Myopic foveoschisis (MF), termed as neuroretina splitting in the macula, is common in patients with pathologic myopia, especially in Asian populations with a high prevalence of myopia.1,2 Spectral-domain optical coherence tomography (SD-OCT) can definitely demonstrate the typical intraretinal abnormality, which is usually combined with foveal detachment, lamellar macular hole (MH), epiretinal membrane, or vitreomacular traction.3 Although the pathogenesis of MF is not well understood, elongation of the posterior sclera as well as abnormal vitreomacular traction is revealed to play crucial roles in the progressive development of foveoschisis in highly myopic eyes.4,5
Currently, many studies have shown that pars plana vitrectomy (PPV), with or without internal limiting membrane (ILM) peeling and gas tamponade, is an effective treatment of MF.6–9 The aim of the surgery is to release the inward traction on the vitreomacular interface and to reattach the posterior retina. Since the introduction of microincision vitrectomy surgery (MIVS), 23-gauge, 25-gauge, and, more recently, 27-gauge vitrectomy have been accepted as surgical options for a variety of vitreoretinal diseases.9–16 In the management of MF, 23-gauge/25-gauge vitrectomy has been evaluated to be effective with high anatomical resolution and great visual improvement.17–19 However, few studies have investigated 27-gauge PPV as a surgical option for MF, mainly due to the concerns associated with the efficiency and maneuverability of the 27-gauge instrumentation in eyes with extremely long axial length and thin sclera. Moreover, it remains unclear whether air could serve as an equivalent tamponade material as extensive gas to provide sufficient surface tension. Therefore, the purpose of this study was to compare the feasibility, safety, and efficiency of 27-gauge PPV with 25-gauge PPV and evaluate the efficacy of air tamponade in the treatment of MF.
Patients and Methods
From March 2016 to February 2017, 60 eyes of 60 consecutive patients were recruited at Zhongshan Ophthalmic Center affiliated with Sun Yat-sen University. Inclusion criteria were high myopia of more than −6.0 diopters (D) (spherical refractive error), axial length greater than 26 mm, and diagnosis with foveoschisis by optical coherence tomography (OCT). Exclusion criteria were eyes with prior PPV, MH–associated retinal detachment, and those unable to complete the scheduled follow-ups. Before surgery, the eyes were randomly assigned to the 27-gauge or 25-gauge group. There were 29 eyes in the 27-gauge group and 31 eyes in the 25-gauge group. Written informed consent was obtained from each subject. The study was approved by the Institutional Review Board of Zhongshan Ophthalmic and performed in accordance with the World Medical Association's Declaration of Helsinki.
All eligible patients underwent comprehensive ophthalmologic examinations, including best-corrected visual acuity (BCVA), noncontact tonometry, slit-lamp microscope, funduscope, refractometer, and B-scan and A-scan ultrasonography. OCT (RTVue OCT; Optovue, Fremont, CA, or Spectralis OCT; Heidelberg Engineering, Heidelberg, Germany) was performed before surgery and at each follow-up point. Using OCT, central foveal thickness (CFT) was measured in the foveal area, which was defined as the distance between the retinal pigment epithelium and the inner surface of the retina.
Under retrobulbar anesthesia, all surgeries were performed by one experienced surgeon (SZ). Standard three-port 27-gauge or 25-gauge PPV (Constellation Vision System; Alcon Laboratories, Fort Worth, TX) was performed. After posterior hyaloids was detached, 0.1 mL of indocyanine green solution (0.5%) was intravitreally injected to stain the ILM. The ILM was peeled using end-gripping forceps (Grieshaber Revolution DSP ILM forceps; Alcon Laboratories, Fort Worth, TX), which was peeled within the vascular arcades. Endolaser photocoagulation was applied if there were any peripheral retinal pathologic features identified. Fluid–gas exchange was performed by flushing with sterilized air under the pressure of 25 mm Hg. Gases such as sulfur hexafluoride (SF6) or perfluoropropane (C3F8) were not used in any cases. All surgeries were completed without conversion to larger gauge in any cases. After removal of all surgical instruments, the sclera incisions were checked. If any leakage was observed, the incision was sutured with 8-0 Vicryl (polyglactin 910; Ethicon, Somerville, NJ) suture. Patients were instructed to remain in face-down position for 5 to 7 days.
