EFFICACY OF VITRECTOMY WITH TRIAMCINOLONE ASSISTANCE VERSUS INTERNAL LIMITING MEMBRANE PEELING FOR HIGHLY MYOPIC MACULAR HOLE

RETINAL DETACHMENT
YONG WEI, MD,* NINGLI WANG, MD, ZHONGQIAO ZU, MD,* CHUNCAO BI, MD,* HUAIZHOU WANG, MD, FENGHUA CHEN, MD, XINGGUANG YANG, MD*
Purpose: To compare the outcomes of pars plana vitrectomy (PPV) with or without the adjuvant surgical procedures: triamcinolone acetonide (TA) assistance and/or internal limiting membrane (ILM) peeling for the treatment of highly myopic macular hole retinal detachment (MHRD). Design: Casecontrol study. Methods: Pars plana vitrectomy combined with 2 kinds of adjuvant surgical procedures were used on 96 highly myopic eyes with MHRD. These eyes were assigned to 4 groups randomly: Group 1, nonTA-assisted PPV and without ILM peeling; Group 2, nonTAassisted PPV with ILM peeling; Group 3, TA-assisted PPV and without ILM peeling; Group 4, TA-assisted PPV with ILM peeling. Anatomical reattachment of the retina, macular hole closure, and best-corrected visual acuity were measured. Results: The rates of both retinal reattachment and macular hole closure were higher in Group 2 (84.0 and 44.0%) and Group 3 (80.8 and 46.2%) than Group 1 (73.9 and 17.4%); however, there were no differences between Group 2 and Group 3 (P . 0.05). The rates of macular hole closure were extremely low in Group 1 and also in eyes with extreme long axial lengths ($29.0 mm), severe chorioretinal atrophy, and posterior staphyloma. Conclusion: Pars plana vitrectomy with either TA assistance or ILM peeling was effective for the treatment of highly myopic MHRD. If you peel the ILM, adding TA does not affect closure rates; and if TA is used to visualize the vitreous, ILM peeling may not be necessary in MHRD. There was a lower anatomical success rate in MHRD with extreme long axial lengths, severe chorioretinal atrophy, and posterior staphyloma. RETINA 33:11511157, 2013

acular holeinduced retinal detachment (MHRD) is a vision-threatening complication to highly myopic eyes, which is more common in Asian adult population.1 An important causative factor of MHRD
From the *Shaanxi Ophthalmic Medical Center, Xian No.4 Hospital, Afliated Guangren Hospital, School of Medicine, Xian Jiaotong, University, Xian, China; and Beijing Tongren Eye Center, Beijing Tongren Hospital, Ophthalmology and Visual Science Key Laboratory, Beijing Ophthalmology School, Capital Medical University, Beijing, China. Supported in part by a grant from Society Development, Medicine Research Foundation, funded by the Xian city government (SF1022[5]). The authors declare no conict of interest. Y. Wei and N. Wang contributed equally to this work. Reprint requests: Yong Wei, MD, Department of Ophthalmology, Xian NO.4 Hospital, #21 JieFang road, Xian 710004, China; e-mail: weiyongdoctor@163.com

might be the tangential traction caused by the premacular vitreous/membrane and the inverse traction caused by the posterior staphyloma.25 Other theories include reduced retinal adherence to the choroid because of retinal pigment epithelial (RPE) atrophy5 and increased tangential traction on the macula from the contraction of the cellular constituents on the surface of the internal limiting membrane (ILM).6 Complete removal of the posterior hyaloid and epiretinal membranes is essential for successful retinal reattachment. Pars plana vitrectomy (PPV) using triamcinolone acetonide (TA) would facilitate removal of the epiretinal membrane, visualization and helping separation, and removal of the residual vitreous cortex.
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The reoperation rate because of preretinal brosis in eyes by PPV without TA is higher than eyes with TA-assisted PPV.7,8 Otherwise, removing of the ILM ensures the complete removal of residual prefoveal vitreous cortex after posterior vitreous detachment (PVD). Pars plana vitrectomy with concomitant ILM peeling also has a high success rate to the surgical treatment of MHRD.9,10 In addition, axial length (AXL), extent of chorioretinal atrophy, and presence of posterior staphyloma are important prognostic factors associated with the anatomical success of PPV for the treatment of MHRD. Little information is currently available on the anatomical outcomes comparing PPV with TA-assisted and/or with concomitant ILM peeling in the treatment of MHRD, although both techniques can ensure the complete removal of residual prefoveal vitreous cortex after PVD. To provide an objective review of these techniques, we conducted a randomized controlled trial to analyze cases with myopic MHRD treated with one of these two techniques to determine the prognostic factors associated with anatomical success in these cases.

