Denice S. Feig MD, MSc, FRCPC

• Associate Professor
• Department of Medicine
• University of Toronto
• Head, Diabetes in Pregnancy Program
• Division of Endocrinology
• Mount Sinai Hospital
• Toronto, Ontario, Canada

Although perivascular sheathing may be due to actual perivascular infiltrates thyroid symptoms dogs purchase levothroid 200 mcg on line, tortuous dilation of the retinal veins probably is not thyroid symptoms low blood sugar purchase levothroid 200 mcg with amex. The veins and arteries may assume a yellowish tinge because of both anemia and leukocytosis thyroid cancer pathology buy levothroid on line. In general thyroid symptoms horses purchase 50 mcg levothroid amex, hematologic parameters are not associated with the presence of cottonwool spots dr oz thyroid cancer x rays buy levothroid 50mcg otc. A systemic hyperviscosity state should be suspected in patients with simultaneous thyroid symptoms low blood sugar buy levothroid 200 mcg lowest price, bilateral retinal vein occlusion. Also, the very high white cell count may lead to a hyperviscosity state that results in poor absorption of cerebrospinal fluid, creating a clinical picture similar to that of benign intracranial hypertension with bilateral disc swelling. Seven of nine patients with chronic myelogenous leukemia and three of 10 patients with chronic lymphocytic leukemia had this finding, but it was not present in any of the 21 patients with acute leukemia. They noted that trypsin digest of the retina was essential or else the change would be overlooked on histopathologic examination. Peripheral retinal neovascularization has been reported in patients with chronic myelogenous leukemia in association with peripheral capillary nonperfusion. Morse and McCready50 reported on a 32-year-old patient with chronic myelogenous leukemia and retinal neovascularization. The fasting blood sugar value was normal, as was the hemoglobin electrophoresis study. A fluorescein study highlighted multiple sea fans, and obliteration of the terminal arterioles was apparent. Numerous sea fans were apparent, and a glucose tolerance test and hemoglobin and serum protein electrophoresis studies were negative. Kincaid and Green,1 however, did not see any cases of peripheral retinal neovascularization in their series. Levielle and Morse48 described a patient with chronic myelogenous leukemia who had a relatively low (33. However, the authors did not emphasize that their patient also had an 11-year history of diabetes mellitus; therefore diabetic retinopathy also may have contributed to retinal capillary nonperfusion and formation of peripheral neovascularization. The patient developed bilateral rubeosis, and after aggressive laser and vitrectomy, her vision declined to 20/200 bilaterally as a result of macular ischemia. The accelerated course of diabetic retinopathy correlated most closely with the anemia accompanying her leukemia and its treatment. They described progression of the neovascularization caused by the additive effects of radiation retinopathy and chemotherapy, resulting in macular traction detachment. The authors postulated that toxic effects of chemotherapy when combined with radiation therapy could lead to a more severe form of ischemic retinal vasculopathy than would be encountered with acute lymphocytic leukemia alone. Although commonly associated with severe leukocytosis, white-centered hemorrhages may be present regardless of the degree of leukocytosis. We have prospectively correlated the ocular findings with hematologic values on presentation in our series of 120 cases examined within a few days of diagnosis. In addition, there was also a statistical difference between hematocrits (a mean of 20. However, a two- or three-point difference in the hematocrit is not of clinical importance. We believe that the platelet count plays a much stronger role in determining the presence or absence of intraretinal hemorrhage. The presence of specific retinal manifestations of leukemic retinopathy and the subsequent risk of developing an intracranial hemorrhage was reported by Jackson et al. No increased risk of intracranial hemorrhage existed with the presence of non-macular intraretinal hemorrhages, white-centered hemorrhages, or cotton-wool spots. Therefore, patients with macular hemorrhages may require