Transkonjunktivale nahtlose Pars-plana-Vitrektomie und Brilliant-Blau-G-assistiertes ILM-Peeling bei Patienten mit Makulaforamen

Zusammenfassung

Hintergrund: Ziel der Studie war es, die Visusergebnisse und den anatomischen Erfolg mittels hochauflösendem OCT nach transkonjunktivaler nahtloser 23-Gauge Pars-plana-Vitrektomie und Brilliant-Peel-(BP-)assistiertem ILM-Peeling bei Patienten mit Makulaforamen zu erfassen.

Methode: In einer retrospektiven Studie bei 41 Augen von 41 konsekutiven Patienten mit Makulaforamen wurde eine standardisierte 23-G Pars-plana-Vitrektomie mit BP-assistiertem ILM-Peeling und Gastamponade durchgeführt. Bei allen Patienten wurde präoperativ der bestkorrigierte Visus bestimmt und mittels hochauflösendem Spectral Domain OCT (SD-OCT; Spectralis; Heidelberg Engineering) der maximale Durchmesser, die Basis und die Höhe des Makulaforamens, sowie intraretinale Veränderungen erfasst. Postoperativ wurde der bestkorrigierte Visus nach 1, 3, and 6 Monaten und die Verschlussrate bestimmt. Daneben wurde die mikrostrukturelle Integrität des Photorezeptor-Inner/Outer-Segments (IS/OS) im SD-OCT erfasst und mit dem Visusergebnis nach Makulaforamenchirurgie korreliert.

Ergebnisse: Der mittlere Ausgangsvisus betrug 0,2 (0,77 logMAR). Er verbesserte sich nach 1, 3 und 6 Monaten signifikant auf 0,4 (0,46 logMAR), 0,44 (0,41 logMAR) und 0,58 (0,28 logMAR). Die Verschlussrate der Makulaforamina betrug 95,1 %. Die Integrität des IS/OS-Segments wurde semiquantitativ bestimmt und zeigte eine positive Korrelation zum bestkorrigierten Visus.

Schlussfolgerung: Die transkonjunktivale nahtlose Pars-plana-Vitrektomie mit Brilliant-Peel- (BP-)assistiertem ILM-Peeling bei Patienten mit Makulaforamen ist eine sehr sichere Operationsmethode, die zu guten funktionellen und anatomischen Ergebnissen führt. Die mikrostrukturelle Integrität des IS/OS-Segments der Netzhaut lässt sich mittels SD-OCT gut beurteilen. Sie ist ein wichtiger prädiktiver Parameter für die Visusentwicklung nach Makulaforamenchirurgie.

Abstract

Purpose: The aim of this study was to evaluate the visual and anatomic outcome after 23-gauge transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes.

Methods: In a consecutive retrospective study in 41 eyes of 41 patients with macular holes a standardised 23-G transconjunctival sutureless pars plana vitrectomy with ILM-peeling and gas tamponade was performed. All patients underwent preoperative measurements of visual acuity (VA), the maximum hole diameter, basis, height, and intraretinal changes using high resolution optical coherence tomography (SD-OCT; Spectralis; Heidelberg Engineering). Main outcome measures included visual acuity 1, 3, and 6 months after surgery and the closure rate. We also evaluated photoreceptor inner/outer segment (IS/OS) integrity as seen in SD-OCT for correlation with visual outcomes after macular hole surgery.

Results: At baseline the mean best corrected visual acuity (BCVA) was 0.2 (0.77 logMAR). BCVA improved significantly to 0.4 (0.46 logMAR) after 1 month, to 0.44 (0.41 logMAR) after 3 months and to 0.58 (0.28 logMAR) after 6 months, respectively. A closure rate of 95.1 % was achieved. The morphological parameter photoreceptor IS/OS integrity was measured semiquantitatively and showed a positive correlation to BCVA.

Conclusion: Transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes is a very safe procedure and leads to good functional and anatomic results. The integrity of the IS/OS segment is a good predictive parameter for BCVA improvement after macular hole surgery.

Schlüsselwörter

Retina - Makulaforamenchirurgie - transkonjunktivale nahtlose Pars-plana-Vitrektomie - Photorezeptor Inner/Outer Segment (IS/OS) - Spectral Domain OCT

Key words

retina - macular hole surgery - transconjunctival sutureless pars plana vitrectomy - photoreceptor inner/outer segment (IS/OS) - spectral domain OCT