Patients and Methods Ninety-one consecutive patients (96 eyes) underwent a PPV from October 2008 to May 2011. All of these eyes were highly myopic with retinal detachment caused by macular hole (MH). Eyes with proliferative vitreoretinopathy, previous intraocular operations, idiopathic and traumatic MHs, and postoperative follow-up of ,6 months were excluded from the analysis. Information collected from each case record included preoperative refraction, AXL, presence of posterior staphyloma, presence of preoperative PVD, preoperative lens status, symptom duration, surgical treatments, pre- and postoperative best-corrected visual acuity, MH closure rate, retinal reattachment rate, and complications. Our study was carried out with approval from the appropriate institutional review board and performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. The possible merits and risks of the present treatment were explained to the patients before surgery, and informed consents were obtained from all patients. The surgeon for each case was randomly determined. A PVD was dened as the separation of the posterior vitreous cortex from the internal limiting lamina of the retina. Diagnosis of PVD was based on slit-lamp biomicroscopy with a 90-diopter lens and B-scan ultrasonography.

Chorioretinal atrophy was considered mild when the atrophy (choroidal tessellation) was located in the peripapillary area, with or without a moderate loss of the RPE in the macular area. Chorioretinal atrophy was considered severe in the presence of extensive peripapillary chorioretinal atrophy with, eventually, a localized or more extensive loss of the choroid in the area included between the temporal vascular arcades.11 Eyes were classied as having moderate long AXL (.26.0 mm but ,29.0 mm) and extremely long AXL ($29.0 mm) based on B-scan ultrasonography. Staphylomas were determined from the B-scan ultrasonographic images. Staphyloma depth was measured according to the method described by Steidl and Pruett.12 Staphylomas were considered mild when the depth was 2 mm or less (Grades 0112). Staphylomas were considered severe when the depth was .2 mm (Grades 2312).13 Anatomical success was dened as complete reattachment of the neurosensory retina to the underlying RPE. Macular hole closure was dened as the absence of a neurosensory defect over the fovea on optical coherence tomography (Carl Zeiss Ophthalmic Systems, Inc, Humphrey Division, Dublin, CA).14 Pars plana vitrectomy was performed in all patients using a 20-gauge 3-port system. If lens opacity obscured the view of the fundus, phacoemulsication was performed before the PPV. After vitreous removal by vitrectomy, a dose of 0.1 mL/4 mg TA aqueous suspension (40 mg/1.0 mL suspension; Lab.It.Biochim.Farm.co Lisapharma S.P.A., Via Licinio, Como, Italy) was injected to the posterior pole in some eyes for visualizing the residual cortical vitreous, after removal of the solvent through a 0.2-mm micropore lter (Millex-GS 0.22 mg, Merck Millipore, Billerica, MA). If a PVD was not present, the posterior hyaloid face was separated from the optic disk and removed using controlled suction of up to 150 mmHg with the vitreous cutter applied close to the optic disk or incision and elevation the posterior hyaloid face near the optic disk using a membrane pick. Airuid exchange was performed while draining the subretinal uid with a soft tipped cannula over the MH. Indocyanine green (ICG) (0.5%) staining of the ILM was done in some patients using 0.2 mL of the solution for 60 seconds. The ILM could be peeled using a diamond-dusted ILM scraper to create an initial ap, and forceps allowed for direct gripping and subsequent removal of the three to four disk diameter ILM around the MH in a concentric manner. Intraocular air was exchanged with a 14% C3F8/air mixture. All patients were asked to remain in the prone position for 2 weeks after surgery. We performed PPV using 4 different surgical procedures: nonTA-assisted PPV and without ILM

