Intravitreal gas injection for macular hole with localized retinal detachment in highly myopic patients
2009; Wiley; Volume: 89; Issue: 2 Linguagem: Inglês
10.1111/j.1755-3768.2009.01649.x
ISSN1755-3768
AutoresFang‐Ting Chen, Po‐Ting Yeh, Chang‐Ping Lin, Muh‐Shy Chen, Chang‐Hao Yang, Chung‐May Yang,
Tópico(s)Intraocular Surgery and Lenses
ResumoActa OphthalmologicaVolume 89, Issue 2 p. 172-178 Free Access Intravitreal gas injection for macular hole with localized retinal detachment in highly myopic patients Fang-Ting Chen, Fang-Ting Chen Department of Ophthalmology, National Taiwan University Hospital, Taipei, TaiwanSearch for more papers by this authorPo-Ting Yeh, Po-Ting Yeh Department of Ophthalmology, National Taiwan University Hospital, Taipei, TaiwanSearch for more papers by this authorChang-Ping Lin, Chang-Ping Lin Department of Ophthalmology, National Taiwan University Hospital, Taipei, TaiwanSearch for more papers by this authorMuh-Shy Chen, Muh-Shy Chen Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, TaiwanSearch for more papers by this authorChang-Hao Yang, Chang-Hao Yang Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, TaiwanSearch for more papers by this authorChung-May Yang, Chung-May Yang Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, TaiwanSearch for more papers by this author Fang-Ting Chen, Fang-Ting Chen Department of Ophthalmology, National Taiwan University Hospital, Taipei, TaiwanSearch for more papers by this authorPo-Ting Yeh, Po-Ting Yeh Department of Ophthalmology, National Taiwan University Hospital, Taipei, TaiwanSearch for more papers by this authorChang-Ping Lin, Chang-Ping Lin Department of Ophthalmology, National Taiwan University Hospital, Taipei, TaiwanSearch for more papers by this authorMuh-Shy Chen, Muh-Shy Chen Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, TaiwanSearch for more papers by this authorChang-Hao Yang, Chang-Hao Yang Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, TaiwanSearch for more papers by this authorChung-May Yang, Chung-May Yang Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, TaiwanSearch for more papers by this author First published: 23 February 2011 https://doi.org/10.1111/j.1755-3768.2009.01649.xCitations: 20 Chung-May Yang MDDepartment of OphthalmologyNational Taiwan University HospitalCollege of MedicineNational Taiwan UniversityNo. 7, Chung-Shan South RoadTaipeiTaiwanTel: + 886 2 2312 3456 (ext. 65187)Fax: + 886 2 2393 4420Email: Chungmay@ntu.edu.tw AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract. Purpose: This study aimed to evaluate treatment effects of intravitreal gas for macular hole with localized retinal detachment (RD) in highly myopic eyes and to examine how the vitreomacular relationship and other factors may influence treatment outcomes. Methods: Twenty highly myopic patients with macular holes and localized posterior RD, treated initially with intravitreal injection of C3F8, were prospectively studied. Recurrent disease was treated with repeated gas injection or vitrectomy according to the extent of detachment. Length of follow-up was ≥ 12 months. Vitreomacular conditions were determined before and within 2 months after gas injection by standard optical coherence tomography. Demographics, refractive errors, axial length, the extent of chorioretinal (CR) atrophy and visual acuity were recorded. Results: The success rate after primary gas injection was 70%. The remaining 30% of patients achieved anatomic success after further treatment, including vitrectomy with gas or silicone oil tamponade and/or scleral buckling. All cases achieved anatomic success after a mean of 1.4 surgeries. Univariate analysis showed that the patterns of the posterior vitreoretinal relationship did not differ significantly between those successfully treated with gas only (group 1) and those requiring vitrectomy (group 2) (p = 1.000). Logistic regression showed no statistically significant differences in any characteristics between groups 1 and 2. Conclusions: Intravitreal gas tamponade alone may achieve anatomic success in more than two-thirds of highly myopic patients with macular holes and localized RD. Patients with different clinical characteristics and vitreoretinal relationships seem to have similar opportunities to achieve reattachment through this relatively non-invasive surgery. Introduction Macular hole in highly myopic