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Woo, Hong, and Jang: Recovery Course of Macular Structure after Macular Hole Surgery: Using a Spectral Domain Optical Coherence Tomography Image
Original Article

J Korean Ophthalmol Soc 2016;57(7):1109-1117.

Published online: 25 September 2016

DOI: https://doi.org/10.3341/jkos.2016.57.7.1109

Recovery Course of Macular Structure after Macular Hole Surgery: Using a Spectral Domain Optical Coherence Tomography Image

In Ho Woo, MD, Jun Gi Hong, MD, Ji Hye Jang, MD

Department of Ophthalmology, Daegu Fatima Hospital, Daegu, Korea

Address reprint requests to Ji Hye Jang, MD Department of Ophthalmology, Daegu Fatima Hospital, #99 Ayang-ro, Dong-gu, Daegu 41199, Korea Tel: 82-53-940-7140, Fax: 82-53-954-7417 E-mail: mjmom99@naver.com

Received 31 March 2016       Accepted 25 May 2016

Copyright © 2016 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To analyze the recovery course of foveal microstructures and evaluate the important structures for visual improvement after vitrectomy for full thickness macular hole (MH) using optical coherence tomography (OCT).

Methods

We retrospectively reviewed the medical records of 34 cases with idiopathic macular hole. We investigated the healing process of foveal microstructures and visual acuity pre- and post-operatively at 1, 3, 6, 12 months after surgery. We evaluated the integrity of four factors by OCT image: existence of MH (Hole, H1,3,6,12), recovery of outer nuclear layer (ONL, O1,3,6,12), recovery of external limiting membrane (ELM, E1,3,6,12), and recovery of inner segment-outer segment (IS/OS) line of the photoreceptor (Photoreceptor, P1,3,6,12). We compared the recovery course and visual acuity of the four groups based on postoperative 12 months.
Results: The mean observed period was 1.85 ± 2.59 months at recovery of ONL, 3.78 ± 3.83 months at recovery of ONL and ELM, and 7.40 ± 3.56 months at recovery of ONL, ELM and IS/OS line. A t postoperative 12 months, the best corrected visual acuity (BCVA) of Groups E and P were better than that of Groups H and O (p < 0.05). Except for group H, all groups had improved BCVA at postoperative 12 months compared to preoperative BCVA (p < 0.05).

Conclusions

Recovery sequences of foveal microstructures were ONL, ELM and IS/OS line after vitrectomy for idiopathic MH. The most important structures for visual acuity were restorations of both ELM and IS/OS line.

Keywords: Macular hole, Macular structure, Recovery course, Spectral domain optical coherent tomography

References

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Figure 1.
Size parameters of macular hole on spectral domain optical coherence tomography. (*) indicates a minimum diam-eter of macular hole, (**) indicates a base diameter of macular hole.
jkos-57-1109f1.tif
Figure 2.
Spectral domain optical coherence tomography (SD-OCT) serial images obtained from patients during 12 months fol-low-up period. (A-E) is a case of group H in 54-year-old female. OCT images showed preoperative state (A), postoperative 1 month (B), 3 months (C), 6 months (D), 12 months (E). SD-OCT images of Group H showed still exist of macular hole at postoperative 12 months (E). (F-J) is a case of group O in 54-year-old female. OCT images showed preoperative state (F), postoperative 1 month (G), 3 months (H), 6 months (I), 12 months (J). SD-OCT images of Group O showed that only outer nuclear layer was restored at postoperative 12 months (J). (K-O) is a case of group E in 54-year-old female. OCT images showed preoperative state (K), post-operative 1 month (L), 3 months (M), 6 months (N), 12 months (O). SD-OCT images of Group E showed that the outer nuclear layer and external limiting membrane were restored at postoperative 12 months (O). (P-T) is a case of group P in 54-year-old female. OCT images showed preoperative state (P), postoperative 1 month (Q), 3 months (R), 6 months (S), 12 months (T). SD-OCT images of Group P showed completely recovery of normal foveal architecture state at postoperative 12 months (T).
jkos-57-1109f2.tif
Figure 3.
Schematic drawing of the various macular hole healing process after surgery. Left images showed recovery in progress. Right top image showed failed processes and right middle and bottom images showed recovery stop. ELM = external limiting membrane; IS/OS = inner segment/outer segment of photoreceptor.
jkos-57-1109f3.tif
Figure 4.
Changes of foveal microstructures after macular hole surgery during follow up. Over the follow-up period (1, 3, 6, 12 months) after operation, foveal microstructures had been gradually restored. H1, H3, H6, H12 mean still a existence of macular hole (Hole) at the follow-up period. O1, O3, O6, O12 mean only recovery state of outer nuclear layer (ONL). E1, E3, E6, E12 mean recovery state of outer nuclear layer and external limiting membrane (ELM). P1, P3, P6, P12 mean recovery state of outer nuclear layer and external limiting membrane and inner segment-outer segment line of photoreceptor (photoreceptor). IS/OS = inner segment/outer segment of photoreceptor.
jkos-57-1109f4.tif
Figure 5.
Changes of foveal microstructures after macular hole surgery of each group that divided by based on the foveal micro-structure status at 12 months. Group H (A) was not changed during the follow-up period after operation. Group O (B) was changed gradually decreasing hole existent state but increasing recovery of outer nuclear layer. Group E (C) was changed gradually increasing recovery of external limiting membrane. Group P (D) was changed gradually increasing recovery of inner segment-outer segment line of photoreceptor. Hole = macular hole; ONL = outer nuclear layer; ELM = external limiting membrane; IS/OS = inner segment/outer segment of photoreceptor.
jkos-57-1109f5.tif
Table 1.
Comparison of visual acuity and period for each step during follow up periods (1, 3, 6, 12 months)
Variables Not recovery (Hole existent) (n = 26) ONL recovery (n = 41) ONL + ELM recovery (n = 41) ONL + ELM + IS/OS recovery (n = 28) * p-value
Postop BCVA (log MAR) 1.25 ± 0.45 0.87 ± 0.40 0.43 ± 0.46 0.29 ± 0.29 <0.001
Mean duration (months) – 1.94 ± 2.71 3.75 ± 3.75 7.40 ± 3.56  

