- Email: [email protected]
Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2
Journal Pre-proof Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2 Alexander G. Miller, Rohit Chandra, Charles Pophal, Jerome P. Schartman, Joan H. Hornik, David G. Miller PII:
S2468-6530(19)30651-7
DOI:
https://doi.org/10.1016/j.oret.2019.11.017
Reference:
ORET 668
To appear in:
Ophthalmology Retina
Received Date: 10 September 2019 Revised Date:
7 November 2019
Accepted Date: 22 November 2019
Please cite this article as: Miller A.G., Chandra R., Pophal C., Schartman J.P., Hornik J.H. & Miller D.G., Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2, Ophthalmology Retina (2019), doi: https://doi.org/10.1016/j.oret.2019.11.017. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © YEAR Published by Elsevier Inc. on behalf of American Academy of Ophthalmology
Macular hole surgery in macular telangiectasia type 2
Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2 Alexander G. Miller1,2 Rohit Chandra 1,2 Charles Pophal 1,2 Jerome P. Schartman1 Joan H. Hornik1 David G. Miller1 1
Retina Associates of Cleveland, Cleveland, OH, United States; 2Northeast Ohio Medical University, Rootstown, OH, United States; Corresponding author: David G. Miller, MD Retina Associates of Cleveland 3401 Enterprise Parkway, Suite 300 Cleveland, Ohio 44122 Phone 216-831-5700 Email [email protected] This material was presented in part at the 2019 meeting of the Association for Research in Vision and Ophthalmology. Financial support: None No conflicting relationship exists for any author. Running head: Macular hole surgery in macular telangiectasia type 2 Address for reprints: Retina Associates of Cleveland, 3401 Enterprise Parkway, Suite 300, Cleveland, Ohio 44122
1
Macular hole surgery in macular telangiectasia type 2 1
Abstract
2 3
Objective: To compare visual acuity (VA) and optical coherence tomography (OCT) outcomes in
4
idiopathic macular telangiectasia Type 2 (IMT Type 2) patients who had pars plana vitrectomy
5
(PPV) surgery for full-thickness macular holes (FTMH) versus those who elected to manage
6
medically (MM) without surgery.
7
Design: Comparative retrospective case series.
8
Subjects: Patients with IMT Type 2 and FTMH.
9
Methods: We reviewed records within an 11-year period and collected data on visual acuity
10
(VA), optical coherence tomography (OCT) changes, development of choroidal
11
neovascularization (CNV), and length of follow-up. VA measurements were standardized from
12
Snellen to LogMAR units for statistical analysis. Two-sample t-tests were used to analyze VA
13
data. OCT changes were assessed by a single masked retinal specialist.
14
Results: There were 12 eyes in the PPV group and 26 eyes in the MM group. There was no
15
statistically significant VA improvement in either group between initial VA recording and last
16
follow-up. The PPV group had no significant change in VA between the pre-operative visit and
17
visits at 3 or 12 months. OCT scans improved by 1 step in 10 PPV patients. None of the MM
18
patients had OCT improvement. CNV developed in 1 eye in the PPV group and 5 eyes in the MM
19
group.
20
Conclusions: There was no significant change in visual acuity in patients who opted to have PPV
21
to treat their IMT Type 2 and FTMH compared with those who did not have surgery. OCT scans
22
improved by qualitative judgment in patients who had surgery compared with those who opted
23
for medical management.
2
Macular hole surgery in macular telangiectasia type 2 24
Idiopathic macular telangiectasia type 2 (IMT Type 2) is a disease that can affect both eyes
25
with aberrant blood vessel growth and neurodegeneration of the macula.1 It is estimated that
26
almost 0.1% of people in certain populations have this disease.2 There currently is no definitive
27
treatment for IMT Type 2.
28
Full-thickness macular holes (FTMH) are a prominent cause of vision loss. The standard of
29
care for FTMH is pars plana vitrectomy (PPV) to help restore the anatomy and visual acuity
30
(VA). IMT Type 2 is an infrequent cause or association of FTMH.3,4 There have been few reports
31
evaluating outcomes with PPV versus observation of these patients. We performed this study
32
to compare visual acuity (VA) and optical coherence tomography (OCT) outcomes in IMT Type 2
33
patients who had surgery for FTMH (PPV) versus those who elected to manage medically (MM)
34
without surgery.
