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PurposeTo assess the proportion of maculopathy detectable only on optical coherence tomography (OCT) versus slit lamp indirect ophthalmoscopy (SLIO) during cataract assessment.MethodsPopulation: Consecutive patients attending cataract assessments. Data collection: All patients underwent OCT and SLIO. SLIO findings were recorded before reviewing OCT. Scans were examined to compare with recorded SLIO findings. Primary outcome: analyse the proportion of eyes with maculopathy missed by SLIO. Secondary outcome: to assess the proportion of patients with maculopathy on OCT, the incidence of maculopathy in the fellow eye on OCT and proportion with cataracts too dense to allow SLIO or OCT.ResultsSix hundred twenty-six patients were enroled. Eighty (12.8%) had maculopathy detectable only on OCT which included: 26 (4.2%) epiretinal membrane (ERM), 25 (4%) dry age-related macular degeneration (AMD), 19 (3%) vitreomacular traction (VMT), 5 (0.8%) lamellar macular hole (LMH), 2 (0.3%) cystoid macular oedema (CMO) and 1 (0.2%) wet AMD. 166 (26.5%) had maculopathy on OCT, of which only 48 (7.7%) had known history of maculopathy. In fellow eyes, 29 (4.6%) had significant findings and 29 (4.6%) were unable to have SLIO or OCT due to dense cataract.ConclusionsA quarter of the patients had occult maculopathy. One-tenth of the occult maculopathy were missed without OCT, with ERM, dry AMD, VMT, LMH, CMO and wet AMD being the primary missed diagnosis. Less than 5% had occult maculopathy in fellow eye, and <5% had dense cataracts where neither SLIO nor OCT was not possible.

PurposeTo compare the anatomical and functional outcomes after primary idiopathic epiretinal membrane (ERM) peeling with or without internal limiting membrane (ILM) peeling.DesignA two-centre randomised, controlled clinical trial with 12 months of follow-up.MethodsOne hundred and two eyes of 102 patients were included in the analysis and were randomised into two groups (ILM peeling (P) and non-ILM peeling (NP) group). Inclusion criteria were: Idiopathic ERM confirmed on optical coherence tomography, age ≥18 years, binocular distortion, best-corrected visual acuity (BCVA) ≤90 ETDRS letters, intraocular pressure ≤23 mm Hg and informed consent. The primary outcome measure was the mean change in the ETDRS distance BCVA at 12 months' follow-up for each group.ResultsThe mean change in distance BCVA at 12 months was 0.30±0.24 logMAR (15 ETDRS letters) in the P group and 0.31±0.23 logMAR (14 ETDRS letters) in the NP group, a change that was not statistically significant (p=0.84). No statistically significant differences were observed when comparing the changes in distance BCVA, the changes in metamorphopsia (Amsler grid) and the changes in central retinal thickness between the two groups at any of the time points studied.ConclusionsOur analysis suggests that ILM peeling in idiopathic ERM surgery does not result in better visual improvement. The more frequent presence of an uninterrupted interdigitation zone in the P group did not result in a better functional outcome of our patients. No recurrent ERMs were noted in either group.

Background/aimsTo compare the visual outcome in early versus deferred surgery in patients with idiopathic epiretinal membrane (ERM) and good presenting visual acuity and mild symptoms.MethodsThis study is a randomised clinical trial. 53 eyes of 53 patients with symptomatic ERM and best-corrected visual acuity (BCVA) at presentation ≥65 early treatment diabetic retinopathy study (ETDRS) letters were randomised to immediate surgery (20 eyes) or to watchful waiting (33 eyes) for 1 year. Primary end-point was BCVA after 12 months. Secondary end-points were central macular thickness and the number of patients that crossed over from the watchful waiting arm to the surgery arm due to deteriorated symptoms.ResultsMean BCVA after 12 months in the watchful waiting group (81 letters) were not significantly different from patients undergoing immediate surgery (82.5 letters, p=0.647). During 1 year of follow-up, eight patients in the watchful waiting group (24%) crossed over to surgery and these patients gained a mean of 3.1 letters (SEM 1.38). Patients randomised to immediate surgery gained approximately one line. Watchful waiting patients who remained without surgery were stable. The visual acuity gain after surgery is slow and gradual until 9 months postoperatively. There were no serious complications such as retinal detachment or infectious endophthalmitis.ConclusionsVitrectomy for early symptomatic ERM is beneficial in preserving excellent vision. A watchful waiting approach with 1 year of follow-up is safe in the sense that this group does not lose five ETDRS letters in waiting. Deferral of surgery by regular monitoring of patients is a safe approach.Trial registration numbersH-C-2008-026 and NCT00902629.

