Comparison of outcomes of idiopathic macular holes treated by vitrectomy with air or silicone oil tamponade based on the hole size

INTRODUCTION

Macular hole is a full-thickness tissue defect in the retinal neuroepithelial layer of the macular region,which can cause visual loss, visual distortion and other clinical manifestations. Clinical treatment are mainly vitrectomy and internal limiting membrane peeling combined with different intraocular tamponade

. Expansile gas is the favorite tamponade, but due to some incidents of infection in China in recent years, it could not be obtained stably clinically. In fact, disinfected airusually has excellent effect on idiopathic macular hole (IMH) in some situations

, but in the meantime there are still a lot of failed reports

, whose main cause is due to the insufficient duration. So sometimes silicone oil is needed to be used. But because of the well-known side effects and limitation, it is often hard to make a choice between disinfected air and silicone oil. There are few articles comparing the effects of air and gas on IMH surgery, but articles about air

silicone oil has not been found. At present, there is no clear guidance for these two tamponades, and the choice relies mainly on the experience of the operators. In this study, we tried to explore the rule and compare the effects of them according to the closure rates, the closure shape, complications, and the improvement of vision.

SUBJECTS AND METHODS

All patients’ data and essential information were retrieved from medical records during the period from January 2017 to December 2019 in the Ophthalmology Department of Chinese PLA General Hospital. All the patients had been given explanation and signed informed consent before every operation under the supervision by the Medical Management Division of the hospital. And tenets of the Declaration of Helsinki were adhered to for this study.

Inclusion criteria: 1) macular full-thickness hole with stage II or above by optical coherence tomography (OCT)measurement; 2) course of disease ≤2y. Exclusion criteria:1) refractive stromal opacity affecting fundus examination or treatment; 2) history of ocular trauma, surgery or intraocular injection; 3) patients with refractive power <-6.00 D or axial length>26 mm; 4) patients with previous vitreoretinal surgery;5) patients with optic neuropathy; 6) patients with heart,lung, liver, kidney dysfunction or other intolerable surgical treatments; 7) patients with incomplete key follow-up records.All patients underwent best corrected visual acuity (BCVA),intraocular pressure (IOP), slit lamp microscope, fundus preset lens, fundus color photography and macular OCT examination.Zeiss Cirrus HD5000-OCT was used to scan IMH center with the scanning depth of 2 mm and the scanning range of 6×6 mm

. Four diameter lines of 0°, 45°, 90°, and 135°were selected. The minimum value of the four diameter lines measured by the built-in tool of OCT was selected as MMHD.BCVA was performed with international standard visual chart and converted to logarithm of the minimum angle of resolution(logMAR) visual acuity.

All eyes underwent conventional three channel pars plana vitrectomy. The posterior vitreous cortex was detached and cut. Internal limiting membrane was peeled from the upper vascular arch to the lower. Intraocular tamponade with air or silicone oil was employed at the end of the intervention.The 30 cases (30 eyes) were filled with air and 45 cases (45 eyes) with silicone oil. All operations were performed by three experienced doctors. After the operation, the patient kept a facedown position, air group for seven days and silicone oil group for two weeks. All cases were not combined with cataract surgery.

我们的出发点仍然是从语言表达着手来理解弗雷格的对象，关键在于理解什么是“不带有空位”的表达，即理解弗雷格的专名。但正如达米特所言，“弗雷格从未费心对‘专名’这一范畴做过任何精确的规定”，而是“满足于让专名与其他类型的表达之间的整个区别依赖于直觉认识，仅以最为马虎的考察为向导”。[注]Dummett, Frege, Philosophy of Language, Harper & Row, Publishers, 1973, p. 54. 斯鲁格则大致总结出了识别弗雷格之专名的四个标准：

SPSS 21.0 was used for statistical analysis, and the measurement data was expressed as mean±standard deviation (mean±SD). The

-test was used to compare the common data between the two groups and between the groups in different MMHD intervals. Fisher exact probability test was used to test the closure rates and closure grade ratio of IMH after operation. BCVA before and after operation was compared with paired

-test.

<0.05 was statistically significant.