35
Methods
36
Sterling Internal Review Board (IRB) determined that the study was exempt from IRB
37
review. Using the practice management software, we retrospectively gathered all patient
38
records with an International Statistical Classification of Diseases and Related Health Problems
39
(ICD 9 and 10) of FTMH and IMT Type 2 over an 11-year period (January 2007‒December 2018)
40
in a single retinal specialty practice comprised of 8 – 13 retinal physicians over that time period.
41
The charts were reviewed for consistency of the diagnosis of IMT Type 2 and FTMH by
42
reviewing the color fundus photos, OCT, and fluorescein angiogram. Patients with the following
43
were included: coincident diseases that did not affect visual acuity (VA), intraoperative
44
complications such as retinal tears, and postoperative complications. Data collected included
3
Macular hole surgery in macular telangiectasia type 2 45
age, sex, surgeon in PPV cases, VA, OCT findings, development of choroidal neovascularization
46
(CNV), and length of follow-up.
47
VA data were collected for surgical patients preoperatively, at 3 months and 12 months
48
postoperatively, and at most recent follow-up. VA data were collected for MM patients at initial
49
diagnosis of concurrent FTMH and IMT type 2 and most recent follow-up. VA measurements
50
were standardized from distance habitual correction with pinhole Snellen to LogMAR units for
51
statistical analysis. Change in LogMAR units from initial diagnosis to most-recent follow up was
52
compared between the 2 groups using 2-sample t-tests. 2-sample t-tests were also conducted
53
to analyze for change in VA from initial diagnosis to milestone visits at 3 and 12 months in PPV
54
group.
55
The same masked retinal specialist graded OCT scans at first diagnosis and most recent
56
follow-up on a 3-point scale, where 1 was typical-appearing open FTMH, 2 was flat edges of
57
FTMH, and 3 was a closed FTMH with opposed edges. The change in grades on the OCT scans
58
between initial diagnosis and last follow-up were tabulated.
59
CNV development was also recorded.
60
Results
61
Patient demographics are shown in Table 1. Four different retinal surgeons performed the
62
PPVs with similar techniques, with one surgeon performing 8 of the cases, and the remaining 3
63
surgeons performing the other 4 cases.
64
There was no statistically significant VA improvement in either group between initial VA
65
recording and last follow-up. In addition, there was no significant change in VA for the PPV
66
group between pre-op recording and visits at 3 or 12 months.
4
Macular hole surgery in macular telangiectasia type 2 67
OCTs were available to read in all patients at initial data point and last follow-up. The OCT
68
scans improved by 1 step (using the 3-point grading system) in 10 PPV patients; there was no
69
improvement in the 2 remaining patients (Figure 1). The OCT scans of 4 patients showed closed
70
or opposed edges (grade 3) at last follow up. None of the MM patients showed any
71
improvement on OCT grading (Figure 2).
72
CNV developed in 1 of 12 eyes in the PPV group and 5of 26 eyes in the MM group. In the
73
PPV group, post-op complications were seen in 2 patients: 1 repeat macular hole surgery for
74
enlarging FTMH following initial surgery and 1 iridotomy for acute angle closure glaucoma.
75
Discussion
76
The prognosis for stage 2-4 FTMH is poor, with central visual acuity deteriorating to the
77
range of 20/100 to 20/400 over time.5 The Vitrectomy for Macular Holes Study Group in the
78
1990s reported that, compared with observation, surgery for stage 2 holes resulted in a
79
significantly lower incidence of hole enlargement; however, there was no significant difference
80
in ETDRS visual acuity measurements.6 The group’s study of stage 3 and stage 4 macular holes
81
found a significant benefit in the rate of hole closure and a marginally significant benefit in
82
ETDRS VA in the surgery group.7 Since those reports, advances in surgical techniques and
83
instrumentation have led to reported rates of hole closure rates of 91% to 98% and median
84
postoperative VA of approximately 20/40.5
85
There are few reports in the literature of FTMH in patients with IMT Type 2 and even
86
fewer of surgical intervention in such patients. 3,4,8-13 Previous publications have only compared
87
surgery as a treatment modality between patients with IMT Type 2 and FTMH versus those with
88
FTMH only or only reported outcomes of surgery for these patients without a comparison
5
Macular hole surgery in macular telangiectasia type 2 89
group of no surgery.4,6 In this study, there does not appear to be any advantage to surgery in
90
patients with FTMH associated with IMT Type 2. Even though the OCT did show some
91
anatomical improvement in most patients who underwent surgery, there was no accompanying
92
VA improvement. Certainly these patients are quite dissimilar to typical FTMH patients, and the
93
accompanying IMT Type 2 is likely limiting the improvement in VA and OCT anatomical results.
