Refractory macular holes typically represent macular holes larger than 400 μm, macular holes in pathological myopic eyes or complicated with myopic schisis, chronic holes longer than 6 months, persistent macular holes after surgeries, and some subtypes of secondary macular holes. A routine pars plana vitrectomy combined with internal limiting membrane peeling yielded a lower closure rate and unsatisfying visual rehabilitation in patients with refractory macular holes, which raised concerns among vitreoretinal surgeons. This editorial reviewed the new upcoming surgical techniques which were reportedly to improve the anatomical and visual prognosis of major subtypes of refractory macular holes. Although with a great variability, these surgical techniques are based the following surgical strategies: firstly, to sufficiently unravel the epi-macular tractional force; secondly, to bridge the defect of neurosensory retina by tissue insertion or implantation and stimulate wound healing process; thirdly, proper tamponade of gas or silicone oil so that the surface tension can stabilize the inserted or implanted tissue and encourage closure of the holes. In conclusion, surgical strategies for refractory macular holes should be made after a comprehensive consideration and a customized design.
Early detection and timely treatment hold the key to cure retinopathy of prematurity (ROP). ROP screening is carried out unevenly in China. Examination equipments and personnel experiences are the major factors to constraint ROP screening. In addition to strengthening personnel training, it is necessary to establish a standard guideline and pipeline for ROP consultation and referral. Laser photocoagulation and cryotherapy are the first options for the threshold ROP and Type 1 prethreshold ROP. Scleral buckling or vitrectomy is needed for advanced ROP when retinal detachment occurs. The clinical efficacy of intravitreal injection of bevacizumab (an anti-vascular endothelial growth factor monoclonal antibody) for severe ROP is encouraging, but needs further verification. Genetic interference and stem cell therapy will be the prosperous futures in the treatment of ROP. The screening and treatment of ROP in China is becoming more common and improved, but it is still a long way to go considering the huge population of China.
Objective To observe the clinical effects of vitrectomy for advanced retinopathy of prematurity (ROP) and evaluate influence factors of anatomical recovery for stage 5 ROP. Methods Fifty-eight eyes of 40 infants with advanced ROP who underwent vitrectomy were retrospectively analyzed. There were 16 eyes of stage 4a, 7 eyes of stage 4b, and 35 eyes of stage 5 ROP. Eighteen eyes received laser photocoagulation, 2 eyes received cryotherapy, and 11 eyes received intravitreous injection of Bevacizumab (IVB) before surgery. The average follow-up time was 17.01 months. Anatomical outcome of retina after surgery was recorded by indirect ophthalmoscope and RetCamⅡ digital camera system. Visual outcome was measured by grating acuity test（lea gratingTM）, and was converted to Snellen acuity values for analysis. For those who cannot cooperate to accomplish the test, we use hand move, light perception and non-light perception to record visual outcome. ResultsAll 16 eyes of stage 4a were anatomically recovered (100.00%). 5/7 eyes of stage 4b were anatomically recovered (71.43%) and 2/7 eyes were anatomically failed(28.57%). 12/35 eyes of stage 5 were anatomically recovered (34.29%); 10/35 eyes were partial anatomically recovered (28.57%); 13 eyes were anatomically failed (37.14%). Anatomical outcome of stage 4a or 4b was better than stage 5 statistically（χ2=22.55，P＜0.05）. Of 16 eyes of stage 4a, 3 eyes were absent for visual function test. In the rest 13 eyes of stage 4a, VA of 6 eyes (46.15%) was between 0.03 and 0.07; 5 eyes (38.46%) were hand move; 2 eyes (15.39%) were light perception. Of 7 eyes of stage 4b, 2 eyes (28.57%) accomplished grating acuity test with VA of 0.008 and 0.017 respectively; 1 eye (14.29%) was hand move; 2 eyes (28.57%) were light perception; 2 eyes (28.57%) were nonlight perception. Of 35 eyes of stage 5, 5 eyes were absent for visual function test. In the rest 30 eyes of stage 5, VA of 2 eyes (6.67%) was 0.004; 4 eyes (13.33%) were hand move; 12 eyes (40.00%) were light perception; 12 eyes (40.00%) were non-light perception. Visual outcome of stage 5 was worse than stage 4a or 4b statistically（χ2=15.734，P＜0.05）.There was no statistically significant relationship between anatomical outcome and birth weight, gestational weeks, age at surgery, IVB therapy, laser or cryotherapy before surgery. ConclusionsVitrectomy can effectively control the lesions progress of stage 4a ROP, and achieve partially anatomically recovery of some stage 4b/5 patients. There was no statistically significant relationship between anatomical outcome and birth weight, gestational weeks, age at surgery, IVB, laser or cryotherapy before surgery.
“The international classification of retinopathy of prematurity (ROP)(The 3rd edition)”, retains current definitions such as zone, stage, and circumferential extent of disease, however, there are also many updates. Major updates include: (1) increase of the definition of posterior pole Ⅱ; (2) introduction of a new concept "notch"; (3) definition of stage 5's subcategorization; (4) recognition that a continuous spectrum of vascular abnormality exists from normal to plus disease. Updates also include the definition of “aggressive ROP” to replace “aggressive-posterior ROP”. ROP regression and reactivation are described in detail, with additional description of long-term sequelae.