Operating time, intraoperative complications, and incision suturing rate were recorded for each patient. Postoperative assessment included BCVA, intraocular pressure (IOP), anatomic success rate, CFT, and postoperative complications. Anatomical resolution was defined as a complete absence of retinoschisis in the central macular region in OCT images. Postoperative visual improvement was defined as a gain of Snellen visual acuity (VA) of more than two lines. A loss of two lines or more than two lines was considered as decreased vision.
Snellen VAs were converted to logarithm of the minimum angle of resolution (logMAR) for statistical analysis. Student t-tests and Chi-square tests were used for the analyses. All data were presented as the mean ± standard deviation, and a P value of less than .05 was considered statistically significant. Analyses were performed using a statistical software package (Statistica, StatSoft, Tulsa, OK).
The demographic characteristics and clinical data of the participants are summarized in Table 1. The demographic features, as well as the baseline BCVA, IOP, and CFT, were not significantly different between the two groups. All eyes were phakic before surgery.
Demographic Characteristics of Patients With MF
Table 2 shows the changes of BCVA from baseline to the end of follow-up. In both groups, the mean BCVA at 3-month postoperative visit, 6-month postoperative visit, and final visit were significantly different from the baseline value. At each examination point, the difference in the mean BCVA was not statistically significant between groups. In the 27-gauge group, the final BCVA improved in 24 eyes (82.8%) and remained unchanged in five eyes (17.2%). In the 25-gauge group, the final BCVA improved in 26 eyes (81.3%) and remained unchanged in six eyes (18.8%). No eyes had worsened postoperative BCVA in both groups.
Postoperative Change of BCVA, IOP, and CFT in Patients With MF (Mean ± SD)
The mean operating time was 29.2 minutes ± 2.7 minutes (range: 25 minutes to 35 minutes) in the 27-gauge group and 28.9 minues ± 2.2 minutes (range: 26 minutes to 34 minutes) in the 25-gauge group. The mean time for vitrectomy was 14.3 minutes ± 2.1 minutes (range: 12 minutes to 18 minutes) in the 27-gauge group and 13.8 mniutes ± 2.5 minutes (range: 11 minutes to 19 minutes) in the 25-gauge group. There was no statistically difference between the two groups in both the operating time (P = .32) and vitrectomy time (P = .20).
At the end of surgery after removal of all instruments, sclerotomies were sutured in six eyes (20.7%) in the 27-gauge group and nine eyes (29.3%) in the 25-gauge group with no statistically significant difference between the groups (P = .46).
The mean preoperative IOP was statistically comparable between the 27-gauge group and the 25-gauge group (P = .43). On the first postoperative day, the mean IOP decreased significantly from the preoperative value in both groups (P < .001), which returned to the baseline IOP at the 7-day postoperative visit. There were no significant differences in postoperative IOP at any follow-up visits between the two groups (Table 2).
Anatomical Success Rate and Central Foveal Thickness
Table 2 and Figure 1 summarize the change of the mean CFT at each follow-up visit, which showed that the CFT remarkably reduced in both groups with significant difference from preoperative values. Table 2 and Figure 2 show the anatomical success rates at 1-month, 3-month, 6-month, and final visit, which gradually increased with no statistical difference between groups at each visit point. Representative OCT images from the two groups are displayed in Figure 3.
Postoperative central foveal thickness (CFT) changes during follow-up in the 27-gauge group and the 25-gauge group. There was no significant difference in the CFT between the two groups at each visit point. d = days; m = months
Postoperative anatomical success rates during follow-up in 27-gauge (G) group and 25-gauge group. There was no significant difference in the success rate between the two groups at each visit point.