94
One can hypothesize that since IMT Type 2 pathophysiology in creating a macular hole is very
95
dissimilar to typical FTMH created by abnormal vitreoretinal traction, the results of surgery
96
would also be different. In IMT Type 2, there is loss of the ellipsoid zone, development and
97
coalescing of cystic cavities, and ultimately a dissolution of the neurosensory retina.4, 13 While
98
the hole maybe closed with surgery in patients with IMT Type 2, there is not a regeneration of
99
the neurosensory retina, which results in lack of improvement in visual acuity. In contrast for
100
FTMH, the neurosensory retinal tissue is still present, and surgical repair places the tissue back
101
into a normal alignment with resultant significant improvement in visual acuity. Due to cost of
102
surgery and risk of surgical complications, patients FTMH associated with IMT Type 2 may
103
benefit more with observation than surgical intervention.
104
This study is limited by several weaknesses including that it was a retrospective study in
105
only one private practice, follow-up was variable, and the small patient population. Further
106
randomized prospective studies could be more definitive in conclusion.
6
Macular hole surgery in macular telangiectasia type 2 107
References
108
1. Charbel Issa PS, Gillies MC, Chew EY, et al. Macular telangiectasia Type 2. Prog Retin Eye Res.
109
2013;34:49-77.
110
2. Klein R, Blodi BA, Meuer SM, Myers CE, Chew EY, Klein BE. The prevalence of macular
111
telangiectasia Type 2 in the Beaver Dam Eye Study. Am J Ophthalmol. 2010;150:55-62.
112
3. Charbel Issa P, Scholl HP, Gaudric A, et al. Macular full-thickness and lamellar holes in
113
association with type 2 idiopathic macular telangiectasia. Eye (Lond). 2009;23:435-441.
114
4. Karth PA, Raja SC, Brown DM, Kim JE. Outcomes of macular hole surgeries for macular
115
telangiectasia type 2. Retina. 2014;34:907-915.
116
5. American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern®
117
Guidelines. Idiopathic Macular Hole. San Francisco, CA: American Academy of Ophthalmology;
118
2017. Available at www.aao.org/ppp. Accessed 15 August 2019.
119
6. Kim JW, Freeman WR, Azen SP, et al, Vitrectomy for Macular Hole Study Group. Prospective
120
randomized trial of vitrectomy or observation for stage 2 macular holes. Am J Ophthalmol
121
1996;121:605-614.
122
7. Freeman WR, Azen SP, Kim JW, et al, The Vitrectomy for Treatment of Macular Hole Study
123
Group. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes: results of a
124
multicentered randomized clinical trial. Arch Ophthalmol. 1997;115:11-21.
125
8. Jaycock PD, Thomas D, Zakir R, Laidlaw DA. Retinal telangiectasia in association with macular
126
hole formation. Eye (Lond). 2004;18:342-343.
127
9. Koizumi H, Slakter JS, Spaide RF. Full-thickness macular hole formation in idiopathic
128
parafoveal telangiectasis. Retina. 2007;27:473-476.
7
Macular hole surgery in macular telangiectasia type 2 129
10. Olson JL, Mandava N. Macular hole formation associated with idiopathic parafoveal
130
telangiectasia. Graefes Arch Clin Exp Ophthalmol. 2006;244:411-412
131
11. Rishi P, Kothari AR. Parafoveal telangiectasia (PFT) has been associated with changes in
132
macular architecture and macular holes (lamellar and full thickness). Retina. 2008;28:184-185.