close monitoring for the possible development of intracranial hemorrhages, and these patients may need platelet transfusions if such an intracranial hemorrhage occurs. Patients with cotton-wool spots were eight times more likely to die in the follow-up period than patients without this finding, possibly because of severe bone marrow dysfunction. The prognostic significance of leukemic retinopathy in childhood leukemia was evaluated in 63 patients by Ohkoshi and Tsiaras. These two studies suggest that patients with clinical leukemic retinopathy may have more aggressive systemic disease that might lead to a worse prognosis. Although peripheral blood counts or retinal hemorrhages and exudates do not seem to be predictors of systemic relapse or mortality, retinal infiltrates defined as whitish irregular patches near or around retinal vessels have been associated with leukemia that has a worse prognosis. Opportunistic Infections Opportunistic infections are common in immunosuppressed patients. Rather, systemic chemotherapy is administered in an attempt to control the underlying systemic problem. It is not known whether or not most systemic chemotherapeutic agents penetrate into the eye. Varying doses have been used,1 and consultation with an experienced radiation oncologist is essential. In addition, the authors cite a number of other cases in which the procedure has been used successfully. In addition, malignant lymphomas are divided into primary intraocular lymphoma and secondary intraocular lymphoma. Primary intraocular lymphoma involves primary central nervous system lymphoma, whereas secondary intraocular lymphoma involves a metastasis from a primary visceral lymphoma. The incidence of neoplastic intraocular involvement in patients with lymphomas is probably much less than that in patients with various leukemias. Lymphoid infiltration of the uvea, formally termed reactive lymphoid hyperplasia, is rare and usually is not associated with systemic disease. They are predominantly of B-cell lymphocytic origin, although some may be derived from T cells. In the past decade there has been a steady increase in the frequency of reports of primary intraocular lymphomas. Retinal hemorrhages and cotton-wool spots related to anemia or thrombocytopenia are common in patients with non-Hodgkin lymphoma, but direct retinal involvement in patients with systemic lymphoma is extremely rare. The patient was treated with 3000 cGy of external beam radiation, and a partial response occurred. The authors believed that the most likely cause was lymphomatous infiltration, although no pathologic examination was performed. Neuroimaging has been shown to have a low sensitivity for differentiating intraocular lymphoma from uveitis or melanoma. The paraneoplastic syndrome of bilateral diffuse uveal melanocytic proliferation has been reported in the single case of a patient with non-Hodgkin systemic lymphoma. Patients with "numerous white deposits in the retinal periphery," chorioretinitis, Roth spots, and perivascular retinitis have been reported. A vitrectomy specimen demonstrated only acute and chronic inflammatory cells, and no tumor cells were seen. Toxoplasmic uveitis and chorioretinitis,133 Nocardia infection,134 and virtually all viral infections of the herpes family have been previously reported. In the past few years, ophthalmologists have employed the use of intravitreal injection of chemotherapeutic agents as an alternative to external beam radiation of the eye. Reports have demonstrated successful use of intravitreal methotrexate and rituximab. There are three stages of the disease: (1) a prolonged phase of premycotic/eczematous skin lesions; (2) a phase characterized by infiltrative plaque lesions; and (3) a final phase of frank cutaneous tumor. Most affected individuals develop the disease in the fifth decade of life, and many die of unrelated causes before widespread involvement. Mycosis fungoides involves the eye in up to one-third of individuals and tends to involve the external eye and adnexa much more commonly than the intraocular structures. The disc swelling was probably related to papilledema because lethargy, confusion, and focal neurologic signs were observed. On histopathologic examination, atypical cells and lymphocytes, as well as polymorphonuclear cells, were