Representative horizontal optical coherence tomography (OCT) images of eyes with myopic foveoschisis (MF) treated by 27-gauge or 25-gauge vitrectomy. Case 1: (A) Preoperative OCT showed foveoschisis. Snellen vision acuity was 20/200. (B) One month after 27-gauge vitrectomy with internal limiting membrane (ILM) peeling and air tamponade, the OCT revealed resolution of foveoschisis. The patient's vision improved to 20/50. Case 2: (C) Preoperative OCT showed foveoschisis with foveal detachment. Snellen vision acuity was 20/200. (D) Six months after 25-gauge vitrectomy with ILM peeling and air tamponade, the OCT revealed resolution of foveoschisis with foveal reattachment. The patient's vision improved to 20/80.
For each surgical procedure, no intraoperative complication occurred. At 1 week after the surgery, IOP elevation higher than 21 mm Hg was found in three eyes in the 27-gauge group and two eyes in the 25-gauge group, which resolved within 5 days with topical anti-glaucoma medications. In both groups, no hypotony, MH, rhegmatogenous retinal detachment, and endophthalmitis was observed during the entire follow-up period.
Compared with 25-gauge vitreous cutter, the internal diameter of the 27-gauge vitrectomy probe is substantially smaller (0.347 mm vs. 0.275 mm).15 Theoretically, a reduction of internal diameter by 20% may result in lower infusion and aspiration rates when using the 27-gauge system, which may cause an increase in total surgery time. Previous study showed that the time for vitrectomy was remarkably longer with 27-gauge instrument in treatment of epiretinal membrane.20 In the current series with 27-gauge instrument, the mean operating time was 29.2 minutes, which was similar to 28.9 minutes with 25-gauge system. Such comparable efficiency can be achieved using higher aspiration and proportional vacuum system. In the current study, the cutting rate was set as 7,000 cuts per minutes and the aspiration rate as 200 mm Hg to 650 mm Hg. This parameter setting could increase vitreous fragmentation and reduce vitreal viscosity, contributing to lower fluid resistance during aspiration.21 Dugel et al.22 also described that the 27-gauge probe with high vacuum level obtained an equivalent fluid flow rate compared with the 25-gauge and 23-gauge probes. Therefore, our findings showed that the 27-gauge cutter with proper parameter setting can could provide sufficient efficiency even in cases as complicated as MF.
Considering the length and stiffness of the 27-gauge cutter, there is concern that the 27-gauge probe may be not sufficient to complete the maneuver in highly myopic eyes with extra-long axial length. Oshima et al.23 described that 27-gauge probe with 25-mm shaft length was feasible to perform the vitrectomy in eyes with the axial length from 22 mm to 28 mm. In our case series, using 27-gauge probe with 27-mm working length, no eyes required conversion to larger-gauge instrumentation during vitrectomy. For further improving its maneuverability, some surgical skill was adopted in this study. Local pressurization could help in reducing distance between the cannula and the posterior pole in eyes with extremely long axial lengths. Only in a very small number of cases, the scleral cannula could be removed to increase the working length of instruments in the vitreous cavity. During vitreous shaving in the periphery, scleral indentation was performed to push the peripheral vitreous toward the center of the vitreous cavity, thereby avoiding the 27-gauge vitrectomy probe from bending. Consequently, our findings demonstrated that the length and rigidity of 27-gauge instrumentation could satisfy the demand of surgical maneuver in highly myopic eyes with MF.