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peeling (Group 1: TA, ILM), nonTA-assisted PPV with ILM peeling (Group 2: TA, ILM+), TA-assisted PPV and without ILM peeling (Group 3: TA+, ILM), and TA-assisted PPV with ILM peeling (Group 4: TA+, ILM+). Triamcinolone acetonide was used to visualize the posterior cortical vitreous, and diluted ICG was used to stain the ILM for peeling. Statistical analysis was performed by SPSS statistical software (version 11.5; SPSS, Chicago, IL). Continuous variables are expressed as mean SD, and categorical variables are expressed as individual counts and proportions. The Snellen best-corrected visual acuity was converted into logarithm of minimum angle of resolution units for analysis.15 Univariate analyses to determine the association between baseline demographics, surgical treatments, and anatomical success after different surgical procedures were performed using one-way analysis of variance, chi-square test, and the Fisher exact test, as appropriate. In addition, logistic regression analysis was performed to establish the determinants of MH closure rate as the dependent variable and AXL, chorioretinal atrophic, posterior staphyloma, concomitant ILM peeling, concomitant TA assistance as independent variables. The critical value of signicance was set at P , 0.05 for all tests.

Results One hundred and three patients (108 eyes) were recruited in this study. After randomization, 26 eyes were assigned to Group 1, 27 eyes to Group 2, 30 eyes to Group 3, and 25 eyes to Group 4. After the 12-month follow-up, 91 enrolled patients (96 eyes, 88.89%) completed the study. No statistically signicant differences were found among 4 groups for variants, such as gender, age, symptom duration, preoperative visual acuity, preoperative refraction, preoperative lens status, extent of retinal detachment, AXL, and presence of chorioretinal atrophy and posterior staphyloma among 4 groups (Table 1). Subgroup analysis of the anatomical success rate was performed at 12 months after surgery. The rates of retinal reattachment and MH closure were higher in Group 2 (84.0 and 44.0%), Group 3 (80.8 and 46.2%), and Group 4 (81.8 and 50.0%) than Group 1. No difference was found for rates of retinal reattachment and MH closure in Group 2 versus Group 3 (P = 1.000 and P = 0.877), Group 2 versus Group 4 (P = 1.000 and P = 0.681), and Group 3 versus Group 4 (P = 1.000 and P = 0.790). For Group 1, retinal reattachment rates were lower (73.9%), especially