patients is frequently associated with retinal detachment (RD). The pathogenesis for this has not been elucidated clearly, but anterior–posterior and tangential vitreomacular traction associated with vitreous degeneration and abnormal eyeball elongation may play an important role (Phillips & Dobbie 1963; Margheria & Schepens 1972; Stirpe & Michels 1990; Morita et al. 1991; Akiba et al. 1999). Large areas of chorioretinal (CR) atrophy in highly myopic eyes may also account for the weak retinal pigment epithelium (RPE) adhesion and poor prognosis after treatment. Many treatment modalities have been advocated, including intravitreal gas injection, pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peeling, and PPV with silicone oil tamponade or macular buckling (Blodi & Folk 1984; Oshima et al. 1998; Scholda & Egger 1998; Mitamura et al. 2000; Sasoh et al. 2000; Ripandelli et al. 2001). However, the treatment of choice remains controversial. Whereas some investigators suggest aggressive surgery as the primary treatment, others have demonstrated that intravitreal gas injection may be more appropriate for first-line treatment (Menchini et al. 1988; Lai 1990; Pernot et al. 1996; Chen et al. 2006). Review of the literature shows that primary intravitreal gas injection may achieve anatomic and functional improvement in certain patients (Miyake 1986; Menchini et al. 1988; Lai 1990; Pernot et al. 1996; Kuo et al. 2003). Although the treatment method is relatively simple and involves few postoperative complications in comparison with PPV, the results are often unpredictable and a wide range of success rates have been cited by different reports. Some patients may develop extensive detachment after the procedure. In addition, localized detachment has been suggested as unsuitable for gas injection, especially in the presence of visible vitreoretinal traction (Miyake 1986; Singalavanija et al. 1996; Chen et al. 2006). Previous studies suggested that vitreoretinal changes in the macular area may be important to the anatomic success rate after gas injection (Ripandelli et al. 2004). We conducted a prospective study to examine the results of intravitreal gas injection as the primary treatment method for high myopic macular hole with localized detachment. We also used optical coherence tomography (OCT) and clinical observation to determine the influence of vitreomacular adhesion and other factors on the anatomic success rate. Materials and Methods Twenty patients, diagnosed with macular hole with localized RD and high myopia, were enrolled for the prospective study between January and December 2007. Inclusion criteria were high axial myopia of > 9 D (spherical equivalent) and RD localized in the posterior retina without extension to the equator. Those with previously treated rhegmatogenous RD (RRD) or vitreoretinal surgeries were excluded. Patients who fulfilled the criteria underwent complete ophthalmological evaluation, axial length measurement, and standard 6-mm OCT (Stratus OCT™; Carl Zeiss Meditec, Inc., Dublin, CA, USA) before receiving intravitreal gas injection. This study was approved by the ethics committee and review board of National Taiwan University Hospital. Informed consent was obtained from all patients. Under topical anaesthesia and proper disinfection, anterior chamber paracentesis was followed by intravitreal injection of C3F8 0.25–0.3 ml. All operations were performed by the same surgeon (CMY). Patients were kept in a prone position for 1 week postoperatively and were followed weekly for 1 month and monthly for ≥ 6 months. After 6 months, the follow-up interval was extended to 2 or 3 months. Optical coherence tomography was performed within 2 months of the procedure. Recurrent detachment was treated with a second gas injection if the extent of the detachment remained localized. Otherwise, vitrectomy was performed with either gas or silicone oil tamponade, and the ILM was preserved or peeled based on the surgeon's judgement. After vitrectomy, patients were followed weekly for 1 month, then monthly for ≥ 6 months. After 6 months, the follow-up interval was extended to 2 or 3 months. Again, OCT was performed within 2 months of vitreous surgery. Background data, including age, sex, duration of symptoms, refractive error, corrected visual acuity (VA), axial length (A-scan or B-scan ultrasound) and lens status were recorded. Preoperative