Avoidance of wound leakage is crucial for patients undergoing MIVS, which can greatly reduce the risk of incision-associated complications such as hypotony, choroidal detachment, and endophthalmitis.24 As described in the literature, the smaller-gauge vitrectomy system requires fewer sutures for the sclerotomy sites because of better self-sealing.11–14 Nevertheless, a self-sealing incision is relatively difficult to create through the thinner sclera with low rigidity in highly myopic eyes. In a study of 33 eyes with MF, Hwang et al.18 reported that suture was needed for at least one sclerotomy sites in 33.3% of patients undergoing 25-gauge MIVS and 44.4% undergoing 23-gauge MIVS. In an earlier study of other vitreoretinal disease, the suturing rate was 7.9% in patients undergoing 25-gauge MIVS and 14.9% of patients undergoing 23-gauge MIVS.14 In the current study, 20.7% of patients undergoing 27-gauge vitrectomy and 29.3% of patients undergoing 25-gauge PPV required sutures for the sclerotomy sites. Thus, other studies and our findings showed that the suturing rate for highly myopic eyes was relatively higher compared with other disease. Although the suturing rate in the 27-gauge group was relatively lower, no statistically significant difference was found between the two groups.
Postoperative hypotony is the most concerning complication of MIVS, which was reported in 0% to 25% of sutureless vitrectomy cases.11–14 Khan et al.25 reported transient postoperative hypotony in five of 95 eyes (5.3%) using 27-gauge system. Oshima et al.23 reported that the overall mean IOP in patients when using the 27-gauge system was stable throughout the follow-up period. Using oblique incisions with 27-gauge trocar, Romano et al.26 did not observe any case of postoperative hypotony in patients with retinal detachment. In the present study, despite the thinner sclera of the patients with high myopia, no eye developed hypotony during the entire follow-up period in the two groups. Moreover, no significant difference was found in the mean postoperative IOP between patients undergoing 27-gauge and 25-gauge PPV at each visit point. It was assumed that smaller incision size, proper wound construction, careful check of the sclerotomy, partial residual of vitreous base, as well as surface tension provided by air tamponade, may help wound sealing in MF patients.
At the end of surgery for MF, C3F8, SF6, or air is available as intraocular tamponade. Although C3F8 tamponade was reported to be associated with a high proportion of postoperative BCVA improvement and anatomical resolution, its role was still controversial in patients undergoing PPV for MF. It is suggested that expansive gas might potentially relate to the formation of postoperative MH.10,18,27,28 On the other hand, some patients cannot tolerate the prone position for a long-term postoperative period, especially for the elderly, overweight, or cases with cardiac system disease. Accordingly, some studies evaluated the efficiency of PPV without gas tamponade in MF patients. Data from literatures shown in Table 3 indicated that sufficient release of the vitreous traction forces by ILM peeling, instead of the choice of intraocular tamponade, may play the crucial role in the anatomical resolution of MF.10,17–19,27–31 However, Kim et al.31 found that balanced salt solution was less effective than C3F8 tamponade for morphological recovery and functional improvement. Therefore, in our cases series, air was used as intraocular tamponade, which was expected to result in a more rapid resolution of MF and better visual outcome than balanced salt solution.
Summary of Surgical Outcomes in the Treatment for Patients With MF
Although the duration of air bubble in the postoperative eye was significantly shorter than expansive gas, previous reports suggested that air tamponade appears to be as effective as C3F8 tamponade. Hwang et al.18 showed that patients with partial air tamponade did not differ from patients with C3F8 in their visual acuity at the last follow-up. In the current study, air was used as tamponade at the end of the 27-gauge and 25-gauge vitrectomy. At the end of the follow-up, BCVA was significantly improved from 1.00 logMAR preoperatively to 0.77 logMAR postoperatively in the 27-gauge group and from 1.05 logMAR to 0.79 logMAR in the 25-gauge group. At the end of the follow-up, the anatomic success rate was 86.2% and 87.1%, respectively, which was similar to that reported by previous studies using C3F8 tamponade.17,19,27,31 Therefore, the morphological and functional improvement in this study and previous literatures proved that air tamponade was sufficient to induce pneumatic repositioning of the splitting retinal layers. Compared with expansive gas, air tamponade can provide an earlier confirmation of the macula state, a quicker visual recovery, and shortened prone positioning period. Compared with balanced salt solution, the advantages of air tamponade are that it can prevent leakage from the sclerotomy sites and also avoid the occurrence of postoperative complications caused by paravascular breaks or iatrogenic MH.