133
12. Gregori N, Flynn HW Jr. Surgery for full-thickness macular hole in patients with idiopathic
134
macular telangiectasia type 2. Ophthalmic Surg Lasers Imaging. 2010;41 Online:1-4.
135
13. Shukla D. Evolution and management of macular hole secondary to type 2 idiopathic
136
macular telangiectasia . Eye (Lond). 2011;25:532-533.
137
8
Macular hole surgery in macular telangiectasia type 2 138
Figure legends
139 140
Figure 1a. 71-year-old male in the PPV group presented with VA of 20/100 in right eye with
141
macular hole and IMT Type 2. OCT graded as open edges (1).
142
Figure 1 b. Last follow up was 86 months post PPV. VA was 20/100. OCT showed 1- step
143
improvement to flat edges (2) but also highly irregular retinal pigment epithelium (RPE)
144
changes.
145
Figure 2a. 61-year-old female in the MM group presented with IMT Type 2 and macular hole in
146
left eye. VA was 20/200. OCT has open edges, or grade 1.
147
Figure 2b. Last follow-up was 49 months later. VA was 20/80 with persistent macular hole. OCT
148
remained graded as open edges (1) with no change.
9
Macular hole surgery in macular telangiectasia type 2
Table 1. Patient demographics Mean age (years)
Males
Females
Mean follow-up (months)
PPV
71 +/- 10
4
8
44 +/- 31
MM
69 +/- 10
16
10
22 +/- 15
PPV = pars plana vitrectomy group MM = medical management group
Macular hole surgery in macular telangiectasia type 2 Table 2. Mean visual acuity, PPV group
Snellen
LogMAR
P (LogMAR)
Pre-op
20/114
0.756 +/- 0.332
3 months post-op
20/113
+0.751+/- 0.332
0.717
12 months post-op
20/94
+0.670 +/- 0.298
0.546
Macular hole surgery in macular telangiectasia type 2
Table 3. VA change from diagnosis to last visit Initial
Last
Change
PPV LogMAR VA
+0.756 +/- 0.332
+0.732 +/- 0.236
-0.013 +/- 0.2
MM LogMAR VA
+0.481 +/- 0.345
+0.477 +/-0.321
+0.004 +/- 0.2
P (PPV vs MM)
0.830
S2468-6530(19)30651-7
DOI:
https://doi.org/10.1016/j.oret.2019.11.017
Reference:
ORET 668
To appear in:
Ophthalmology Retina
Received Date: 10 September 2019 Revised Date:
7 November 2019
Accepted Date: 22 November 2019
Please cite this article as: Miller A.G., Chandra R., Pophal C., Schartman J.P., Hornik J.H. & Miller D.G., Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2, Ophthalmology Retina (2019), doi: https://doi.org/10.1016/j.oret.2019.11.017. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © YEAR Published by Elsevier Inc. on behalf of American Academy of Ophthalmology
Macular hole surgery in macular telangiectasia type 2
Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2 Alexander G. Miller1,2 Rohit Chandra 1,2 Charles Pophal 1,2 Jerome P. Schartman1 Joan H. Hornik1 David G. Miller1 1
Retina Associates of Cleveland, Cleveland, OH, United States; 2Northeast Ohio Medical University, Rootstown, OH, United States; Corresponding author: David G. Miller, MD Retina Associates of Cleveland 3401 Enterprise Parkway, Suite 300 Cleveland, Ohio 44122 Phone 216-831-5700 Email [email protected] This material was presented in part at the 2019 meeting of the Association for Research in Vision and Ophthalmology. Financial support: None No conflicting relationship exists for any author. Running head: Macular hole surgery in macular telangiectasia type 2 Address for reprints: Retina Associates of Cleveland, 3401 Enterprise Parkway, Suite 300, Cleveland, Ohio 44122
1
Macular hole surgery in macular telangiectasia type 2 1
Abstract
2 3
Objective: To compare visual acuity (VA) and optical coherence tomography (OCT) outcomes in
4
idiopathic macular telangiectasia Type 2 (IMT Type 2) patients who had pars plana vitrectomy
5
(PPV) surgery for full-thickness macular holes (FTMH) versus those who elected to manage
6
medically (MM) without surgery.
7
Design: Comparative retrospective case series.