Purpose: To evaluate the outcome of vitrectomy with multilayered inverted internal limiting membrane flap technique (ML-IILM) versus vitrectomy with standard ILM peeling for large macular holes in terms of visual acuity and anatomical closure. Methods: A hospital-based, prospective, randomized, interventional study was conducted during three calendar years with a total 150 eyes (75 in each group) in two groups-vitrectomy with ILM peeling (Group A) and vitrectomy with ML-IILM flap technique (Group B) after informed consent of study participants who met the inclusion criteria. Results: The mean minimum and maximum diameter of macular hole did not differ statistically in both the groups. Macular hole index had no significant difference between both groups Pre-operative visual acuity was not statistically significantly different between the two groups. During follow-up, best corrected visual acuity (BCVA) at 1 month, 3 months, 6 months, and 12 months was significantly better in Group B (0.12 ± 0.07 at 1 month, 0.14 ± 0.10 at 3 months, 0.18 ± 0.11 at 6 months, and 0.19 ± 0.12 at 12 months) compared to Group A (0.20 ± 0.11 at 1 month, 0.22 ± 0.13 at 3 months, 0.30 ± 0.12 at 6 months, and 0.31 ± 0.14 at 12 months) (P = 0.001 for each). Type 1 anatomical closure (flattening of cuff and opposition of edges of hole) was achieved in 78.66% (59/75) cases in Group A and 93.33% (70/75) cases in Group B (P 0.0016). Conclusion: Vitrectomy with multilayered inverted ILM flap technique had significantly higher anatomical closure and better visual outcome than vitrectomy with standard ILM peeling.

PurposeThe purpose of this study was to evaluate the effectiveness and safety of an intravitreal dexamethasone (DEX) implant for the treatment of macular edema (ME) following pars plana vitrectomy (PPV) and removal of the primary epiretinal membrane (ERM) and to assess the impact of the integrity of the ellipsoid zone (EZ) and disorganization of the retinal inner layer (DRIL) grade on visual and anatomical outcomes.MethodsForty-two pseudophakic patients who developed ME following PPV and removal of the primary stage 2–3 ERM were included. Patients were divided into two groups when ME was diagnosed via spectral domain optic coherence tomography (SD-OCT). In the DEX group (n = 22), DEX was implanted for the treatment of ME. In the control group (n = 20), only observation was conducted, without any treatment. The best-corrected visual acuity (BCVA) and macular thickness (MT) of the two groups were compared at baseline and 1, 6, and 12 months after DEX implantation. The effects of OCT parameters such as EZ integrity and DRIL grade were also evaluated in terms of decreases in MT and increases in VA in the treatment of ME with DEX implantation. Intraocular pressure (IOP), number of DEX implantations and adverse effects were also recorded.ResultsWhile a statistically significant increase in the mean BCVA was observed in the DEX group (p < 0.001 at months 1, 6, and 12, respectively), no such increase was detected in the control group (p = 0.169, p = 0.065, and p = 0.058 at months 1, 6 and 12, respectively) compared with the baseline. A statistically significant decrease in the mean MT was observed in the DEX group (p  < 0.001 at months 1, 6, and 12); however, no significant difference was observed in the control group (p  = 0.081, p  = 0.065, and p  = 0.054 at months 1, 6 and 12, respectively) compared with the baseline. Significant differences were found between the two groups in terms of the increase in BCVA (p  < 0.01) and decrease in MT (p  < 0.01) at all visits, with the outcomes being more favorable in the DEX group. A statistically significant relationship was found between the increase in VA and EZ integrity and DRIL grade in both groups. Ten patients (45.4%) received two injections of DEX during the follow-up. An increase in IOP was observed in five patients (22.7%) who were treated with topical antiglaucomatous drops. No significant side effects were observed.ConclusionDEX implantation was found to be effective and safe for the treatment of ME following PPV and primary ERM removal, although some eyes may require repeated injections to achieve visual and anatomical success. Additionally, a relationship was found between EZ integrity, DRIL grade and visual-anatomical outcomes.