This study has several limitations, including its retrospective, small sample size, and a short follow-up period. Therefore, further randomized and prospective studies are required in patients with MF with larger sample size and longer follow-up.
In conclusion, this study showed that the 27-gauge vitrectomy system is equally efficient, safe, and feasible as the 25-gauge system for MF in highly myopic patients. Also, it was illustrated that air tamponade could provide sufficient supporting force and good postoperative anatomic resolution with earlier visual recovery and shorter prone posture period in the treatment of MF.
- Takano M, Kishi S. Foveal retinoschisis and retinal detachment in severely myopic eyes with posterior staphyloma. Am J Ophthalmol. 1999;128(4):472–476. doi:10.1016/S0002-9394(99)00186-5 [CrossRef]
- Benhamou N, Massin P, Haouchine B, Erginay A, Gaudric A. Macular retinoschisis in highly myopic eyes. Am J Ophthalmol. 2002;133(6):794–800. doi:10.1016/S0002-9394(02)01394-6 [CrossRef]
- Sayanagi K, Morimoto Y, Ikuno Y, Tano Y. Spectral-domain optical coherence tomographic findings in myopic foveoschisis. Retina. 2010;30(4):623–628. doi:10.1097/IAE.0b013e3181ca4e7c [CrossRef]
- Rey A, Jurgens I, Maseras X, Carbajal M. Natural course and surgical management of high myopic foveoschisis. Ophthalmologica. 2014;231(1):45–50. doi:10.1159/000355324 [CrossRef]
- Gaucher D, Haouchine B, Tadayoni R, et al. Long-term follow-up of high myopic foveoschisis: Natural course and surgical outcome. Am J Ophthalmol. 2007;143(3):455–462. doi:10.1016/j.ajo.2006.10.053 [CrossRef]
- Kanda S, Uemura A, Sakamoto Y, Kita H. Vitrectomy with internal limiting membrane peeling for macular retinoschisis and retinal detachment without macular hole in highly myopic eyes. Am J Ophthalmol. 2003;136(1):177–180. doi:10.1016/S0002-9394(03)00243-5 [CrossRef]
- Kobayashi H, Kishi S. Vitreous surgery for highly myopic eyes with foveal detachment and retinoschisis. Ophthalmology. 2003;110(9):1702–1707. doi:10.1016/S0161-6420(03)00714-0 [CrossRef]
- Ikuno Y, Sayanagi K, Ohji M, et al. Vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Am J Ophthalmol. 2004;137(4):719–724.
- Kwok AK, Lai TY, Yip WW. Vitrectomy and gas tamponade without internal limiting membrane peeling for myopic foveoschisis. Br J Ophthalmol. 2005;89(9):1180–1183. doi:10.1136/bjo.2005.069427 [CrossRef]
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- Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina. 2005;25(2):208–211. doi:10.1097/00006982-200502000-00015 [CrossRef]
- Fine HF, Iranmanesh R, Iturralde D, Spaide RF. Outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy surgery for posterior segment disease. Ophthalmology. 2007;114(6):1197–1200. doi:10.1016/j.ophtha.2007.02.020 [CrossRef]
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- Osawa S, Oshima Y. 27-gauge vitrectomy. Dev Ophthalmol. 2014;54:54–62. doi:10.1159/000360449 [CrossRef]