• Literatur

• 1 Machemer R, Parel JM, Buettner H. A new concept for vitreous surgery. I. Instrumentation. Am J Ophthalmol 1972; 73: 1-7
• 2 Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991; 09: 654-659
• 3 Tognetto D, Grandin R, Sanguinetti G et al. Macular Hole Surgery Study Group. Internal limiting membrane removal during macular hole surgery: results of a multicenter retrospective study. Ophthalmology 2006; 113: 1401-1410
• 4 Bainbridge J, Herbert E, Gregor Z. Macular holes: vitreoretinal relationships and surgical approaches. Eye (Lond) 2008; 22: 1301-1309
• 5 Christensen UC, Krøyer K, Sander B et al. Value of internal limiting membrane peeling in surgery for idiopathic macular hole stage 2 and 3: a randomised clinical trial. Br J Ophthalmol 2009; 93: 1005-1015
• 6 Abdelkader E, Lois N. Internal limiting membrane peeling in vitreo-retinal surgery. Surv Ophthalmol 2008; 53: 368-396
• 7 Ezra E. Idiopathic full thickness macular hole: natural history and pathogenesis. Br J Ophthalmol 2001; 85: 102-108
• 8 Sanisoglu H, Sevim MS, Aktas B et al. Outcomes of 23-gauge pars plana vitrectomy and internal limiting membrane peeling with brilliant blue in macular hole. Clin Ophthalmol 2011; 5: 1177-1183
• 9 Smiddy WE, Flynn jr. HW. Pathogenesis of macular holes and therapeutic implications. Am J Ophthalmol 2004; 137: 525-537
• 10 Dithmar S. Makulaforamen. Überblick und aktuelle chirurgische Konzepte. Ophthalmologe 2005; 102: 191-206
• 11 Yooh HS, Brooks jr. HL, Capone jr. A et al. Ultrastructural features of tissue removed during idiopathic macular hole surgery. Am J Ophthalmol 1996; 122: 67-75
• 12 Haritoglou C, Kampik A. Färbetechniken in der Makulachirurgie. Ophthalmologe 2006; 103: 927-934
• 13 Michalewska Z, Michalewski J, Cisiecki S et al. Correlation between foveal structure and visual outcome following macular hole surgery: a spectral optical coherence tomography study. Graefes Arch Clin Exp Ophthalmol 2008; 246: 823-830
• 14 Inoue M, Watanabe Y, Arakawa A et al. Spectral-domain optical coherence tomography images of inner/outer segment junctions and macular hole surgery outcomes. Graefes Arch Clin Exp Ophthalmol 2009; 247: 325-330
• 15 Wakabayashi T, Fujiwara M, Sakaguchi H et al. Foveal microstructure and visual acuity in surgically closed macular holes: spectral-domain optical coherence tomographic analysis. Ophthalmology 2010; 117: 1815-1824
• 16 Sano M, Shimoda Y, Hashimoto H et al. Restored photoreceptor outer segment and visual recovery after macular hole closure. Am J Ophthalmol 2009; 147: 313-318.e1
• 17 Shimozono M, Oishi A, Hata M et al. Restoration of the photoreceptor outer segment and visual outcomes after macular hole closure: spectral-domain optical coherence tomography analysis. Graefes Arch Clin Exp Ophthalmol 2011; 249: 1469-1476
• 18 Itoh Y, Inoue M, Rii T et al. Significant correlation between visual acuity and recovery of foveal cone microstructures after macular hole surgery. Am J Ophthalmol 2012; 153: 111-119.e1
• 19 Baba T, Yamamoto S, Arai M et al. Correlation of visual recovery and presence of photoreceptor inner/outer segment junction in optical coherence images after successful macular hole repair. Retina 2008; 28: 453-458
• 20 Chang LK, Koizumi H, Spaide RF. Disruption of the photoreceptor inner segment-outer segment junction in eyes with macular holes. Retina 2008; 28: 969-975
• 21 Christensen UC, Krøyer K, Sander B et al. Prognostic significance of delayed structural recovery after macular hole surgery. Ophthalmology 2009; 116: 2430-2436
• 22 Oh J, Smiddy WE, Flynn jr. HW et al. Photoreceptor inner/outer segment defect imaging by spectral domain OCT and visual prognosis after macular hole surgery. Invest Ophthalmol Vis Sci 2010; 51: 1651-1658
• 23 Shimoda Y, Sano M, Hashimoto H et al. Restoration of photoreceptor outer segment after vitrectomy for retinal detachment. Am J Ophthalmol 2010; 149: 284-290
• 24 Hikichi T, Kosaka S, Takami K et al. 23- and 20-gauge vitrectomy with air tamponade with combined phacoemulsification for idiopathic macular hole: a single-surgeon study. Am J Ophthalmol 2011; 152: 114-121.e1
• 25 Recchia FM, Scott IU, Brown GC et al. Small-gauge pars plana vitrectomy: a report by the American Academy of Ophthalmology. Ophthalmology 2010; 117: 1851-1857
• 26 Henrich PB, Priglinger SG, Haritoglou C et al. Quantification of Contrast Recognizability during Brilliant Blue G- and Indocyanine Green-Assisted Chromovitrectomy. Invest Ophthalmol Vis Sci 2011; 52: 4345-4349
• 27 Nakamura Y, Kondo M, Asami T et al. Comparison of macular hole surgery without internal limiting membrane peeling to eyes with internal limiting membrane peeling with and without indocyanine green staining: three-year follow-up. Ophthalmic Res 2009; 41: 136-141
• 28 Kwok AK, Lai TY, Yuen KS et al. Macular hole surgery with or without indocyanine green stained internal limiting membrane peeling. Clin Experiment Ophthalmol 2003; 31: 470-475
• 29 Farah ME, Maia M, Rodrigues EB. Dyes in ocular surgery: principles for use in chromovitrectomy. Am J Ophthalmol 2009; 148: 332-340
• 30 Rodrigues EB, Meyer CH. Meta-analysis of chromovitrectomy with indocyanine green in macular hole surgery. Ophthalmologica 2008; 222: 123-129
• 31 Enaida H, Sakamoto T, Hisatomi T et al. Morphological and functional damage of the retina caused by intravitreous indocyanine green in rat eyes. Graefes Arch Clin Exp Ophthalmol 2002; 240: 209-213
• 32 Ueno A, Hisatomi T, Enaida H et al. Biocompatibility of brilliant blue G in a rat model of subretinal injection. Retina 2007; 27: 499-504
• 33 Enaida H, Hisatomi T, Hata Y et al. Brilliant blue G selectively stains the internal limiting membrane/brilliant blue G-assisted membrane peeling. Retina 2006; 26: 631-636
• 34 Kwok AKh, Lai TY, Yuen KS. Epiretinal membrane surgery with or without internal limiting membrane peeling. Clin Experiment Ophthalmol 2005; 33: 379-385
• 35 Shimada H, Nakashizuka H, Hattori T et al. Double staining with brilliant blue G and double peeling for epiretinal membranes. Ophthalmology 2009; 116: 1370-1376