Purpose: To evaluate retinal functional changes after idiopathic macular hole (MH) surgery using heavy brilliant blue G (hBBG) dye for internal limiting membrane (ILM) staining. Methods: Forty-four eyes with idiopathic MH were randomized into two groups - 24 eyes undergoing vitrectomy with ILM peeling using hBBG staining and 20 eyes without staining; anatomical and functional status (with microperimetry (MP)) at baseline and during postoperative follow-up were noted and compared. Results: All eyes had closure of MH postoperatively and overall baseline MP indices (average threshold, AT; foveal sensitivity, FS) improved significantly at 6 weeks and 6 months of follow-up. AT and FS showed significant improvement at 6 weeks and 6 months from baseline in both individual groups (P < 0.001). Intergroup comparison showed that there was no statistically significant difference in AT and FS values at any point of time (baseline, 6 weeks, 6 months) between staining and no-stain group. No eyes in our cohort had any unexplained visual loss. Conclusion: Functional parameters of macula improved significantly after successful MH surgery using hBBG for staining the ILM.

Background To evaluate the potential efficacy and safety of inner limiting membrane (ILM) staining with brilliant blue G (BBG) under air infusion. Methods 63 patients, treated by one surgeon with macular hole or idiopathic epiretinal membrane were evaluated prospectively. BBG was applied under air infusion in 38 patients (group 1), and injected into the vitreous cavity in 25 (group 2). Main outcome measures were the chromaticity difference between the stained ILM and the unstained underlying retina, anatomical–functional outcomes and complications of the surgery. Chromaticity difference was measured by an objective and quantitative analysis method to describe colour contrast strengths as they are perceived by the human eye. Anatomical and functional outcomes were assessed using optical coherence tomography (OCT), visual field analyses (VFA) and multifocal electroretinography (mfERG). Results CIELAB scores showed a significantly superior contrast for group 1 (16.72±2.36) than group 2 (10.34±1.29) (p<0.001). Visual acuity had increased in 28 eyes and remained stable in 10 eyes in group 1. In group 2, visual acuity had improved in 17 patients and remained unchanged in 8 patients. Based on postoperative OCT, anatomical success rate was 100%. During the follow-up period, mfERG and VFA demonstrated no case of BBG toxicity in either group. Cataract progression was the main postoperative complication (six eyes in group 1 and four eyes in group 2) and did not show a significant difference between the groups (p=0.45). Conclusions BBG under air infusion yields a significantly higher contrast staining and easy peeling of ILM associated with anatomical and functional improvement and no retinal toxicity after macular surgery.

Background/AimsTo report the prevalence of treatable complications (cystoid macular oedema, CME; epiretinal membrane, ERM and cataract) in patients with retinitis pigmentosa (RP).MethodsConsecutive patients with RP attending a tertiary eye clinic in 2012. Spectral domain-optical coherence tomography was used to determine presence of CME and ERM. Clinic records were reviewed to identify cataract and pseudophakia. Multivariable analyses adjusted for age, gender and other confounders.ResultsData are presented for 338 eyes from 169 patients. CME was present in 58.6% of patients and 50.9% of eyes and was bilateral in 73.7%. ERM, cataract and pseudophakia were present in 22.8%, 23.4% and 11.2% eyes, respectively. In multivariable analyses, CME was associated with younger age (OR 0.81, 95% CI 0.67 to 0.98) but not with gender. Patients with ERM and cataract/pseudophakia were less likely to also have CME (OR 0.19, 95% CI 0.09 to 0.40 and OR 0.37, 95% CI 0.16 to 0.84, respectively). CME was most prevalent in patients with autosomal-dominant inheritance (71.4%), followed by autosomal recessive/sporadic inheritance (58.9%) and least likely in persons with X linked inheritance (12.5%, p<0.001).ConclusionsThe prevalence of treatable RP complications is high and suggests it may be clinically beneficial to screen patients with RP to identify those who may benefit from current or future interventions.