8
Subjects: Patients with IMT Type 2 and FTMH.
9
Methods: We reviewed records within an 11-year period and collected data on visual acuity
10
(VA), optical coherence tomography (OCT) changes, development of choroidal
11
neovascularization (CNV), and length of follow-up. VA measurements were standardized from
12
Snellen to LogMAR units for statistical analysis. Two-sample t-tests were used to analyze VA
13
data. OCT changes were assessed by a single masked retinal specialist.
14
Results: There were 12 eyes in the PPV group and 26 eyes in the MM group. There was no
15
statistically significant VA improvement in either group between initial VA recording and last
16
follow-up. The PPV group had no significant change in VA between the pre-operative visit and
17
visits at 3 or 12 months. OCT scans improved by 1 step in 10 PPV patients. None of the MM
18
patients had OCT improvement. CNV developed in 1 eye in the PPV group and 5 eyes in the MM
19
group.
20
Conclusions: There was no significant change in visual acuity in patients who opted to have PPV
21
to treat their IMT Type 2 and FTMH compared with those who did not have surgery. OCT scans
22
improved by qualitative judgment in patients who had surgery compared with those who opted
23
for medical management.
2
Macular hole surgery in macular telangiectasia type 2 24
Idiopathic macular telangiectasia type 2 (IMT Type 2) is a disease that can affect both eyes
25
with aberrant blood vessel growth and neurodegeneration of the macula.1 It is estimated that
26
almost 0.1% of people in certain populations have this disease.2 There currently is no definitive
27
treatment for IMT Type 2.
28
Full-thickness macular holes (FTMH) are a prominent cause of vision loss. The standard of
29
care for FTMH is pars plana vitrectomy (PPV) to help restore the anatomy and visual acuity
30
(VA). IMT Type 2 is an infrequent cause or association of FTMH.3,4 There have been few reports
31
evaluating outcomes with PPV versus observation of these patients. We performed this study
32
to compare visual acuity (VA) and optical coherence tomography (OCT) outcomes in IMT Type 2
33
patients who had surgery for FTMH (PPV) versus those who elected to manage medically (MM)
34
without surgery.
35
Methods
36
Sterling Internal Review Board (IRB) determined that the study was exempt from IRB
37
review. Using the practice management software, we retrospectively gathered all patient
38
records with an International Statistical Classification of Diseases and Related Health Problems
39
(ICD 9 and 10) of FTMH and IMT Type 2 over an 11-year period (January 2007‒December 2018)
40
in a single retinal specialty practice comprised of 8 – 13 retinal physicians over that time period.
41
The charts were reviewed for consistency of the diagnosis of IMT Type 2 and FTMH by
42
reviewing the color fundus photos, OCT, and fluorescein angiogram. Patients with the following
43
were included: coincident diseases that did not affect visual acuity (VA), intraoperative
44
complications such as retinal tears, and postoperative complications. Data collected included
3
Macular hole surgery in macular telangiectasia type 2 45
age, sex, surgeon in PPV cases, VA, OCT findings, development of choroidal neovascularization
46
(CNV), and length of follow-up.
47
VA data were collected for surgical patients preoperatively, at 3 months and 12 months
48
postoperatively, and at most recent follow-up. VA data were collected for MM patients at initial
49
diagnosis of concurrent FTMH and IMT type 2 and most recent follow-up. VA measurements
50
were standardized from distance habitual correction with pinhole Snellen to LogMAR units for
51
statistical analysis. Change in LogMAR units from initial diagnosis to most-recent follow up was
52
compared between the 2 groups using 2-sample t-tests. 2-sample t-tests were also conducted
53
to analyze for change in VA from initial diagnosis to milestone visits at 3 and 12 months in PPV
54
group.
55
The same masked retinal specialist graded OCT scans at first diagnosis and most recent
56
follow-up on a 3-point scale, where 1 was typical-appearing open FTMH, 2 was flat edges of
57
FTMH, and 3 was a closed FTMH with opposed edges. The change in grades on the OCT scans
58
between initial diagnosis and last follow-up were tabulated.
59
CNV development was also recorded.