MH closure (17.4%). Compared with Groups 2 and 3, the rates of MH closure in Group 1 were signicantly lower (Group 1 vs. Group 2, P = 0.047; Group 1 vs. Group 3, P = 0.032), while there were no differences in the rates of retinal reattachment in Group 1 versus Group 2 (P = 0.487) and Group 1 versus Group 3 (P = 0.566) (Table 2). Of 96 eyes with MHRD, 57 eyes had a consistent moderate long AXL, mild chorioretinal atrophy, and posterior staphyloma (Group A) and 25 eyes had a consistent extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma (Group B). The rates of retinal reattachment and MH closure were higher in Group A compared with Group B (P = 0.005 and P = 0.001) (Table 3). The functional outcome was much better in those eyes with myopic MH closure than those without in Group A (P = 0.011, Table 4). Logistic regression showed that the method of operation was strongly associated with MH closure rate in highly myopic MH retinal detachment. Pars plana vitrectomy concomitant TA assistance is the rst factor that inuenced the rate of MH closure (Wald chi-square = 4.876, P = 0.027), and concomitant ILM peeling is the second factor that inuenced it (Wald chi-square = 4.767, P = 0.029) in these eyes. Other factors such as AXL, presence of chorioretinal atrophy, and posterior staphyloma were found by logistic regression to have no correlation with MH closure rate (Table 5). Intraoperative complications included iatrogenic retinal breaks in 3 eyes of 96 eyes. Submacular deposition of TA crystals was found in 3 eyes of 48 eyes, and it spontaneously disappeared after 2 weeks. Postoperatively, 10 eyes developed epiretinal membranes in 96 eyes. Four eyes suffered from MH reopened after initial closure (from 4 weeks to 3 months). Of the 52 eyes with lens preservation after surgery, 13 eyes (25.0%) developed visually detrimental cataracts during the course of the follow-up and later required cataract surgery (follow-up 6 months to 1 year, mean 8.6 months). Fifteen eyes of 96 eyes (15.6%) developed increased intraocular pressure requiring more than 1 antiglaucomatous medication during the rst 2 weeks of the postoperative period (Table 2). Seventeen eyes of 19 eyes in which primary PPV failed underwent reoperation. Thirteen were treated with silicone oilair exchange and 4 were treated again with C3F8uid exchange concomitant with endolaser photocoagulation of the MH rim. Anatomical success was achieved in 6 of 13 silicone oil tamponade eyes after silicone oil removal. In 7 of 13 silicone oil tamponade eyes with extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma, the oil was

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Table 1. Preoperative Clinical Characteristics in Different Surgical Procedure Groups Group 1 (23 Eyes) Group 2 (25 Eyes) Group 3 (26 Eyes) Group 4 (22 Eyes) Age, years Range Mean Gender Men Women Visual acuity (logMAR units) Myopia, D Range Mean Lens status (eyes) Pseudophakic Aphakic Phakic PVD (eyes) Yes No AXL (eyes) ,29.0 mm $29.0 mm Chorioretinal atrophic (eyes) Mild Severe Posterior staphyloma Mild Severe Duration of symptoms, months Range Mean Extent of the RD (eyes) PR PR-1Q PR-2Q PR-3Q TD 45 to 68 55.7 6.5 5 18 1.8 0.2 7 to 22 12.1 4.3 2 1 20 17 6 16 7 15 8 16 7 1 to 4 1.7 0.8 5 7 5 3 3 45 to 71 57.3 6.1 6 19 1.9 0.5 7 to 24 12.9 4.3 3 0 22 18 7 17 8 18 7 18 7 1 to 4 1.7 0.9 7 6 6 4 2 45 to 65 56.2 5.4 9 17 1.7 0.3 7 to 22 12.3 4.2 4 1 21 19 7 16 10 18 8 17 9 1 to 4 1.9 0.9 6 8 5 3 4 45 to 71 58.0 6.9 0.707 5 17 1.8 0.2 7 to 24 12.6 4.0 3 2 17 0.999 16 6 0.929 14 8 0.967 15 7 0.924 14 8 0.323 1 to 4 1.7 0.9 0.990 6 6 3 4 3 0.240 0.827 0.727 P 0.600

Group 1: TA, ILM; Group 2: TA, ILM+; Group 3: TA+, ILM; Group 4: TA+, ILM+. TA, nonTA-assisted PPV; ILM, without ILM peeling; TA+, TA-assisted PPV; ILM+, with ILM peeling. logMAR, logarithm of the minimum angle of resolution; PR, posterior retina; Q, quadrant; RD, retinal detachment; TD, total detachment of the retina.

left in place and there were no complications related to silicone oil use. In 2 of 4 C3F8 tamponade eyes concomitant with endolaser photocoagulation of the MH rim, retina failed reattachment again, and nally, eyes were tamponade with silicone oil.