data included extent of RD, degree of CR atrophy, vitreous status, and the presence of posterior staphyloma. The status of peripheral vitreous adhesion observed during vitrectomy was also recorded. Postoperative VA, retinal status, follow-up duration and complications were recorded. The extent of RD was classified in three grades (Sasoh et al. 2000). Grade 1 represented RD limited to the perimacular area and within the major vascular arcades. Grade 2 referred to RD extending beyond the arcades in one or two quadrants. Grade 3 represented RD extending beyond the arcades in more than two quadrants. The degree of CR atrophy at the macular area was graded as either grade 1 (focal atrophy) or grade 2 (large focal or diffuse atrophy [obvious atrophic patch at the macula]). Vitreous status, derived from OCT images and clinical biomicroscopic examination, was classified into three categories: no posterior vitreous detachment (PVD), defined as thin membrane attached and running parallel on the surface of the macula; partial PVD, defined as partial separation of the vitreous membrane and the macula with vitreous attachment remaining at the edges of the hole or paramacular area, or complete PVD, defined as no visible preretinal membrane or visible membrane completely separated from the retina in the macular area (Fig. 1A–C). Figure 1Open in figure viewerPowerPoint Types of vitreomacular adhesion on optical coherence tomography. (A) Case 13: no posterior vitreous detachment (PVD), defined as thin membrane adherent and running parallel to the macular surface. (B) Case 6: partial PVD, defined as vitreous membrane partially separated from the macula with vitreoretinal adherence at the paramacular area. Foveoschisis was present in this case. (C) Case 19: complete PVD, defined as no membrane visible on the macular surface. Anatomic success after primary gas injection was defined by an attached retina in the macular area for ≥ 12 months after a single course of gas injections, regardless of the opening or closure of the hole. Improvement of VA was indicated if VA improved from hand motion (HM) to numbering digits (ND), from ND to ≥ 20/400, or by ≥ 1 line (Snellen). Visual acuity of ND at 100 cm was deemed equal to Snellen acuity of 2/200. Statistical analysis Continuous values in the text were expressed as mean ± standard deviation (SD). Categorical variables were reported in percentages. Differences among continuous variables were evaluated by Mann–Whitney test. Non-continuous variables were assessed using the chi-squared test. If any of the expected values was < 5, Fisher's exact test was used. To further verify the correlation between anatomic success and associated risk factors after primary gas tamponade, we performed multivariate logistic regression analysis to determine the significance of the following factors: age; duration of symptoms; axial length; lens status; extent of detached retina; degree of CR atrophy, and degree of PVD. The level of statistical significance was set at p < 0.05. Results Clinical characteristics for all patients are shown in Table 1. The mean age of the study group was 57.6 ± 9.2 years (range 43–78 years). Fourteen women (70%) and six men (30%) were enrolled. The mean duration of symptoms was 1.1 ± 1.4 months (range 0–6 months). The mean refractive error (available in 14 patients) was – 14.71 ± 5.37 D (range − 9.0 D to − 26.0 D), and the mean axial length was 29.42 ± 1.71 mm (range 26.76–33.02 mm). Preoperative VA ranged from HM to 20/100. Of all the patients, 15 (75%) were phakic and five (25%) were pseudophakic. Table 1. Clinical characteristics of patients with retinal detachment who received intravitreal gas injection. Patient no. Sex/ age, years/ lesion eye Duration of symptoms, months Refraction error, D Axial length, mm Extent of RD Extent of CR atrophy Lens status Types of PVD Foveoschisis Anatomic outcome of IVI gas Reop, n BCVA Follow-up, months Preop Postop 1 M/59/R 1 − 10.5 29.62 1 2 P 1 + Failure 2 ND 20/800 18 2 F/73/L 1 N/A* 27.62 2 2 N 3 − Failure 1 HM HM 12 3 M/61/L 0.5 − 25.5 31.01 1 2 P 3 − Failure 1 ND 2/200 18 4 F/63/R 0.3 N/A* 32.34 1 2 N 2 − Success 0 20/400 20/400 18 5 M/52/L 2 − 26.0 33.02 1 1 P 1 − Success 0 20/400 20/200 18 6 F/78/L 2 N/A* 29.03 1 1 N 2 + Success 0 20/400 20/800 17 7 F/43/R 0.3 − 9.5 26.76 1 1 P 1 − Success 0 2/200 20/500 18 8 F/43/R 0 − 17.0 27.68 2 1 P 3 − Success 0 ND ND 15 9 F/57/L 0.3 − 12.5 29.93 1 1 P 3 − Success 0 ND HM 16 10 F/55/L 1 N/A† 28.03 2 1 P 1 − Success 0 20/100 20/200 15 11 F/52/L 1 − 14.0 28.76 3 1 P 3 − Success 0 ND 20/400 18 12 M/57/L 2 − 11.5 29.93 1 1 P 1 − Failure 1 20/200 20/400 14 13 F/68/R 0 − 15.0 27.37 2 2 P 1 − Success 0 2/200 20/400 12 14 F/48/R 6 − 18.0 30.55 1 1 P 3 + Success 0 20/400 20/150 14 15 M/47/L 0.3 − 12.0 28.05 1 1 P 1 − Success 0 2/200 20/400 12 16 F/55/R 0.3 N/A* 30.86 2 2 N 2 − Failure 2 20/400 20/150 12 17 F/57/R 0.3 − 14.5 31.06 1 1 P 1 − Success 0 2/200 2/200 18 18 F/65/R 2 N/A* 29.29 1 2 N 3 − Success 0 20/400 20/150 12 19 M/63/L 0.3 − 11.0 29.72 2 1 P 3 − Failure 1 20/400 20/500 12 20 F/56/R 0.3 − 9.0 27.77 2 1 P 3 − Success 0 ND 2/200 12 * Cases 2, 4, 6, 16 and 18: no refraction data before cataract surgery. † Case 10: no refraction data before radial keratotomy. RD = retinal detachment; CR = chorioretinal; PVD = posterior vitreous detachment; IVI = intravitreal injection; Reop = reoperation; BCVA = best corrected visual acuity; Preop = preoperative; Postop = postoperative; R = right eye; L = left eye; P = phakia; N = pseudophakia; ND = numbering digits; HM = hand motion. Grading of RD extent: grade 1 = RD limited to the perimacular area and within the major vascular arcades; grade 2 = RD extending beyond the arcades in one or two quadrants; grade 3 = RD extending beyond the arcades in more than two quadrants. Grading of CR atrophy at the macular area: grade 1 = focal atrophy; grade 2 = large focal or diffuse atrophy. Grading of PVD (according to optical coherence tomography findings): 1 = no PVD; 2 = partial PVD; 3 = complete PVD at macular area. Twelve cases (60%) had grade 1 RD extension, seven (35%) had grade 2, and one (5%) had grade 3. Thirteen patients (65%) had grade 1 CR atrophy, and seven patients (35%) had grade 2 CR atrophy. Eight patients (40%) had no PVD, three (15%) had partial PVD and nine (45%) had complete PVD. Three patients had concurrent foveoschisis in addition to macular hole-related RD. All patients in our study had prominent posterior staphyloma demonstrated in both biomicroscopic examination and OCT images. Fourteen patients (70%) had retinal attachment after a single gas injection, whereas six (30%) had persistent or recurrent RD that required additional surgery to achieve retinal attachment. In those who achieved anatomic success after primary gas injection, the macula usually became completely reattached within 1 week, and the residual surrounding fluid, mainly in the inferior part, was reabsorbed within 2 weeks. Additional surgeries to achieve anatomic success included vitrectomy in three patients (cases 2, 3 and 12), with or without silicone oil tamponade. One patient (case 16) received another session of intravitreal C3F8 injection; however, disease recurred in this patient and vitrectomy was needed. The remaining two patients (cases 1 and 19) suffered from RRD 1 month after gas injection, and scleral buckling with vitrectomy was performed to achieve retinal reattachment. The mean number of operations was 1.4 (range 1–3). All recurrences occurred within the first 2 months. Although all patients achieved attachment of the retina, none showed closure of the macular hole at the latest visit. Comparison of pre- and postoperative OCT images showed no significant change in the status of vitreomacular adhesion after primary gas injection whether or not anatomic success was achieved. Postoperative VA ranged from HM to 20/150. Seven patients (35%) achieved improvement in VA; 10 patients (50%) achieved stable VA and three patients (15%) had worse VA despite the reattached retina after surgery. Mean follow-up duration was 15.1 ± 2.6 months (range 12–18 months). Postoperative complications occurred in five patients with transient elevation of intraocular pressure (IOP) and two patients had RRD at 1 month and 1.5 months, respectively, after gas injection. The relationships between patient characteristics and anatomic outcomes are described in Table 2. Age, duration of symptoms, axial length, lens status, extent of RD, and CR atrophy showed no statistical difference in terms of treatment success between patients who received intravitreal gas (group 1) and those who had vitrectomy (group 2). Analysis of preoperative vitreomacular relationships shows that the two groups had similar proportions of absence of