seen in the vitreous. Similar atypical cells infiltrated the retina, and a perivascular lymphocytic infiltrate was noted. Rossi reported on a patient with bilateral papilledema, venous stasis, retinal edema, and retinal hemorrhages. A 16-year-old girl who died of visceral mycosis fungoides had no light perception in either eye or bilateral disc swelling. The largest series of patients with mycosis fungoides reported in the ophthalmic literature is that of Stenson and Ramsay. Note disc hyperfluorescence, perivascular staining, and foci of hyperfluorescence at the level of the retinal pigment epithelium. Burkitt lymphoma is the most common childhood tumor in Africa, but it occurs only rarely in the United States. Burkitt lymphoma commonly involves the orbital structures, and the authors did not rule out the possibility that an invasive orbital neoplasm secondarily involved the intraocular structures. Histopathologic study demonstrated diffuse neoplastic infiltration of the optic disc and peripapillary retina. Chronic myeloid leukemia presenting with bilateral central retinal vein occlusion and massive retinal infiltrates. A prospective ophthalmic evaluation of patients with acute myeloid leukemia: correlation of ocular and hematologic findings. Retinopathy in acute leukaemia at initial diagnosis: correlation of fundus lesions and haematological parameters. A histopathologic study of 716 selected eyes in patients with cancer at the time of death. Orbital and ocular manifestations of acute childhood leukemia: clinical and statistical analysis of 180 patients. Unilateral optic nerve infiltration as an initial site of relapse of acute lymphoblastic leukemia in remission. Multiple myeloma recurrence with optic nerve infiltration diagnosed by vitrectomy, immunohistochemistry, and in situ hybridization. Retinal angiopathy resembling unilateral frosted branch angiitis in a patient with relapsing acute lymphoblastic leukemia. Ocular manifestations and pathology of adult T-cell leukemia/lymphoma associated with human T-lymphotropic virus type 1. It may be related to hyperviscosity,155 although a frank hyperviscosity syndrome is not as common in patients with multiple myeloma as it is in patients with, The retinal findings are chiefly those of systemic hyperviscosity, although manifestations of anemia or thrombocytopenia may be seen. Clinically, patients may present with bilateral venous dilation, which is difficult to differentiate from the findings of central retinal vein obstruction. Leukemic retinopathy: relationship between fundus lesions and hematologic parameters at diagnosis. Macular hemorrhage in adult acute leukemia patients at presentation and the risk of subsequent intracranial hemorrhage. Human T-cell lymphocytic virus type-1 associated T-cell leukemia/lymphoma masquerading as necrotizing retinal vasculitis. Ocular manifestations of leukemia: leukemic infiltration versus infectious process. Acquired toxoplasmic retinitis in an immunosuppressed patient: diagnosis by transvitreal fine-needle aspiration biopsy. Ischemic retinopathy occurring in patients receiving bone marrow allografts and Campath-1G: a clinicopathological study. Hyperleucocytic retinopathy in chronic granulocytic leukaemia: the role of intensive leukapheresis. Serous retinal detachment in a case with chronic lymphocytic leukemia: no response to systemic and local treatment. Bullous exudative retinal detachment due to infiltration of leukemic cells in a child with acute lymphoblastic leukemia. Manifestations of hairy cell leukemia with dramatic response to 2-chloro-deoxyadenosine. Optic disc neovascularization associated with ocular involvement in acute lymphocytic leukemia. The association of pale-centered retinal hemorrhages with intracranial bleeding in infancy. The role of abnormal hemorrheodynamics in the pathogenesis of diabetic retinopathy. Relation of viscosity of blood to leukocyte count with particular reference to chronic myelogenous leukemia. Occlusive microvascular retinopathy with optic disc and retinal neovascularization in acute lymphocytic leukemia. Clinical features, laboratory investigations and survival in ocular reticulum cell sarcoma. Choroidal infiltrates as the initial manifestation of lymphoma in rheumatoid arthritis after treatment with low-dose methotrexate.