Discussion Tangential traction caused by the premacular vitreous/membrane is a critical causative factor for MHRD. One of the principal goals of PPV is to completely remove the premacular vitreous/membrane from the retina. Extremely thin translucent sheets of epiretinal tissue around the hole are always harvested intraoperatively, despite the absence of detectable tissue on preoperative examinations. The premacular vitreous/

membrane forms the posterior wall of a posterior precortical vitreous pocket that progressively enlarges because of extensive liquefaction of the vitreous, which is characteristic of highly myopic eyes.16 The thin premacular vitreous/membranes are friable in many highly myopic eyes and rmly adherent to the retina, and this makes it difcult to grasp and remove from the retina as a single sheet. In addition, many patients who are initially thought to have a PVD are found to have plaques of cortical vitreous adhering to the retina.17,18 These plaques cannot be visualized and are not apparent based on the sh-strike sign.19 Using TA as an aid to visualize the vitreous and assist in separation of the posterior hyaloid during PPV was described by Peyman et al.17 The white suspension is dispersed in the vitreous cavity and trapped in the gel structure of the residual epiretinal tissue, and it can be

TRIAMCINOLONE ASSISTANCE VERSUS ILM PEELING  WEI ET AL Table 2. Postoperative Clinical Characteristics in Different Surgical Procedure Groups Group 1 (23 Eyes) MH closure rate Retinal reattachment rate Combined phacoemulsication (eyes) Performed Not performed Intraoperative complications (eyes) Retinal breaks Postoperative complications (eyes) Epiretinal membrane MH reopen Cataract Glaucoma Final BCVA (eyes) Improvement Unchanged Worsened 17.4% (4 eyes) 73.9% (17 eyes) 7 13 1 5 3 4 3 9 10 4 Group 2 (25 Eyes) 44.0% (11 eyes) 84.0% (21 eyes) 7 15 1 2 1 2 4 15 8 2 Group 3 (26 Eyes) 46.2% (12 eyes) 80.8% (21 eyes) 8 13 0 1 0 3 5 13 10 3

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Group 4 (22 Eyes) 50.0% (11 eyes) 81.8% (18 eyes) 6 11 1 2 0 4 3 12 8 2

Group 1: TA, ILM; Group 2: TA, ILM+; Group 3: TA+, ILM; Group 4: TA+, ILM+. TA, nonTA-assisted PPV; ILM, without ILM peeling; TA+, TA-assisted PPV; ILM+, with ILM peeling. BCVA, best-corrected visual acuity.

seen on the retina as either a diffuse membrane or small islands. This allows for clear visualization of the residual epiretinal tissue, which can then be removed using a membrane pick, surgical forceps, or a silicone-tipped needle.7,17,18 The ILM represents the structural boundary between the retina and the vitreous. It has a smooth vitreal surface and an irregular retinal surface in close apposition with the plasma membrane of the Mller cells.20 Macular holes develop from contraction of the prefoveal vitreous and enlarge by contraction of the myobroblasts on the inner surface of the ILM.9,10 Removing the ILM ensures complete removal of the adherent areas of the vitreous and relieves the tangential traction of the residual prefoveal vitreous after PVD by default. Additionally, ILM removal may induce the contraction of epiretinal cellular constituents, resulting in closure of the MH.6,10 The ILM may have an important function during early embryogenesis,21 and although to date there are no obvious detrimental effects of its removal, the benets or detriments of ILM removal in the aged human eye remain unclear. Furthermore, the ILM is thin, friable, and rmly adherent to the thin highly myopic

retina. Internal limiting membrane peeling may be more difcult and prone to induce retinal break in highly myopic retina. Indocyanine green toxicity to atrophic RPE may exist in highly myopic eyes with the use of ICG staining, because potentially ICG falls through the hole on the RPE even when airuid exchange was performed. Using TA to visualize the vitreous and assist in the separation of the posterior hyaloids is easier than ILM peeling in highly myopic MHRD. In our study, ICG was used under air, and after a uidair exchange, the dye was applied only over the desired area, preventing the access of ICG into the subretinal space and also limiting the unwanted staining of the lens capsule and anterior vitreous. Therefore, it may reduce the inuence to the outcomes when ICG is used in ILM peeling. Triamcinolone acetonide crystals were rinsed through a Millipore lter in an attempt to remove the vehicle and yield a suspension of TA with none or a low amount of vehicle to reduce the intraocular toxicity of TA containing preservatives. In our study, the MH closure rate was lower in ILMpreserved eyes without TA-assisted PPV. Without the use of TA assistance and without ILM peeling, the