- Masri I, Steel DH. Outcomes of 27 gauge microincision vitrectomy surgery for posterior segment disease. Am J Ophthalmol. 2016;164:147–148. doi:10.1016/j.ajo.2016.01.012 [CrossRef]
- Mii M, Matsuoka M, Matsuyama K, Otsu Y, Nishimura T. Favorable anatomic and visual outcomes with 25-gauge vitrectomy for myopic foveoschisis. Clin Ophthalmol. 2014;8:1837–1844. doi:10.2147/OPTH.S67619 [CrossRef]
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- Zhang Z, Wei Y, Jiang X, Zhang S. Pars plana vitrectomy and wide internal limiting membrane peeling with perfluoropropane tamponade for highly myopic foveoschisis-associated macular hole. Retina. 2017;37(2):274–282. doi:10.1097/IAE.0000000000001146 [CrossRef]
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Demographic Characteristics of Patients With MF
|27-Gauge group (n = 29)||25-Gauge Group (n = 31)||P Value|
|Male / Female||22 / 7||23 / 8|
|Eye (Right / Left)||13 / 16||18 / 13|
| Mean ± SD||54.5 ± 8.2||55.4 ± 7.1||.34|
| Range||41 – 69||45 – 67|
| Mean ± SD||1.00 ± 0.40||1.05 ± 0.39||.31|
| Range||0.40 – 1.70||0.52 – 1.70|
|IOP (mm Hg)|
| Mean ± SD||15.5 ± 2.6||15.7 ± 3.7||.43|
| Range||10.4 – 19.6||9.8 – 21.7|
|Axial Length (mm)|
| Mean ± SD||30.22 ± 2.81||29.90 ± 2.47||.29|
| Range||26.9 – 35.7||26.3 – 34.5|
| Mean ± SD||528 ± 67||531 ± 74||.44|
| Range||405 – 639||399 – 648|
|Mean ± SD||11.2 ± 3.2||12.1 ± 3.5||.14|
|Range||6 – 15||6 – 18|
Postoperative Change of BCVA, IOP, and CFT in Patients With MF (Mean ± SD)
|Preop||1 Day||7 Days||1 Month||3 Months||6 Months||Final Visit|
|27-gauge group||1.00 ± 0.40||0.96 ± 0.34||0.85 ± 0.31||0.78 ± 0.29*||0.76 ± 0.29*||0.77 ± 0.29*|
|25-gauge group||1.05 ± 0.39||1.00 ± 0.31||0.91 ± 0.31||0.83 ± 0.30*||0.82 ± 0.29*||0.79 ± 0.27*|
|IOP (mm Hg)|
|27-gauge group||15.5 ± 2.6||12.1±3.0*||16.8 ± 4.2||14.9 ± 3.1||15.6 ± 3.5||15.7 ± 2.8||15.9 ± 2.6|
|25-gauge group||15.7 ± 3.7||12.5 ± 2.5*||17.7 ± 4.5||14.5 ± 2.5||14.8 ± 3.6||15.5 ± 2.8||15.8 ± 2.6|
|27-gauge group||528 ± 67||442 ± 54*||385 ± 49*||324 ± 37*||288 ± 31*||256 ± 26*|
|25-gauge group||531 ± 74||454 ± 55*||405 ± 49*||353 ± 50*||298 ± 39*||243 ± 39*|
Summary of Surgical Outcomes in the Treatment for Patients With MF
|Author||MIVS Gauge||ILM Peeling||No. of Eyes||Tamponade Material||Anatomic Success Rate||Postop MH Formation|
|Zheng et al. 201129||20||Y||18||C3F8 in 11 eyes, BSS in 7 eyes||100% vs. 14% in 3 m after surgery||0|
|Shin et al. 201227||25||Y||38||C3F8 / SF6||89.5%||5.3%|
|Lim. et al. 201230||Y||8||BSS||75%|
|Kim.et al. 201231||Y||17||C3F8 in 9 eyes, BSS in 8 eyes||88.9%||75%|
|Hwang et al. 201318||23 / 25||Y||33||C3F8 in 13 eyes, air in 15 eyes, silicon oil in 5 eyes||96%|
|Mii et al. 201417||25||Y||40||SF6 in 4 eyes, air in 5 eyes||7.5%|
|Uchida et al. 201428||23 / 25||Y||10||BSS||80%||20%|
|Qi. et al. 201610||23||N||112||C3F8||95%||5%|
|Zhang et al. 201719||23 / 25||Y||25||C3F8||84%|