PVD, partial PVD and complete PVD (p = 1.000). Logistic regression analysis confirmed that no specific factors were significantly associated with anatomic success (Table 3). Table 2. Patient characteristics for anatomic success and failure groups after primary gas tamponade. Characteristic Anatomic outcome after intravitreal gas injection alone Success (n = 14) (70%) Failure (n = 6) (30%) p-value Mean patient age, years (range) 56.0 (43∼78) 61.3 (55∼73) 0.160 Mean duration of symptoms, months (range) 1.1 (0∼6) 0.9 ( 0.3∼2) 0.636 Mean axial length, mm (range) 29.26 (26.76∼33.02) 29.79 (27.62∼31.01) 0.433 Lens status, n (%) Phakic 11 (78.6) 4 (66.7) 0.613 Pseudophakic 3 (21.4) 2 (33.3) Extent of RD, n (%) Grade 1 9 (64.3) 3 (50) 0.732 Grade 2 4 (28.6) 3 (50) Grade 3 1 (7.1) 0 (0) Extent of CR atrophy, n (%) Grade 1 11 (78.6) 2 (33.3) 0.122 Grade 2 3 (21.4) 4 (66.7) Type of PVD, n (%) No PVD 6 (42.9) 2 (33.3) 1.000 Partial PVD 2 (14.2) 1 (16.7) Complete PVD 6 (42.9) 3 (50.0) Mean follow-up, months (range) 15.4 (12∼18) 14.3 (12∼18) 0.463 Statistical analyses of age, duration of symptoms, axial length and follow-up duration were performed using Mann–Whitney U-test. Other analyses were performed using chi-squared test. If any of the expected values were < 5, Fisher's exact test was performed. p < 0.05 was considered statistically significant. CR = chorioretinal; PVD = posterior vitreous detachment. Table 3. Logistic regression analysis of risk factors affecting anatomic results after primary gas tamponade. Presumed factors influencing anatomic success Odds ratio 95% confidence interval p-value Age, years 0.91 0.72–1.14 0.393 Duration of symptoms, months 0.91 0.30–2.75 0.876 Axial length, mm 0.61 0.22–1.71 0.345 Lens status 0.15 0.00–5.36 0.295 Extent of detached retina 0.38 0.03–5.49 0.481 Degree of CR atrophy 0.10 0.00–2.05 0.133 Degree of PVD 0.78 0.18–3.40 0.742 CR = chorioretinal; PVD = posterior vitreous detachment. Discussion Various vitreoretinal surgical techniques, including vitrectomy, scleral buckling and pneumatic retinopexy, have been proposed to treat RD associated with macular hole in high myopia. Each may have its own benefits and drawbacks. Uemoto et al. (2004) reviewed their surgical results of ILM-preserved and ILM-peeled vitrectomy and found the ILM-peeled group had a higher initial success rate (92.3% versus 50%). However, ILM peeling on the detached retina is technically demanding, and the macular toxicity of the staining dye (indocyanine green [ICG]), especially in the presence of an opened macular hole, would be of great concern. Other studies have reported favourable longterm treatment outcomes of episcleral macular buckling with sponge or plomb (Theodossiadis & Theodossiadis 2005; Ando et al. 2007). The latter group reported a higher success rate using episcleral macular buckling in comparison with vitrectomy (93.3% versus 50.0%). However, there may be potential risks of optic nerve or vortex vein damage unless B-scan ultrasonography is used to identify the proper sponge location during macular buckling procedures. Furthermore, the use of sonography guidance may increase the complexity of the surgery and is more time-consuming. In addition, although macular buckling may remodel the curve of the posterior staphyloma and may decrease the axial length, the procedure raises concerns about perfusion interference from mechanical compression on a very thin ocular coat. Gas tamponade is the simplest technique with which to treat the disease. One study reported a 71.4% success rate after primary C3F8 injection with a median follow-up of 27.5 months (Pernot et al. 1996). However, another study reported a lower success rate in gas tamponade alone (12.5%) in comparison with other surgical procedures (the highest success rate [75%] was reported for combined PPV scleral buckling and silicone oil infusion) (Chen et al. 2006). There is great diversity in surgical outcomes after similar procedures and, because of inter-group differences in sample size, patient characteristics, detachment area and follow-up duration, these results cannot be adequately compared. In the present study, we specifically aimed to examine the results of gas injection in highly myopic patients with localized RD. We found that after a single session of treatment, anatomic success could be achieved in more than two-thirds of cases. After further