Table 3. Postoperative Clinical Characteristics in Eyes with Different AXL, Extent of Chorioretinal Atrophy, and Posterior Staphyloma Group A (57 Eyes) MH closure rate Retinal reattachment rate 54.4% (31 eyes) 89.5% (51eyes) Group B (25 Eyes) 16.0% (4 eyes) 60.0% (15 eyes) P 0.001 0.005

Group A: eyes with consistent moderate long AXL, mild chorioretinal atrophy, and posterior staphyloma. Group B: eyes with consistent extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma.

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Table 4. Postoperative Clinical Characteristics of Eyes with Moderate Long AXL, Mild Chorioretinal Atrophy, and Posterior Staphyloma MH Closure (32 Eyes) Final BCVA (eyes) Improvement Unchanged Worsened Retinal reattachment rate
BCVA, best-corrected visual acuity.

MH Nonclosure (25 Eyes) 10 9 5 76.0% (19 eyes)

P 0.011

24 8 0 100% (32 eyes)

remaining vitreous during PPV may act as a scaffold for the epiretinal membrane, thereby exerting traction on both the MH and retina in the posterior pole, thus limiting MH closure or even promoting reopening. Myobroblasts may be a prominent feature only in cases of long-standing wide-ranging retinal detachment threatening to progress to proliferative vitroretinopathy rather than in our study, so better results may be achieved if the vitreous is completely removed in the posterior pole, whether the ILM is peeled or preserved during PPV. Of course, removing the ILM also ensures complete removal of the prefoveal vitreous by default. So, the surgical approach for TA-assisted PPV without ILM peeling or PPV with ILM peeling without using TA assistance based on these features seems logical, and may help the surgeon to achieve better results for the patients. In our study, the anatomical success rate was higher both in ILMpreserved eyes with TA-assisted PPV and in ILMpeeled eyes without TA-assisted PPV and there was no signicant difference between the results. It is generally believed that it is more difcult to obtain retinal reattachment in eyes with severe high myopia.2224 One reason is that AXL elongation contributed signicantly to MH enlargement, which may prohibit sealing of the MH. Another reason is that the posterior staphyloma shape, choroidal atrophic changes, or both of them vary widely in highly myopic patients. When posterior staphyloma is present, the retina must be reattached not only along the normal contour of the globe but also along the curvature of the posterior staphyloma. Posterior prolapse and stretching of the sclera could lead to a disparity in the length of the sclera and retina. Retinal adhesion can be overcome

by inverse traction produced by this disparity of the enlarged posterior staphyloma.5 Absence of the RPE in areas of chorioretinal atrophy could lead to reduced natural retinal adhesion.25 In these cases, PPV, even concomitant with endolaser photocoagulation and/or ILM peeling, and together with the injection of a long-acting gas such as C3F8 for tamponade, is insufcient to achieve MH closure and retinal reattachment. Silicone oil in this particular situation is especially advantageous for maintaining the retinal reattachment and may counteract the centrifugal stretching force caused by posterior staphyloma and contribute to retinal reattachment. The success rate using C3F8 tamponade is lower than that using silicone oil tamponade.25,26 In the present study, there was a lower rate of retinal reattachment and MH closure in MHRD with an extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma than those eyes with a moderate long AXL, mild chorioretinal atrophy, and posterior staphyloma. In summary, PPV with either TA or ILM peeling was effective for the treatment of highly myopic MHRD. If you peel the ILM, adding TA does not seem to affect closure rates; however, if you do not peel the ILM, then using TA improves closure rates, probably because of better visualization of the vitreous, hence a more complete vitrectomy and separation of the posterior hyaloid. So ILM peeling might not be necessary in TA-assisted PPV eyes. In addition to the various surgical options, the anatomical characteristics of the eyes also contribute to the postoperative outcome. There was a higher rate of retinal reattachment and MH closure in MHRD with a moderate long AXL, mild chorioretinal atrophy, and posterior