Values are presented as mean ± SD unless otherwise indicated.

ONL = outer nuclear layer; ELM = external limiting membrane; IS/OS = inner segment/outer segment of photoreceptor; BCVA = best corrected visual acuity; log MAR = logarithm of the minimal angle resolution.

* Statistically significant differences (p-value < 0.05) in Kruskal-Wallis test, statistically significant differences (p-value < 0.008) in Mann-Whitney U-test by Bonferroni's method.

Table 2.
Comparative characteristics of preoperative state of the four groups group that divided by based on the foveal microstructure status at 12 months
Variables Group H (n = 5) Group O (n = 6) Group E (n = 8) Group P (n = 15) * p-value
Age (years) 64.8 ± 14.95 68.5 ± 13.39 62.37 ± 5.04 64.33 ± 7.59  
Male:female 1:4 3:3 2:6 3:12  
Preop BCVA (log MAR) 1.30 ± 0.36 1.02 ± 0.40 0.86 ± 0.35 0.91 ± 0.37 0.264
MH size          
   Base diameter (μ m) 1,258.2 ± 437.81 988.16 ± 272.70 889.62 ± 323.52 555.86 ± 293.36 0.003
   Minimum diameter (μ m) 760 ± 217.03 516.16 ± 199.62 473.37 ± 179.55 286.53 ± 203.18 0.004
Preoprative lens state          
   Phakia (%) 4 (80) 2 (33) 8 (100) 14 (93)  
   Pseudophakia (%) 1 (20) 4 (67) 0 (0) 1 (6.6)  
Axial length (mm) 24.56 ± 3.81 24.69 ± 3.38 22.72 ± 0.90 23.50 ± 0.86 0.187

Values are presented as mean ± SD unless otherwise indicated.

Preop = preoperative; BCVA = best corrected visual acuity; logMAR = logarithm of the minimal angle resolution; MH = macular hole.

* Statistically significant differences (p-value < 0.05) in Kruskal-Wallis test, Statistically significant differences (p-value < 0.008) in Mann-Whitney U-test by Bonferroni's method.

Table 3.
Comparative characteristics of postoprative state and change of visual acuity after the surgery of the four groups that divided by based on the foveal microstructure status at 12 months
Variables Group H (n = 5) Group O (n = 6) Group E (n = 8) Group P (n = 15) * p-value
Postop BCVA (log MAR)          
   POD 1 month 1.42 ± 0.43 1.12 ± 0.45 1.35 ± 0.45 0.61 ± 0.50 0.060
   POD 3 months 1.22 ± 0.45 1.07 ± 0.32 0.60 ± 0.30 0.43 ± 0.14 0.002
   POD 6 months 1.14 ± 0.54 0.92 ± 0.34 0.39 ± 0.28 0.32 ± 0.34 0.003
   POD 12 months 1.20 ± 0.59 0.79 ± 0.27† 0.26 ± 0.19† 0.30 ± 0.35† 0.001
Combined cataract surgery (%) 4 (80) 2 (33) 8 (100) 13 (87)  
Complication          
   ERM (%) 0 0 0 2 (13.3)  

Values are presented as mean ± SD unless otherwise indicated.

Postop = postoperative; BCVA = best corrected visual acuity; log MAR = logarithm of the minimal angle resolution; POD = postoperative day; ERM = epiretinal membrane.

* Statistically significant differences (p-value < 0.05) in Kruskal-Wallis test, Statistically significant differences (p-value < 0.008) in Ma-nn-Whitney U-test by Bonferroni's method

† Statistically significant differences (p-value < 0.05) in Wilcoxon signed-rank test (preoperative BCVA vs. POD 12 months BCVA).

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