vitrectomy, all cases obtained complete retinal reattachment. In the present study, there were no significant differences in patient age, duration of symptoms, axial length, lens status, extent of RD, extent of CR atrophy and follow-up duration between the gas injection success group and failure group. Importantly, we found no major discrepancies regarding PVD status between the two groups. Ripandelli et al. (2004) used different approaches to repair myopic RD-associated macular hole, based on vitreoretinal relationships and the extent of CR atrophy. Only in cases with complete PVD was pneumatic retinopexy used. In this selected group, the authors obtained a 92% (23/25 eyes) retinal reattachment rate by treating the patients with pneumatic retinopexy, external drainage and diode laser at the macula. Those with vitreoretinal adhesions were treated with vitrectomy. Ripandelli et al. (2004) suggested the use of vitrectomy with or without epiretinal membrane removal or macular buckling, rather than pneumatic repair alone for patients with vitreous traction, incomplete PVD, vitreous veils or strands and posterior vitreous schisis (PVS). In our present study, we could not verify the hypothesis that closely or partially adherent vitreous membrane negatively affects the anatomic success of intravitreal gas alone. In other words, in high myopia with macular hole and localized RD, eyes with different vitreoretinal adhesion patterns would not have different rates of retinal reattachment. Although previous investigators have questioned the sufficiency of intravitreal gas tamponade alone in overcoming the curvature of posterior staphyloma in highly myopic eyes, our results suggest that longterm anatomic success after gas tamponade alone can be achieved (Chen et al. 2006). The large area of CR atrophy in highly myopic eyes is also considered to contribute to their poor retinal adhesion to the underlying RPE after surgery. We found that the successful group, after primary gas tamponade, had less extensive CR atrophy compared with the failed group, but the difference was of no statistical significance. All patients in our study had only localized detachment. The limited extent of RD may indicate weaker vitreoretinal traction or more efficient pigment epithelium pumping. We postulate that the expansile gas may stretch the vitreous hyaloid, thus weakening the vitreomacular traction and making it easier for the retina to stay attached. Although in some cases the gas bubble may not conform tightly to the curvature of posterior staphyloma, it should be able to seal the macular hole with elevated retina without difficulty. As subretinal fluid is partially pushed away by the gas bubble and further fluid influx into the subretinal space via the hole is prevented, retinal elevation may be markedly reduced. Once the detached retina and underlying RPE approximate, the subretinal fluid will be rapidly pumped out by RPE cells. Thus retinal reattachment may not require constant contact between gas bubble and hole edge. We hypothesize that if the pumping function of RPE cells overcomes the force of vitreous traction and the speed of fluid influx, the retina will stay attached. Conversely, failure to achieve this dynamic balance will result in recurrent disease during gas absorption, and it may explain why all of our recurrence occurred shortly after gas injection (i.e. within 2 months). However, no significant predictive factor for success was identified in our study. By contrast, because OCT only accesses a limited area of the posterior pole, partial PVD with mid-peripheral vitreoretinal adhesion may be interpreted as complete PVD. The beneficial effect of a truly complete PVD may possibly be underestimated. Ripandelli et al. (2004) found that both B-scan ultrasonography and OCT can assess vitreoretinal adhesion. They suggested that combined interpretation of the results from B-scan ultrasound and OCT scans would allow better definition of PVD and PVS. However, as the authors pointed out, the examination and interpretation of B-scan ultrasonography can be difficult. For practical reasons, only OCT was used for the evaluation of the vitreoretinal relationship in the present study. This limitation may make the assessment of correlations between vitreoretinal relationships and the efficacy of gas injection less than ideal. In our study, we noticed that vitreous