60
Results
61
Patient demographics are shown in Table 1. Four different retinal surgeons performed the
62
PPVs with similar techniques, with one surgeon performing 8 of the cases, and the remaining 3
63
surgeons performing the other 4 cases.
64
There was no statistically significant VA improvement in either group between initial VA
65
recording and last follow-up. In addition, there was no significant change in VA for the PPV
66
group between pre-op recording and visits at 3 or 12 months.
4
Macular hole surgery in macular telangiectasia type 2 67
OCTs were available to read in all patients at initial data point and last follow-up. The OCT
68
scans improved by 1 step (using the 3-point grading system) in 10 PPV patients; there was no
69
improvement in the 2 remaining patients (Figure 1). The OCT scans of 4 patients showed closed
70
or opposed edges (grade 3) at last follow up. None of the MM patients showed any
71
improvement on OCT grading (Figure 2).
72
CNV developed in 1 of 12 eyes in the PPV group and 5of 26 eyes in the MM group. In the
73
PPV group, post-op complications were seen in 2 patients: 1 repeat macular hole surgery for
74
enlarging FTMH following initial surgery and 1 iridotomy for acute angle closure glaucoma.
75
Discussion
76
The prognosis for stage 2-4 FTMH is poor, with central visual acuity deteriorating to the
77
range of 20/100 to 20/400 over time.5 The Vitrectomy for Macular Holes Study Group in the
78
1990s reported that, compared with observation, surgery for stage 2 holes resulted in a
79
significantly lower incidence of hole enlargement; however, there was no significant difference
80
in ETDRS visual acuity measurements.6 The group’s study of stage 3 and stage 4 macular holes
81
found a significant benefit in the rate of hole closure and a marginally significant benefit in
82
ETDRS VA in the surgery group.7 Since those reports, advances in surgical techniques and
83
instrumentation have led to reported rates of hole closure rates of 91% to 98% and median
84
postoperative VA of approximately 20/40.5
85
There are few reports in the literature of FTMH in patients with IMT Type 2 and even
86
fewer of surgical intervention in such patients. 3,4,8-13 Previous publications have only compared
87
surgery as a treatment modality between patients with IMT Type 2 and FTMH versus those with
88
FTMH only or only reported outcomes of surgery for these patients without a comparison
5
Macular hole surgery in macular telangiectasia type 2 89
group of no surgery.4,6 In this study, there does not appear to be any advantage to surgery in
90
patients with FTMH associated with IMT Type 2. Even though the OCT did show some
91
anatomical improvement in most patients who underwent surgery, there was no accompanying
92
VA improvement. Certainly these patients are quite dissimilar to typical FTMH patients, and the
93
accompanying IMT Type 2 is likely limiting the improvement in VA and OCT anatomical results.
94
One can hypothesize that since IMT Type 2 pathophysiology in creating a macular hole is very
95
dissimilar to typical FTMH created by abnormal vitreoretinal traction, the results of surgery
96
would also be different. In IMT Type 2, there is loss of the ellipsoid zone, development and
97
coalescing of cystic cavities, and ultimately a dissolution of the neurosensory retina.4, 13 While
98
the hole maybe closed with surgery in patients with IMT Type 2, there is not a regeneration of
99
the neurosensory retina, which results in lack of improvement in visual acuity. In contrast for
100
FTMH, the neurosensory retinal tissue is still present, and surgical repair places the tissue back
101
into a normal alignment with resultant significant improvement in visual acuity. Due to cost of
102
surgery and risk of surgical complications, patients FTMH associated with IMT Type 2 may
103
benefit more with observation than surgical intervention.
104
This study is limited by several weaknesses including that it was a retrospective study in
105
only one private practice, follow-up was variable, and the small patient population. Further
106
randomized prospective studies could be more definitive in conclusion.
6
Macular hole surgery in macular telangiectasia type 2 107
References
108
1. Charbel Issa PS, Gillies MC, Chew EY, et al. Macular telangiectasia Type 2. Prog Retin Eye Res.
109
2013;34:49-77.
110
2. Klein R, Blodi BA, Meuer SM, Myers CE, Chew EY, Klein BE. The prevalence of macular
111
telangiectasia Type 2 in the Beaver Dam Eye Study. Am J Ophthalmol. 2010;150:55-62.