Diseases

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Evidence of cross-link formation of vitreous collagen during experimental ocular 30 thyroid gland throat order levothroid in united states online. Rhegmatogenous retinal detachment complicated by severe intraocular inflammation thyroid cancer ribbon images trusted 200 mcg levothroid, hypotony thyroid gland labeled best levothroid 50 mcg, and choroidal detachment thyroid cancer website discount levothroid 100 mcg on-line. Randomized clinical trial of cryotherapy versus laser photocoagulation for retinopexy in conventional retinal detachment surgery thyroid in neck levothroid 200 mcg online. Silicone oil in the surgical treatment of endophthalmitis associated with retinal detachment thyroid urination levothroid 100 mcg with amex. Laser photocoagulation repair of macula-sparing cytomegalovirus-related retinal detachment. Repair of retinal detachment caused by cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome. A masked prospective evaluation of outcome parameters for cytomegalovirus-related retinal detachment surgery in patients with acquired immune deficiency syndrome. Treatment of retinal detachments in patients with the acquired immune deficiency syndrome. Clear lens extraction with intraocular lens implantation during retinal detachment repair in patients with autoimmune deficiency syndrome and cytomegalovirus retinitis. Cataract extraction after silicone oil repair of retinal detachment due to necrotizing retinitis. Pathologic myopia is defined as high myopia with any posterior myopia-specific pathology from excess axial elongation. Pathologic myopia is characterized by posterior staphyloma formation and also is associated with specific macular complications such as choroidal neovascularization and chorioretinal atrophy. Myopic foveoschisis and macular holes with or without retinal detachment are also specific to myopia and major indications for surgical intervention. Observation of a myopic macular area using a contact or non-contact lens has been challenging because the atrophy lowers the contrast. This has hindered detailed observation and consequent understanding of the pathophysiology, although myopia-specific macular diseases have been well known for a long time. Some of the incidence rates worldwide range from 1% in Black Americans,1 2% in Caucasian Americans,1 2. This information has led to revolutionary changes in the disease concept of myopia-specific macular diseases. This procedure maximizes the signal and enhances the contrast of the pathology being targeted. Third, large internal fixation or external fixation must be used to avoid unnecessary ocular movement in cases with a large central scotoma. For instance, a small macular hole is sometimes outside the fovea, and other micropathologies such as retinal vascular microfolds, internal limiting membrane detachments, and paravascular microholes are far outside the macula. The use of the 5-lines or grid scan has a significantly higher rate of detection of these pathologies than the use of a single B-scan alone. Imaging technologies have identified myopic foveoschisis, which is a relatively new pathology that was recognized about 15 years ago. This information is also helpful for understanding the process and pathophysiology of macular holes and retinal detachments, which are the most problematic complications for vitreoretinal surgeons. In this article, we review the recent studies and shed light on the vitreoretinal complications of high myopia. We normally use a 25-gauge system for vitrectomy, and a small-gauge system works well in cases of high myopia. Myopic foveoschisis is also referred to as a posterior retinal detachment without a macular hole in highly myopic eyes, described by Phillips in 1958, who reported a case with a retinal detachment within posterior staphyloma but no apparent macular hole. The prevalence of any type of retinal detachment increases in association with the degree of negative refractive error. The fundus photograph (inset) shows a slightly elevated retina at the posterior pole, although it is not visually apparent. A horizontal optical coherence tomography scan involving the macula shows retinoschisis in multiple retinal layers and a retinal detachment at the fovea (asterisk). There is glial tissue bridging the inner and outer layers of the retinoschisis (a so-called column, arrow). Preretinal membranes, which can be hard to recognize clinically and are found only at the microscopic level in highly myopic eyes,24 cause deterioration in the retinal flexibility. Histologic studies have shown retinoschisis at multiple levels in the outer plexiform layer, inner plexiform layer, ganglion cell layer, and nerve fiber layer. The vitreous cortex adhering to the retinal surface around the hole causes tangential traction that generates an inward vector component in deep staphyloma in highly myopic eyes, resulting in a retinal detachment. A