Χειρουργική Ωχράσ Κηλίδασ. Γ. Γ. Παππάς, Βεληδέιεηο ΓΝ

Transcription

1 Χειρουργική Ωχράσ Κηλίδασ Γ. Γ. Παππάς, Βεληδέιεηο ΓΝ

2 FREQUENCY OF MACULAR SURGERY Incidence= 8 in (McCannel 2009) Prevalence = between 0.2 (Mitchell 2007) and 3.3 (Baltimore Eye Survey 1996) 2nd most common procedure requiring pars plana vitrectomy* Other 30% Retinal Detachment 46% Macular hole 24% * Survey of tertiary vitreoretinal centres in Japan 2005 n=18448 Sakamoto T et al., Nippon Ganka Gakkai Zashi (2008) 112:45

3 Macular interface surgery

4 Διάγνωςτικά μζςα Παθοφυςιολογία πάθηςησ ωχράσ κηλίδασ Μζγεθοσ προβλήματοσ Μορφή Στάδιο Λειτουργικότητα Αποτζλεςμα Χειρουργείου (λειτουργικόανατομικό)

5 OCT

6 Microperymetry

7 Microperimetry Non Invasive Difficult for patient Takes time

8 SD OCT it all starts inocuously

9 I can t see 6/6

10 it s getting worse still 6/6

11 Now it s bad

12 oh my God.

13 Lamellar Macular Hole three different pathogeneses: antero-posterior traction tangential traction de-roofing of cystoid macular oedema. OCT Criteria presence of an irregular foveal contour break in inner fovea dehiscence of the inner foveal retina from the outer retina (intraretinal dissociation) absence of a full foveal defect (intact foveal photoreceptors) Witkin AJ, Ko TH, Fujimoto JG, et al. Redefining lamellar holes and the vitreomacular interface: an ultrahigh-resolution optical coherence tomography study. Ophthalmology 2006; 113:

14 1. Witkin A. J. et al., Ophthalmology (2006); 113: Gaudric A. et al., Arch Ophthalmol (1999); 117: Pictures from Garcia Fernandez M. et al., Can J Ophthalmol (2012); 47: Criteria for OCT diagnosis LMHs 1 Irregular foveal contour (1) Break in the inner fovea (2) Intraretinal split (3) Normal perifoveal retinal thickness (4) Absence of a full thickness foveal defect (4) Intact foveal photoreceptors (4) MPHs (Macular Pseudoholes) 2 Normal central retinal thickness (1) Partial thickness macular defect Steepened defect with typically verticalized foveal slopes (2) Increase in perifoveal thickness (3)

15 Gass Macular Hole Stages Stage 1a Loss of foveal depression central yellow spot Stage 1b Stage 2 Stage 3 Stage 4 Yellow ring κm < 300κm defect; Pseudo-operculum κm defect, +/- operculum PVD separated from macula Full PVD

16 Pathogenesis Pre-foveolar vitreous tangential traction Anteroposterior orientation over fovea

17 SD OCT supports the a/p traction hypothesis

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20 Macular Hole Surgery Pars plana vitrectomy Posterior hyaloid removal PVD Post-op tamponade and head positioning ILM removal increases closure rate Vision varies; OCT closed hole

21 Tornambe Hydration Theory Fluid hydrates the fovea and retinal edge creating drawbridge effect Tamponade, gas or oil, "dehydrates" edge closing the drawbridge Mechanism is retinal dehydration

22 Schubert Glial Cell Migration Theory Macular holes: migratory gaps and vitreous as obstacles to glial closure. Schubert HD, et al Mechanism is glial cell migration, arising from the inner retina, along the edge and floor of hole Our results indicate that gaps in the migratory surface, caused and ggravated by eversion and the presence of vitreous, present obstacles to glial migration and closure of macular holes

23 Observations on Surgical Macular Hole Closure PVD and Posterior Hyaloid Removal Required for hole closure Lack of PVD and hyaloid removal common cause of failure Tamponade Gas is requirement not silicone oil! ILM Peeling Increases closure rate Shorter tamponade duration Hole closure without strict head positioning Mac Hole Size Lower success rate holes > 400 microns

24 Mechanism of Closure These observations suggest a mechanism which involves a bridging of the hole to occur along the inner retinal surface; not along the outer RPE bed The persistence of subretinal fluid questions validity of dehydration and RPE fluid pumping mechanisms