membranes may be of different thicknesses, and more than one layer of membrane may be identified by OCT in some cases. When the latter condition exists, it is difficult to determine the predominant direction of traction. However, the presence of vitreous schisis did not seem to be a major factor leading to anatomic failure by gas injection in our study. All of our patients had non-closure of the macular hole, despite reattachment of the retina. Other studies using different surgical treatments have also shown the rate of regaining normal macular configuration to be unsatisfactory. Ikuno et al. (2003) reported only that only 44% (7/16) of eyes had a normal concave shape of the macula postoperatively. Fang et al. (2009) found that 46% (11/24) of eyes had a normal foveal contour after vitrectomy with epiretinal membrane peeling. Ichibe et al. (2003) studied 10 cases of macular hole with RD receiving vitrectomy with ILM peeling. They found a low macula hole closure rate (10%), and observed postoperative enlargement of the hole in seven cases. There may be a possible imbalance between the retina and the choroid–sclera complex associated with elongated axial length and posterior staphyloma in highly myopic eyes. In those cases that underwent vitrectomy, complex vitreoretinal adhesions were noted. Most had variable degrees of vitreous detachment. Even in cases with complete PVD, vitreoretinal attachment was noted far below the vitreous base. After gas injection, the vitreous fibre may be stretched around the gas bubble. This mechanism may explain the more extensive detachment when gas injection failed as the primary procedure. Another related complication is new break formation and detachment. Within 2 months after the procedure, two patients, one without PVD (case 1) and one with complete PVD (case 19), suffered from RRD with multiple peripheral breaks. Algvere et al. (1988) treated 58 RRD patients with pneumatic retinopexy alone and found new breaks occurred in 12% of eyes and RD in previously uninvolved quadrants was found in 24%. The incidence may be higher in highly myopic eyes because of complex vitreoretinal adhesion and the frequent presence of peripheral retinal degeneration. Apart from the increased severity of RD, other complications after gas injection were few. Five patients in this study had transient elevation of IOP that was easily controlled by medication. Only a few (35%) patients in our study achieved an improvement in VA after primary gas tamponade, whereas 50% had stable VA and 15% had worsened vision. Nearly all of our patients had VA < 20/200, either pre- or postoperatively. Other studies have also shown limited visual recovery, regardless of retina status after surgery. In the study by Ichibe et al. (2003), an improvement in VA of ≥ 2 logMAR after PPV and ILM peeling was noted in 80% of patients. However, 90% of patients had postoperative VA ≤ 20/200. Another study by Lam et al. (2006) showed that VA after vitrectomy and gas tamponade was improved in 38.3%, unchanged in 38.3%, and worsened in 23.3% of cases. Mean pre- and postoperative BCVAs were 20/538 and 20/505, respectively. Available data suggest that postoperative VA is poor in myopic macular hole with RD, despite anatomic success. The thin retina, choroids and sclera, with their low retinal sensitivity, in highly myopic eyes may account for the limited functional recovery. There are inherent limitations to the study of macular hole with RD in high myopia that arise from the rarity of the disease. Currently, there is no consensus for optimal management. Our study had some limitations, including a small sample size, limited assessment of vitreoretinal relationships and lack of comparison with other surgical modalities. In addition, our follow-up time was relatively short. It may be possible that some cases with initial anatomic success may ultimately result in recurrent RD after longer follow-up. However, in a disease with such poor functional outcome, our study indicates that intravitreal gas injection may still be an appropriate first-line treatment in patients with localized disease, even if PVD is not present. In addition, this relatively non-invasive procedure does not preclude the feasibility of further vitreoretinal surgery if necessary, and, in our experience, the ultimate anatomic outcome is good. 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