上述的三类传统算法主要基于图像整体信息的变化来选定关键帧，容易造成关键帧选取错误、计算量大、实时性差等问题。因此，本文在此基础上使用一种基于深度学习的目标检测方法，通过建立卷积神经网络(Convolutional Neural Network，CNN)模型，分类提取视频中列车头部、尾部及车身所在关键帧，使得基于深度学习的目标检测在关键帧提取的应用中成为可能。

RESULTS

Totally 75 patients (75 eyes) with IMH who underwent vitrectomy combined with internal limiting membrane peeling were included in this study. There were 21 males and 54 females with the average age of 61.2±8.1y. The courses of disease ranged from two weeks to 24mo. The average course was 3.8±7.2mo.

In the air group, there were 8 males and 22 females with the average age of 63.1±9.6y and the average course of 3.6±8.5mo. In the silicone oil group, there were 13 males and 32 females with the average age of 58.7±7.0y and the average course of disease of 4.0±6.5mo. There was no significant difference in age and course of disease between the two groups(all

>0.05). In the range of MMHD ≤400 μm (MMHD1)there were 23 eyes in air group and 16 eyes in silicone oil group; the average of MMHD were (277.6±43.9) and(303.4±43.1) μm respectively; the average of BCVA were 1.23±0.46 and 1.27±0.50 respectively; there was no statistical difference (

>0.05). In the range of MMHD>400 μm (MMHD2)there were 7 eyes in air group and 29 eyes in silicone oil group;the average of MMHD were (491.6±70.8) and (525.4±103.6)μm respectively; the average of BCVA were 1.41±0.32 and 1.40±0.39 respectively; there was no statistical difference(

>0.05).

In this retrospective study, there was no difference in the overall closure rates of IMH between air group and silicone oil group. Venkatesh

studied various quantitative parameters of IMH by observing pre- and post-operative OCT images, and found a significant negative correlation of IMH closure with MMHD. Similarly, we found that the closure rate of MMHD1 in air group was higher than that of MMHD2;although there was no difference in silicone oil group between MMHD1 and MMHD2, MMHD1 was higher than MMHD2 in absolute value. Furthermore, we subdivided MMHD and compared air group with silicone oil group again. There was no significant difference in MMHD1 closure rates between the two groups; the closure rate of MMHD2 silicone oil group was higher than that of air group. The results showed that the two tamponades both have satisfactory closure effects for smaller IMH, and there was little difference between them; for larger IMH, the closure rate of silicone oil was obviously higher than that of air.

One month after the operation, BCVA, IOP, slit lamp microscope, fundus color photography and OCT were performed with the same equipment and method as before.The closure rates, complications and BCVA of air group and silicone oil group in different MMHD intervals before and after the treatment were compared and analyzed. The disappearance of neuroepithelial layer defect in macular area showed by OCT examination was regarded as IMH closure, while its existence was regarded as IMH unclosed (Figure 1A)

. According to the reference

, the closed IMHs were divided into two grades:A (bridge closure) and B (good closure). Grade A: Subretinal fluid was still present in the class a fovea (Figure 1B). Grade B:fovea was restored to a basically normal structure (Figure 1C).

实验目的 《新疆维吾尔自治区农村双语幼儿园课程设置方案（试行）》（新教双〔2017〕15号）要求：“激发各族幼儿学习国家通用语言的兴趣，让他们能够在生动活泼的教育活动中获得国家通用语言的听、说能力。”通过实验验证信息技术能够提升南疆农村幼儿国家通用语言听说能力的发展。

One month after the operation, there was no significant change in the lens of all eyes in the air group, but the lens opacity of three eyes deteriorated in the silicone oil group. No serious complications such as endophthalmitis occurred in all cases.