Table 5. Logistic Regression Model Summary for MH Closure After Primary PPV Dependent Variable MH closure after primary PPV Independent Variable AXL Chorioretinal atrophic Posterior staphyloma Concomitant ILM peeling Concomitant TA assistance Wald 0.885 0.062 0.923 4.767 4.876 P 0.347 0.804 0.337 0.029 0.027

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staphyloma than eyes with a extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma, and the functional outcomes were better in eyes with myopic MH closure than in those without. Currently, there is no established optimal surgical technique for eyes with an extremely long AXL, severe chorioretinal atrophy, and posterior staphyloma. Further studies are needed to examine these alternative surgical techniques in patients with poor prognostic factors. Key words: highly myopic, macular hole, retinal detachment, internal limiting membrane peeling, triamcinolone acetonide. References
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11. Ripandelli G, Coppe AM, Parisi V, et al. Fellow eye ndings of highly myopic subjects operated for retinal detachment associated with a macular hole. Ophthalmology 2008;115:1489 1493. 12. Steidl SM, Pruett RC. Macular complications associated with posterior staphyloma. Am J Ophthalmol 1997;123:181187. 13. Hsiang HW, Ohno-Matsui K, Shimada N, et al. Clinical characteristics of posterior staphyloma in eyes with pathologic myopia. Am J Ophthalmol 2008;146:102110. 14. Kang SW, Ahn K, Ham DI. Types of macular hole closure and their clinical implications. Br J Ophthalmol 2003;87:1015 1019. 15. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997;13:388391. 16. Spaide RF. Measurement of the posterior precortical vitreous pocket in fellow eyes with posterior vitreous detachment and macular holes. Retina 2003;23:481485. 17. Peyman GA, Cheema R, Conway MD, et al. Triamcinolone acetonide as an aid to visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy. Retina 2000; 20:554555. 18. Sonoda KH, Sakamoto T, Enaida H, et al. Residual vitreous cortex after surgical posterior vitreous separation visualized by intravitreous triamcinolone acetonide. Ophthalmology 2004; 111:226230. 19. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109: 654659. 20. Fine BS. Limiting membranes of the sensory retina and pigment epithelium. An electron microscopic study. Arch Ophthalmol 1961;66:847860. 21. Halfter W, Willem M, Mayer U. Basement membrane-dependent survival of retinal ganglion cells. Invest Ophthalmol Vis Sci 2005;46:10001009. 22. Sayanagi K, Ikuno Y, Tano Y. Macular hole diameter after vitrectomy for macular hole and retinal detachment. Retina 2005;25:608611. 23. Wolfensberger TJ, Gonvers M. Surgical treatment of retinal detachment owing to macular hole. Semin Ophthalmol 2000; 15:122127. 24. Ripandelli G, Parisi V, Friberg TR, et al. Retinal detachment associated with macular hole in high myopia: using the vitreous anatomy to optimize the surgical approach. Ophthalmology 2004;111:726731. 25. Wolfensberger TJ, Gonvers M. Long-term follow-up of retinal detachment due to macular hole in myopic eyes treated by temporary silicone oil tamponade and laser photocoagulation. Ophthalmology 1999;106:17861791. 26. Scholda C, Wirtitsch M, Biowski R, et al. Primary silicone oil tamponade without retinopexy in highly myopic eyes with central macular hole detachments. Retina 2005;25:141146.