macular hole with retinoschisis typically presents with deeper posterior staphyloma, which explains the lower anatomic success rate in this subtype. In addition, with deep staphyloma it is more difficult to close the macular hole because of excess stretching in the retina. While shallower, posterior staphyloma generates less tractional force and the retina is flat as seen in nonmyopic eyes. This flat configuration exerts less stretching in the retina, and, thus, the macular hole is more likely to close. The type of macular hole is highly dependent on the depth of the posterior staphyloma and underlying tractional force, which affect the anatomic success rate. In highly myopic eyes, multiple components adhere to the retinal surface in most cases and are often recognized during vitreous surgery. This microfold is associated with the retinal vessels and warrants microvascular traction on the retina. Multiple, small and round retinal holes are located along the retinal vessels of the temporal arcade (arrows). Microholes are typically small, round or oval retinal holes associated with posterior major vessels. However, if the patient presents with only retinoschisis but not a foveal retinal detachment, the surgery is not as urgent. In cases with a very atrophic retina, it can be difficult to distinguish retinoschisis from a retinal detachment, and the presence of the column is an important clue for diagnosing retinoschisis but not a detachment. This is coincident with retinal vessels and the so-called retinal microvascular traction. The first stage is the development of the so-called retinoschisis type, in which only retinoschisis is present and not a retinal detachment. Patients may be aware of an absolute scotoma at the center of the relative scotoma when a macular hole opens. Patients also report visual loss at the involved area if an extensive retinal detachment is complicated. This stage is the so-called foveal detachment type, and a retinal detachment involving the fovea and retinoschisis around the macula are present. This is how a macular hole appears as a consequence of retinoschisis with a retinal detachment. Small macular holes are often difficult to visualize in a B-scan image because the fixation point has shifted. As discussed previously, there are two types of macular holes in highly myopic eyes. There is no retinal detachment around the hole clinically, and this type usually does not progress for months or years. This type of macular hole results from myopic foveoschisis and can be considered a transition from foveoschisis to a macular hole with a retinal detachment. This type of macular hole typically progresses rapidly and is likely to complicate the retinal detachment because of underlying traction (see Etiology and pathophysiology, above). Appearance of subretinal fluid after macular hole formation indicates a worse prognosis. A localized retinal detachment in the posterior staphyloma from the macular hole often develops; however, there may be surgical benefits only in selected cases. The surgery should be performed as soon as possible if the situation progresses, because patients are at risk of total visual loss. A macular hole with an extensive retinal detachment is a good indication for surgery. However, sometimes the traction persists from the retinal vessels even after a complete vitrectomy, leading to recurrence of the retinal detachment. Treating the posterior staphyloma is theoretically required for these cases, and placing a macular buckle might be considered. Therefore, the expectation for anatomic success is not as high as that associated with vitrectomy with complete removal of any traction. The visual outcome associated with myopic foveoschisis is favorable if no macular hole develops. We reported that a substantial visual gain was achieved after vitrectomy in either group and that the final vision was similar between the foveal detachment type and the retinoschisis type; however, the visual change was significantly greater in the foveal detachment group than in the retinoschisis group. We investigated the incidence of postoperative macular hole formation and explored the risk factors. Investigators have reported that the vision decreased in 69% of patients, a macular hole developed in 31% after 3 years of follow-up,44 and in 50% of patients with retinoschisis a macular hole or retinal detachment developed after 2 years. SurgicalIndications Myopic foveoschisis is sometimes asymptomatic, especially in cases with simple retinoschisis and no retinal detachment. Even though patients are aware of a visual disturbance, turbulence, or visual loss, surgery can be postponed until the vision decreases to about 20/40 because there is still a chance of visual worsening after vitrectomy. The chance of visual improvement after surgery is about 80% in cases with a foveal detachment and 50% with retinoschisis alone. The vitreous tightly and extensively adheres to the retinal surface