The postoperative BCVA of the air group, the silicone oil group and the subgroup according to the MMHD were improved compared with the preoperative (all

<0.05). There was no significant difference in the postoperative BCVA between the overall air group and the overall silicone oil group, while the MMHD1 air group was better than the silicone oil group(

<0.05), and there was no significant difference between the MMHD2 air group and the silicone oil group (

>0.05; Table 3).According to the literature, ocular hypertension (OHT) has been defined as a postsurgical IOP>21 mm Hg or an increase of >10 mm Hg over the IOP baseline

, and ocular hypotony has been defined as a postsurgical IOP≤7 mm Hg

. There were seven eyes (15.56%) with ocular hypertension in silicone oil group and none in air group. Under the treatment with captopril hydrochloride and brinzolamide eye drops, all the IOP returned to normal within one week. There were two eyes(6.7%) with ocular hypotony in the air group, but without retinal nor choroidal detachment.

One month after operation, there was no significant difference in closure grade between MMHD1 air group and silicone oil group (

>0.05), but the proportion of Grade B in MMHD2 silicone oil group was higher than that in air group (

<0.05;Table 2).

DISCUSSION

The closure of macular hole is mainly due to the release of traction in the vertical and tangential directions

, and the top pressure of tamponade on the neuroepithelium at the edge of the hole

. It is generally considered that inert gas is a relatively ideal tamponadematerial because of its long duration effect and few side effects

. However, in recent years, most of Chinese medical institutions lack of inert gas because of infection and related problems. So, the surgeons could only choose between disinfected air and silicone oil.

One month after operation, IMHs were closed in 26 eyes out of 30 eyes in air group, and the closure rate was 86.67%. IMHs were closed in 43 eyes out of 45 eyes in silicone oil group,and the closure rate was 95.56%. There was no significant difference in IMH closure rate between the two groups(

>0.05). In MMHD1, IMHs were closed in 22 eyes out of 23 eyes in air group, and the closure rate was 95.65%; IMHs were

all closed in 16 eyes in silicone oil group, and the closure rate was 100.0%, there was no significant difference between the two groups (

>0.05). In MMHD2, IMHs were closed in four eyes out of seven eyes in air group (57.14%), and in 27 eyes out of 29 eyes in silicone oil group (93.1%), so the silicone oil group showed a better result than the air group (

<0.05).The closure rate of MMHD1 in air group was higher than that of MMHD2 (

<0.05), while the closure rate of different MMHD didn’t exist significant difference in silicone oil group(

>0.05), but the rate of absolute value in MMHD1 was higher than that in MMHD2 (Table 1).

For smaller IMH (≤400 μm), the efficacy of vitrectomy combined with air should be considered better than silicone oil; for larger IMH (>400 μm), the efficacy of silicone oil may be better than air.

There was no significant difference in BCVA between the overall air group and the overall silicone oil group. Because some studies had shown that the improvement of visual function was closely related to both the MMHD and the closure rate of IMH

, each group was subdivided according to MMHD in our study. It was found that BCVA of MMHD1 air group was better than silicone oil group, but significant difference was not found in MMHD2 between the two tamponades. There are many determinants of visual acuity after IMH surgery. For the comparison of air and silicone oil, the main factors are the closure rate, closure shape and complications

. There was no significant difference in the closure rate and shape between the two MMHD2 groups. The difference of BCVA was mainly due to the complications of silicone oil, such as complicated cataract and secondary glaucoma. In addition, the side effects of silicone oil on visual acuity include promoting preretinal proliferation and even causing macular fold

. Besides, there are many reports about the damage of optic nerve and optic chiasm caused by silicone oil drops

. In our study, the silicone oil group was better than the air group in terms of the closure rate and closure shape in MMHD2 because of the better efficacy of continuous top pressure. But at the same time,the complications of silicone oil offset those advantages.As a result, there was no significant difference in BCVA between the two MMHD2 groups.

Through this study, it can be concluded that for smaller IMH,choosing air can obtain better vision with similar closure rate,and relieve patients from pain and complications; for larger IMH, choosing silicone oil can achieve better closure efficacy with similar postoperative vision.

（1）完善顾客导向型偏离量表的文化普适性。虽然Leo等学者严格按照量表开发程序，最终形成顾客导向型偏离的测量量表，但该量表是以澳大利亚接待业一线员工基于自身工作经历而形成的问项池，直接用于测量我国酒店业一线员工的顾客导向型偏离时，是否存在文化差异还不得而知。因此，顾客导向型偏离量表的文化普适性和外部效度还需要进一步验证、完善。

Except for the size of IMH, age, axial length, epiretinal membrane,

, may be the influenced factors to the closure of IMH. It has to say that was a defect in this research.And if the observation elements were extended, that would be more complete.