25 Lateral Capillary Forces Theory

26 What if Posterior Hyaloid Remains?

27 Δρ.1 : Σε ποηό ζηάδηο παρεκβαίλοσκε

28 CLOSURE OF MACULAR HOLE BY PVD ALONE Spontaneous (5-10%)

29 Δρ. 2 Οπή Ωτράς 2 οσ ζηαδίοσ. Peeling or Not

30 PEELING VS. NO PEELING ILM-Peeling increases anatomical success rates Tendency (but no proof) that peeling improves functional success rates Primary closure rates (%) No Peeling Peeling Brooks 2000 Foulquier 2002 Sheidow 2003 Kwok 2005 Lois 2011 Brooks Jr HL, Ophthalmology (2000) 107:1939 Foulquier S et al., J Fr Ophthalmol (2002) 25:1026 Sheidow TG et al., Ophthalmology (2003) 110:1697 Kwok AK et al., Hong Kong Med J (2005) 11:259 Lois N et al. IOVS (2011) Mar 1;52(3):

31 Peeling Harms Tadayoni, BJO, 2012 Decreased retinal sensitivity after ILM peeling for MH surgery And more microscotomas Sugestions: -DONFL appearance may not correlate to worse functional outcome - Peeling when necessary

32 Δρ.3 Φαθοζρσυία καδί κε τεηροσργείο οπής ή 2 τεηροσργεία?

33 Trend When you can visualize clearly the ILM When you are not confident to perform combined cataract Young patient (needs accommodation)

34 Combined Simcock P, Pappas G et al, Retina, Mar 2003 Combined Surgery in presbyopic patients is the best option due to higher volume tamponade and due to best aproach to the patient s pathology

35 Δρ 4. Face down or Not?

36 MACULAR HOLE CLOSURE RATES PVD No posture Face down 30 % 70 % 90 % courtesy of H Heimann

37 Posturing Vx Closure Note the residual subfoveal fluid 14 days post surgery Reported cases of delayed visual recovery correlate with persistent subfoveal fluid

38 Posturing Vx Closure Claus Eckardt Retina September Closed by 48 hrs

39 Is Prone Positioning Necessary?

40 Is Prone Positioning Necessary Depends on Bubble Size 80% 50%

41 Conclusion Lateral Capillary Forces created by interface disturbance at the macular hole are attractive apposes the edges Function of distance between edges larger holes generate less force Higher Surface Tension creates more force Oil lower surface tension than gas ILM peeling increases retinal compliance requires less force to mobilize and appose edges Hole closes within hours

42 Conclusion Interface contact with the hole is critical. Maximize bubble size Larger gas bubble allows for greater contact area and more liberal head positioning Remove ALL vitreous and repeat fluid-air exchange after a 5 minute wait Strict long term head positioning not required Failure can be identified early

43 Δρ.5 Τη τρεζηκοποηείηαη? Α. SF6 ( Higher face tension, less time) B. C3F8 C. Αέρα

44 Δρ 6 Όιες οη οπές θιείλοσλ?

45 UNCLOSED MACULAR HOLES Liverpool Series Valldeperas X et al., Ophthalmology (2008) 115: year period of macular hole surgery ILM-peeling 4% Autologous platelets 94% (now abandoned) Total Never closed Re-opened

46 Holes that have not been closed initially will never be as good

47 Δρ 7 Φαρκαθεσηηθή αγφγή

48 Δρ.8 Τη θάλεηε ζηης Μσφπηθές Οπες Ωτράς? Α. Gas B. Silicone oil Γ. Buckling Γ. Indocyanine green or brilliant peel

49 Δρ. 9: Θα τεηροσργούζαηε Lamellar Macular Hole θαη πόηε?

50 Stable condition According to the findings of a non comparative observational case series that studied the natural course of LMH as examined by OCT: The VA was found stable in 80% of patients over a follow up period of 37,1 months. 1 A decrease of 10% of macular thickness was observed during that time. In another recent prospective study of the evolution of LMHs using SD- OCT in a mean follow-up period of 18 months, it was found: No significant change in BCVA 2 Only a 3% decrease of foveal thickness 2 No change in the size of LMH in 80% of the patients 2 N 1. Theodossiadis P. G. et al., Graefes Arch Clin Exp Ophthalmol (2009); 247: Bottoni F. et al., Graefes Arch Clin Exp Ophthalmol (2013); 251:

51 Sustained, Long-Term Outcomes RETINA 32: , 2012 retrospective case series 31 consecutive patients follow up was 39 months (range months) ICG used as dye Vision improved from 0.41 (± 0.33) to 0.23 (± 0.23) 18 eyes (58.1%) improved 2 lines 28 (90.3%) had improved OCT

52 Technique

53 Large macular Holes/ Unclosed holes

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56 Instrumentation

57 Patient 1: F/51, stage 4 FTMH

58 Patient 2,M/64,Stage 4 FTMH

59 Patient 2 Microperimetry

60 Patient 3: pre-op Patient 3: 2 weeks post-op

61 Patient 4: pre-op Patient 4: 2 weeks post-op

62 Thank You