112
3. Charbel Issa P, Scholl HP, Gaudric A, et al. Macular full-thickness and lamellar holes in
113
association with type 2 idiopathic macular telangiectasia. Eye (Lond). 2009;23:435-441.
114
4. Karth PA, Raja SC, Brown DM, Kim JE. Outcomes of macular hole surgeries for macular
115
telangiectasia type 2. Retina. 2014;34:907-915.
116
5. American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern®
117
Guidelines. Idiopathic Macular Hole. San Francisco, CA: American Academy of Ophthalmology;
118
2017. Available at www.aao.org/ppp. Accessed 15 August 2019.
119
6. Kim JW, Freeman WR, Azen SP, et al, Vitrectomy for Macular Hole Study Group. Prospective
120
randomized trial of vitrectomy or observation for stage 2 macular holes. Am J Ophthalmol
121
1996;121:605-614.
122
7. Freeman WR, Azen SP, Kim JW, et al, The Vitrectomy for Treatment of Macular Hole Study
123
Group. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes: results of a
124
multicentered randomized clinical trial. Arch Ophthalmol. 1997;115:11-21.
125
8. Jaycock PD, Thomas D, Zakir R, Laidlaw DA. Retinal telangiectasia in association with macular
126
hole formation. Eye (Lond). 2004;18:342-343.
127
9. Koizumi H, Slakter JS, Spaide RF. Full-thickness macular hole formation in idiopathic
128
parafoveal telangiectasis. Retina. 2007;27:473-476.
7
Macular hole surgery in macular telangiectasia type 2 129
10. Olson JL, Mandava N. Macular hole formation associated with idiopathic parafoveal
130
telangiectasia. Graefes Arch Clin Exp Ophthalmol. 2006;244:411-412
131
11. Rishi P, Kothari AR. Parafoveal telangiectasia (PFT) has been associated with changes in
132
macular architecture and macular holes (lamellar and full thickness). Retina. 2008;28:184-185.
133
12. Gregori N, Flynn HW Jr. Surgery for full-thickness macular hole in patients with idiopathic
134
macular telangiectasia type 2. Ophthalmic Surg Lasers Imaging. 2010;41 Online:1-4.
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13. Shukla D. Evolution and management of macular hole secondary to type 2 idiopathic
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macular telangiectasia . Eye (Lond). 2011;25:532-533.
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Macular hole surgery in macular telangiectasia type 2 138
Figure legends
139 140
Figure 1a. 71-year-old male in the PPV group presented with VA of 20/100 in right eye with
141
macular hole and IMT Type 2. OCT graded as open edges (1).
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Figure 1 b. Last follow up was 86 months post PPV. VA was 20/100. OCT showed 1- step
143
improvement to flat edges (2) but also highly irregular retinal pigment epithelium (RPE)
144
changes.
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Figure 2a. 61-year-old female in the MM group presented with IMT Type 2 and macular hole in
146
left eye. VA was 20/200. OCT has open edges, or grade 1.
147
Figure 2b. Last follow-up was 49 months later. VA was 20/80 with persistent macular hole. OCT
148
remained graded as open edges (1) with no change.
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Macular hole surgery in macular telangiectasia type 2
Table 1. Patient demographics Mean age (years)
Males
Females
Mean follow-up (months)
PPV
71 +/- 10
4
8
44 +/- 31
MM
69 +/- 10
16
10
22 +/- 15
PPV = pars plana vitrectomy group MM = medical management group
Macular hole surgery in macular telangiectasia type 2 Table 2. Mean visual acuity, PPV group
Snellen
LogMAR
P (LogMAR)
Pre-op
20/114
0.756 +/- 0.332
3 months post-op
20/113
+0.751+/- 0.332
0.717
12 months post-op
20/94
+0.670 +/- 0.298
0.546
Macular hole surgery in macular telangiectasia type 2
Table 3. VA change from diagnosis to last visit Initial
Last
Change
PPV LogMAR VA
+0.756 +/- 0.332
+0.732 +/- 0.236
-0.013 +/- 0.2
MM LogMAR VA
+0.481 +/- 0.345
+0.477 +/-0.321
+0.004 +/- 0.2
P (PPV vs MM)
0.830