Yin L: contributed to the conception of the study and wrote the manuscript; Liu AQ: conducted the statistical analysis and wrote the manuscript; Jin X: conducted the statistical analysis; Jia L: retrieved from medical records;Wang FX: contributed to the analysis and constructive instructions.

邢玠勘播后，杨应龙并没有收敛其暴虐之心。“二十四年，应龙残余庆，掠大阡、都坝，焚劫草堂、余庆二司，遍及兴隆、都匀各卫。又遣兆龙围黄平，戮重安长官家，势复大炽。二十五年，应龙流劫江津及南川，临合江，索其仇袁子升缒城下，磔之。秋七月，播州宣慰使杨应龙叛”[3]1254。杨应龙的再次反叛，似乎暗示邢玠勘播的失败，其没有遏制住杨应龙的叛逆之心。朝臣及时人对邢玠的勘播事提出质疑，其勘播事究竟如何？

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1 Frisina R, Gius I, Tozzi L, Midena E. Refractory full thickness macular hole: current surgical management.

2022;36(7):1344-1354.

2 Liu J, Hu ZZ, Zheng XH, Li YL, Huang JL, Cao EB, Yuan ST, Xie P, Liu QH. Displacement of the retina after idiopathic macular hole surgery with different internal limiting membrane peeling patterns.

2021;14(9):1408-1412.

3 Tao JW, Chen H, Chen YQ, Yu JX, Xu JW, Mao JB, Lin L, Shen LJ.Efficacy of air tamponade treatment of idiopathic macular holes of different diameters and of follow-up intravitreal air tamponade for persistent holes.

2022;42(5):877-882.

4 He F, Dong FT, Yu WH, Dai RP. Recovery of photoreceptor layer on spectral-domain optical coherence tomography after vitreous surgery combined with air tamponade in chronic idiopathic macular hole.

2015;46(1):44-48.

5 Yu YP, Liang XD, Wang ZY, Wang J, Liu XX, Chen JQ, Liu W. Internal limiting membrane peeling and air tamponade for stage iii and stage iv idiopathic macular hole.

2020;40(1):66-74.

6Veith M, Vránová J, Němčanský J, Studnička J, Penčák M, Straňák Z, Mojžíš P, Studený P, Piñero DP. Surgical treatment of idiopathic macular hole using different types of tamponades and different postoperative positioning regimens.

2020;2020:8858317.

7 Zhao XY, Meng LH, Zhang WF, Yu WH, Chen YX, Min HY. PUMCH experience and strategy for the management of idiopathic macular hole:a retrospective cohort study.

2022;42(4):1133-1145.

8 Kang SW, Ahn K, Ham DI. Types of macular hole closure and their clinical implications.

2003;87(8):1015-1019.

9 Liu PP, Sun YY, Dong CY, Song D, Jiang YR, Liang JH, Yin H, Li XX, Zhao MW. A new method to predict anatomical outcome after idiopathic macular hole surgery.

2016;254(4):683-688.

10 Liesenborghs I, Schouten JSAG, Berendschot TTJM, Beckers HJM, Nuijts RMMA, Visser N, Webers CAB. Risk factors for the development of ocular hypertension after keratoplasty: a systematic review.

2020;39(3):394-402.

11 Abbas A, Agrawal P, King AJ. Exploring literature-based definitions of hypotony following glaucoma filtration surgery and the impact on clinical outcomes.

2018;96(3):e285-e289.

12 Chen N, Zheng K. Internal limiting membrane peeling without vitrectomy for laser-induced macular holes in two children.

2022;32(3):NP41-NP45.

13 Alberti M, la Cour M. GAS-FOVEAL CONTACT: a new approach to evaluating positioning regimens in macular hole surgery.

2018;38(5):913-921.