in highly myopic eyes. Use of triamcinolone acetonide is essential for visualization and to identify residual cortex. To create posterior vitreous separation, a vitreous cutter and silicone-tipped backflush needle with active suction are normally used. A diamond-dusted membrane scraper62 is another option for an extremely thin vitreous cortex. The vitreoretinal adhesion is normally tight around the optic nerve disc, and, therefore, the surgeon might consider starting temporally where the adhesion is normally the weakest. Importantly, great care is needed to separate the vitreous at the macula because the macula is tightly adhered to the vitreous; placing stress on the macula may lead to macular hole formation. This procedure is difficult to perform in the detached retina, and a bimanual technique can be considered for a safe separation. This is partly because of higher mechanical tension of the posterior eye wall inside the posterior staphyloma. Tamponade In cases of macular holes with or without a retinal detachment, gas tamponade must be performed at the end of surgery. Several case series have been reported with better surgical outcome in eyes with a macular hole and retinal detachment. Most recently use of silicone sponges with bendable metallic wire inside the sponge has been reported. The arm is adjusted to fit the scleral curve so that the tip of the buckle reaches the macula. Macular buckling reportedly has a higher success rate for retinal reattachment than vitrectomy,60,61 likely because of the change in the vector force. Tangential traction generates the inward vector force in the posterior staphyloma, which is concave in shape. Macular buckling changes the macular area to a convex shape, and the vector force changes in direction to reattach the retina. However, metamorphopsia and disruption of the choroidal circulation with protrusion of the posterior pole are the major concerns after macular buckling surgery. This maneuver is associated with a learning curve for placing the tip at the macula because it is a blinded procedure. However, if the retina detaches again because of macular hole reopening, macular buckling is performed, since another vitrectomy would not work well. Attention must be paid to detecting any small macular holes before vitrectomy because the holes are normally stretched and enlarged postoperatively. Simply using a long-acting gas injection is not well accepted for postoperative macular holes, because this complication results from a shortage of retinal redundancy. Recurrence of a retinal detachment is a major postoperative complication after vitrectomy performed to treat a macular hole with a retinal detachment. However, it is sometimes difficult to identify the apparent cause of a redetachment. In those cases, persistent traction, such as microvascular traction, is responsible. Numerous interesting findings have suggested the presence of underlying traction in highly myopic eyes. This is useful in deciding upon the most minimally invasive and effective procedures for vitrectomy in patients with myopic macular complications. Prevalence and risk factors for refractive errors in an adult inner city population. Prevalence and causes of low vision and blindness in a Japanese adult population: the Tajimi Study.

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The attachments of the posterior hyaloid to the foveal center and optic disc are the last to be released thyroid cancer risk factors generic levothroid 200mcg otc. It might be due to the action of oblique anteroposterior forces that follows the direction of the collagen fibers of the vitreous body thyroid receptor antibody purchase levothroid 200 mcg without prescription. Both mechanisms might lead to the creation of oblique tractional forces on the foveal floor thyroid nodules bad taste in mouth buy cheap levothroid. They concluded that idiopathic macular cysts and holes were part of the same disorder and described the role of the vitreous body in their formation thyroid zoning out buy levothroid 100mcg lowest price. The ellipsoid zone (EllZ thyroid problems discount levothroid online mastercard, yellow arrow) is intact thyroid cancer and graves disease order levothroid 100mcg on-line, but a small section of the interdigitationzone(IdgZ)isdetached(yellow arrow). A hyperreflective columnar structure links the internal and external limitingmembranes. At any stage, complete normalization of the fovea may occur after vitreofoveal separation. Other methods have also been described,71,72 but the minimum hole width tends to be a standard. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. The visual prognosis depends not only on the closure of the hole but also on the topography of the other lesions. The more likely role is that the gas bubble acts first by dehydrating the hole edge and then by preventing fluid currents from hampering the healing process. Their pathogenesis may be different from that of nonmyopic eyes because the vitreous cortex often remains adherent to the retinal surface. Optical coherence tomography has also occasionally been performed through silicone oil126 or through the gas bubble. Histopathology showed that the substance that was separated from the retinal surface exactly corresponded to the vitreous cortex. The 23- and even 25- or 27-G vitreous probes, whose aspirating port is narrower and closer to the tip of the probe, are now very effective for firm aspiration and detachment of the posterior hyaloid. Direct aspiration of the vitreous fibers attached to the Weiss ring appears to be the most effective way of lifting the vitreous cortex en bloc and gradually extending its detachment to the equator in all the quadrants of the fundus. Shaving the vitreous base, especially in the lower periphery, also reduces the risk of postoperative lower retinal breaks and detachment by preventing the gas bubble from exerting traction on the remaining vitreous fibers. They can be removed by brushing the retinal surface with the soft tip of a back-flush cannula, which is more efficient than forceps. Extensive Vitrectomy Although there is no way of proving that extensive vitrectomy is better than partial vitrectomy, there are several arguments in favor of the most extensive vitrectomy possible. The staining occurs after a brief contact with the dye injected onto the retinal surface. The rationale for preferring one gas to another is based on the expected duration of the gas bubble. With this mixture, the gas bubble still covers the macula 1 week after surgery if the head is in the upright position, and still fills more than 70% of the vitreous cavity. The essential characteristic of the gas mixture is not so much to persist for a long time in the eye as to decrease slowly in quantity during the first postoperative week. Silicone oil has been used to avoid the need for positioning in patients unable to maintain the face-down position, to allow air travel after surgery, or to ensure prolonged tamponade in case of failure of the initial surgery. In such cases, some authors stressed the advantages of the use of silicone oil, which gave good results. The upright position allows the gas bubble to cover the macula for a period of time that depends on the extent of the vitrectomy, the surgery of the lens, the way in which the vitreous cavity is filled with air, the tightness of the sclerotomies, and how fast the gas mixture is resorbed. The time for which a tamponade is needed depends on the duration of the healing process, which is certainly related to hole diameter. In such cases, the patient will only be advised to avoid the supine position, even during the night. The same authors discussed the negative effect of the long duration of the hole on the success rate. It is clearer today that the indication for an alleviated position should take into account the hole diameter67 and be kept for small holes. Visual Outcome Overall Results There are few recent prospective studies in which visual acuity has been recorded in a controlled procedure. A relative or absolute microscotoma detected by microperimetry persists in some cases. However, as early as 1997 Tornambe obtained a reasonable success rate of 79% for hole closure without any face-down positioning. In a randomized prospective trial comparing face-down and seated positioning, face-down positioning was found to give a better closure rate. These breaks have been attributed to the traction exerted by the gas bubble on the inferior vitreous in the upright position. In more recent publications the rate of retinal detachment tended to decrease to 5% in a meta-analysis of randomized studies218 and even under 2% for more recent studies,67,219,220 probably due to a more efficient search for retinal breaks during surgery and to more thorough removal of the inferior peripheral vitreous. It has been used in several clinical trials to create a posterior vitreous detachment. Foveal pseudocyst as the first step in macular hole formation: a prospective study by optical coherence tomography. Vitreoretinal interface and foveal deformation in asymptomatic fellow eyes of patients with unilateral macular holes. Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Perifoveal vitreous detachment is the primary pathogenic event in idiopathic macular hole formation. The international vitreomacular traction study group classification of vitreomacular adhesion, traction, and macular hole. The role of the premacular liquefied pocket and premacular vitreous cortex in idiopathic 7. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Prevalence of full-thickness macular holes in urban and rural adult Chinese: the Beijing Eye Study. Prevalence of idiopathic macular hole in adult rural and urban south Indian population. The epidemiology of vitreoretinal interface abnormalities as detected by spectraldomain optical coherence tomography: the Beaver Dam Eye Study. Incidence of idiopathic fullthickness macular holes in fellow eyes: a 5-year prospective natural history study. Macular hole formation in fellow eyes with a perifoveal posterior vitreous detachment of patients with a unilateral macular hole. Measurement of the posterior precortical vitreous pocket in fellow eyes with posterior vitreous detachment and macular holes. Characterization of outer retinal morphology with high-speed, ultrahighresolution optical coherence tomography. Relationship between macular hole size and the potential benefit of internal limiting membrane peeling. Nonsupine positioning in macular hole surgery: a noninferiority randomized clinical trial. A novel segmentation algorithm for volumetric analysis of macular hole boundaries identified with optical coherence tomography. A comparison of several methods of macular hole measurement using optical coherence tomography, and their value in predicting anatomical and visual outcomes. Effects of preoperative and postoperative epiretinal membranes on macular hole closure and visual restoration. Prevalence, correlates, and natural history of epiretinal membranes surrounding idiopathic macular holes. Immunocytochemical and ultrastructural evidence of glial cells and hyalocytes in internal limiting membrane specimens of idiopathic macular holes. Diagnosis of macular pseudoholes and lamellar macular holes by optical coherence tomography. Redefining lamellar holes and the vitreomacular interface: an ultrahigh-resolution optical coherence tomography study. Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery. Comparing functional and morphologic characteristics of lamellar macular holes with and without lamellar hole-associated epiretinal proliferation. Lamellar holeassociated epiretinal proliferation in comparison to epiretinal membranes of macular pseudoholes. Lamellar macular hole: a clinicopathologic correlation of surgically excised epiretinal membranes. Progression from macular retinoschisis to retinal detachment in highly myopic eyes is associated with outer lamellar hole formation. Macular Hole closure over residual subretinal fluid by an inverted internal limiting membrane flap technique in patients with macular hole retinal detachment in high myopia. An aspirating forceps to remove the posterior hyaloid in the surgery of full-thickness macular holes. Incidence of retinal detachment after macular surgery: a retrospective study of 634 cases. Incidence and causes of iatrogenic retinal breaks in idiopathic macular hole and epiretinal membrane. The use of internal limiting membrane maculorrhexis in treatment of idiopathic macular holes. Histopathological examination of internal limiting membrane surface after scraping with diamond-dusted membrane scraper. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study. Mechanisms of intravitreal toxicity of indocyanine green dye: implications for chromovitrectomy. Retinal pigment epithelial changes after macular hole surgery with indocyanine green-assisted internal limiting membrane peeling. Toxic effect of indocyanine green on retinal pigment epithelium related to osmotic effects of the solvent. Histology of the vitreoretinal interface after staining of the internal limiting membrane using glucose 5% diluted indocyanine and infracyanine green. Persistence of fundus fluorescence after use of indocyanine green for macular surgery. Retinal ganglion cells toxicity caused by photosensitising effects of intravitreal indocyanine green with illumination in rat eyes. Vital dyes and light sources for chromovitrectomy: comparative assessment of osmolarity, pH, and spectrophotometry. Spontaneous closure of a macular hole caused by a ruptured retinal arterial macroaneurysm. Macular hole formation in patients with retinitis pigmentosa and prognosis of pars plana vitrectomy. The development and evolution of full thickness macular hole in highly myopic eyes. Residual defect in the foveal photoreceptor layer detected by optical coherence tomography in eyes with spontaneously closed macular holes. The magnitude of the bubble buoyant pressure: implications for macular hole surgery. Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Clinicopathologic correlation of a macular hole treated by cortical vitreous peeling and gas tamponade. Clinicopathologic correlation of an untreated macular hole and a macular hole treated by vitrectomy, transforming growth factor-beta 2, and gas tamponade. Features of macular hole closure in the early postoperative period using optical coherence tomography. Posturing time after macular hole surgery modified by optical coherence tomography images: a pilot study. Observation of idiopathic full-thickness macular hole closure in early postoperative period as evaluated by optical coherence tomography. Dynamics of macular hole closure in gas-filled eyes within 24 h of surgery observed with swept source optical coherence tomography.

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