6 months' duration or longer, 9 (69%) had macular holes that were closed with 1 operation and 4 (31 %) had a final visual acuity of 20/50 or better. Complications attributed to the operation included retinal tears, retinal detachments, postoperative macular puckers, and macular light toxicity. The anatomic and visual results in this series are good. The current technique is similar to that of conventional macular hole surgery except for the use of intravitreous air, internal-limiting membrane peeling in all eyes, and only 4 days of postoperative positioning. This study would suggest that peeling of the internal-limiting membrane is an important adjuvant for successful closure of macular holes.
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              Internal limiting membrane removal in the management of full-thickness macular holes.

              To determine the effectiveness of removal of the internal limiting membrane in the treatment of full-thickness macular holes. Data were reviewed from a prospective study on 47 consecutive eyes with full-thickness macular holes undergoing vitrectomy, internal limiting membrane maculorhexis, and fluid-gas exchange. No eye underwent repeat macular hole surgery. A meta-analysis was performed to compare the outcomes of different surgical techniques in the treatment of full-thickness macular holes. The outcome measures were disappearance of the submacular fluid and the change in best-corrected visual acuity. The surgery was anatomically successful in 44 of the 46 eyes (96%) and 39 of the eyes (85%) showed an improvement of at least two Snellen lines. Best-corrected final vision was 20/40 in 18 (39%) eyes. No permanent complications specifically caused by the removal of the macular internal limiting membrane were detected; the minor hemorrhages and retinal edema seen in most eyes resolved spontaneously. Retinal detachment developed and was successfully treated in three eyes (7%). A meta-analysis on 1,654 eyes from published reports showed that internal limiting membrane maculorhexis appears to significantly (P <.0001) increase the anatomical and functional success rates in macular hole surgery. Internal limiting membrane removal is an important development in the evolving field of macular hole surgery. A randomized, prospective, multicenter clinical trial should be performed to determine which surgical technique is the most beneficial in patients with full-thickness macular holes.

                Author and article information

                S. Karger AG
                February 2008
                22 February 2008
                : 222
                : 2
                : 123-129
                aDepartment of Ophthalmology, Philipps University Marburg, Marburg, Germany; bRetina Department, Ophthalmology Service, Hospital Regional Sao Jose, Instituto de Olhos Florianopolis, Florianopolis, Brazil
                112630 Ophthalmologica 2008;222:123–129
                © 2008 S. Karger AG, Basel

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                Page count
                Tables: 3, References: 53, Pages: 7
                Original Paper


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