14 González-Cortés JH, Olvera-Barrios A, Treviño-Rodríguez HA,González-Cantú JE, M-Hamsho J. Closure of stage 2 macular hole with a low-dose intravitreal injection of perfluoropropane.

2019;87(5):564-567

15 Bikbova G, Oshitari T, Baba T, Yamamoto S, Mori K. Pathogenesis and management of macular hole: review of current advances.

2019;2019:3467381.

16 Venkatesh R, Mohan A, Sinha S, Aseem A, Yadav NK. Newer indices for predicting macular hole closure in idiopathic macular holes: a retrospective, comparative study.

2019;67(11):1857-1862.

17 Sul S, Gurelik G, Korkmaz Ş, Ozsaygili C. Choroidal thickness in macular holes.

2019;39(11):2595-2601.

18 Fallico M, Jackson TL, Chronopoulos A,

. Factors predicting normal visual acuity following anatomically successful macular hole surgery.

2021;99(3):e324-e329.

19 Baumann C, El-Faouri M, Ivanova T, Patton N, Ch’ng SW, Dhawahir-Scala F, Jalil A. Manchester Revisional Macular Hole Study: predictive value of optical coherence tomography parameters on outcomes of repeat vitrectomy, extension of internal limiting membrane peel, and gas tamponade for persistent macular holes.

2021;41(5):908-914.

20 Shiode Y, Morizane Y, Matoba R, Hirano M, Doi S, Toshima S, Takahashi K, Araki R, Kanzaki Y, Hosogi M, Yonezawa T,Yoshida A, Shiraga F. The role of inverted internal limiting membrane flap in macular hole closure.

2017;58(11):4847-4855.

21 Bonińska K, Nawrocki J, Michalewska Z. Mechanism of “flap closure”after the inverted internal limiting membrane flap technique.

2018;38(11):2184-2189.

22 Chen X, Yao Y, Hao XL, Liu XC, Liu TC. A comparative study of vitrectomy combined with internal limiting membrane peeling for the treatment of idiopathic macular hole with air or C3F8 intraocular tamponade.

2018;2018:1672501.

23 Özkan B, Karabaş VL, Yılmaz Tuğan B, Altıntaş Ö. Limited vitrectomy in patients with idiopathic macular hole.

2019;36(6): 320-323.

24 Mehta N, Lavinsky F, Larochelle R,

. Assessing the ability of preoperative quantitative spectral-domain optical coherence tomography characteristics to predict visual outcome in idiopathic macular hole surgery.

2021;41(1):29-36.

25 Liu BS, Cui WN, Niu R, Chen Q, Nie ZT, Wei JT, Hu BJ. Refractive outcomes after vitrectomy combined with phacoemulsification of idiopathic macular holes.

2021;14(2):250-254.

26 Park SH, Park KH, Kim HY, Lee JJ, Kwon HJ, Park SW, Byon IS, Lee JE. Square grid deformation analysis of the macula and postoperative metamorphopsia after macular hole surgery.

2021;41(5):931-939.

27 Shukla D, Kalliath J. Internal limiting membrane peeling for large macular hole: tailoring the rhexis to the shape of the hole.

2022;70(1):182-186.

28 Hirata A, Takano A, Kawaji T, Nakamura KI. Macular pucker formation after macular hole surgery with inverted internal limiting membrane flap technique and silicone oil tamponade.

2020;19:100847.

29 Lam SC, Chan AYY, Yuen HKL. Extraocular silicone oil migration to orbit and retrolaminar region: case report and systematic review.

2020;258(12):2799-2807.

30 Chaudhary K, Mak MYK, Gizicki R, Muni RH, Wong DT, Altomare F, Berger AR. Proportion of patients with macular hole surgery who would have been favorable ocriplasmin candidates: a retrospective analysis.

2017;37(1):76-79.

31 Wu LL, Ho TC, Yang CH, Yang CM. Vitreo-retinal relationship and post-operative outcome of macular hole repair in eyes with high myopia.

2016;254(1):7-14.

32 Abdul-Kadir MA, Lim LT. Update on surgical management of complex macular holes: a review.

2021;7(1):75.