Purpose To investigate the clinical characteristics, imaging features, and predictive factors for spontaneous separation in patients with idiopathic or secondary ERM. Methods The overall cohort was divided into two subgroups: idiopathic ERM (28 eyes, 56%) and secondary ERM (22 eyes, 44%). Electronic records and multimodal imaging were reviewed. Results Among the 50 eyes included in this study, the self-separation of ERM occurred over a mean duration of 28.1 ± 25.3 months (median: 25.4 months). Compared with the secondary ERM group, the idiopathic group had a shorter interval to separation (idiopathic vs. secondary, 23.4 vs. 34.1 months, respectively; P  = .01) and better vision at diagnosis (logMAR 0.094 vs. 0.224; P  = .009) and after separation (logMAR 0.097 vs. 0.188; P  = .01). Overall, in both subgroups, spontaneous ERM separation appeared to have been induced by posterior vitreous detachment (PVD) ( P  < .001). Multivariate analysis revealed that the self-separation interval (odds ratio [OR] 0.936) and IRF (OR 0.049) were significantly associated with complete ERM separation (all P  < .05). Additionally, secondary ERM (OR 15.224) and lower initial best-corrected visual acuity (OR 267.589) were significantly associated with improvements in vision after self-separation (all P  < .05). Conclusion The self-separation of ERM appears to be induced by PVD development in most eyes. Owing to the possibility of complete spontaneous separation, surgical membrane peeling may be delayed by up to 28 months in eyes without PVD, regardless of whether the cause is idiopathic or secondary. Patients with secondary ERM may experience favorable visual improvement after self-separation despite having poor vision at diagnosis and IRF on OCT. Key messages What is known • An epiretinal membrane (ERM), the most prevalent retinal disease in adults, is less understood regarding clinical factors and the accurate mechanism of spontaneous separation. What is new • The separation of ERM appears to be induced by PVD development in most eyes. • Favorable vision outcomes were associated with secondary ERMs and lower initial visual acuity. • Complete ERM separation was associated with a shorter self-resolution interval and the absence of intraretinal fluid (IRF) in OCT imaging.

PurposeTo evaluate clinical features and visual outcomes in macular pseudohole (MPH) and to investigate associations between visual acuity and optical coherence tomography (OCT) parameters in patients with MPH.MethodsWe retrospectively reviewed consecutive patients with MPH who underwent vitrectomy and were followed for at least 6 months after surgery. MPH was diagnosed based on spectral-domain OCT findings. Analysed factors included axial length, spherical equivalent, overlapping cases of epiretinal membrane foveoschisis (ERM-FS) and lamellar macular hole (LMH), presence of glaucoma, preoperative and postoperative best-corrected visual acuity (BCVA), presence of inner and outer retinal cysts, epiretinal proliferation (EP) and ellipsoid zone (EZ) disruption.ResultsThis study enrolled 76 eyes of 75 patients, with overlapping cases that included MPH+ERM FS (17 eyes), MPH+LMH (18 eyes) and MPH+ERM FS + LMH (3 eyes). BCVA significantly improved from 0.29±0.25 preoperatively to 0.06±0.17 postoperatively (p<0.001). Preoperative BCVA and the presence of EP exhibited significant associations with worse postoperative BCVA (p<0.0005 and p<0.05, respectively). Presence of EZ disruption at 3 and 6 months postoperatively was associated with worse postoperative BCVA (p<0.001 and p<0.01, respectively).ConclusionThere was significant improvement in patients with MPH after undergoing surgery. Current results suggest preoperative poor visual acuity, preoperative presence of EP and postoperative EZ disruption are negative prognostic factors for visual outcomes.