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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 33-37

Correlation between the health of the cone outer segment tips line and ellipsoid zone with vision after macular hole surgery


Department of Retina, Chaithanya Eye Hospital, Trivandrum, Kerala, India

Date of Web Publication11-Nov-2016

Correspondence Address:
Sanika Jain
Chaithanya Eye Hospital, Kesavadasapuram, Pattom, Trivandrum - 695 004, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6677.193878

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  Abstract 


Purpose: To determine whether preoperative cone outer segment tips (COST) line, ellipsoid zone (EZ), and external limiting membrane (ELM) defects is significantly related with postoperative recovery of photoreceptors and vision after type 1 macular hole closure.
Materials and Methods: A retrospective observational study was conducted on 28 eyes of 28 patients with surgically closed macular holes. Heidelberg's Spectralis optical coherence tomography (OCT) was used to obtain images of the foveal area, and lengths of COST line defect, EZ defect, and ELM defect were measured preoperatively and at 1 month, 3 months, and 6 months after surgery. The pattern of recovery of the photoreceptor layers was observed as complete recovery, incomplete recovery, or disrupted.
Results: It was observed that 13 out of 28 eyes with a mean preoperative length of foveal COST line defect 303.8 microns, showed a significant visual improvement in the range of 0.17 logMAR units (6/9-6/6) with complete or incomplete recovery of the EZ and ELM. Twelve patients with mean preoperative length of foveal COST line defect 632 microns showed only slight visual improvement by one or two lines in the range of 0.47 logMAR units (6/18), with an incomplete pattern of photoreceptor recovery. However, 3 patients with a mean preoperative COST line defect of 815 microns did not show any visual improvement of 0.61 logMAR units (6/36) with EZ and ELM disruptions postoperatively.
Conclusion: The length of preoperative COST line defect is predictive of the recovery and arrangement of photoreceptors and best corrected visual acuity after type 1 macular hole closure. Eyes with complete and incomplete recovery of COST, EZ, and ELM were associated with significantly better visual acuity as compared to eyes with a disrupted pattern of photoreceptor recovery.

Keywords: Cone outer segment tips line; ellipsoid zone; macular hole surgery.


How to cite this article:
Jain S, Nair UK, Manoj S, Nambiar R. Correlation between the health of the cone outer segment tips line and ellipsoid zone with vision after macular hole surgery. Kerala J Ophthalmol 2016;28:33-7

How to cite this URL:
Jain S, Nair UK, Manoj S, Nambiar R. Correlation between the health of the cone outer segment tips line and ellipsoid zone with vision after macular hole surgery. Kerala J Ophthalmol [serial online] 2016 [cited 2019 Aug 22];28:33-7. Available from: http://www.kjophthal.com/text.asp?2016/28/1/33/193878




  Introduction Top


Aim

To determine whether preoperative cone outer segment tips (COST) line defect, ellipsoid zone (EZ) defect, and external limiting membrane (ELM) defect is significantly correlated with postoperative recovery of photoreceptors and vision after type 1 macular hole closure.


  Materials and Methods Top


A retrospective observational study was conducted on 28 eyes of 28 patients with surgically closed macular holes who underwent surgery between May 2014 to March 2015.

Inclusion criteria

Idiopathic full thickness macular holes (Grade 2, 3, and 4) and duration of symptoms ≤2 years were included in the study.

Exclusion criteria

Cases with other significant macular diseases such as diabetic retinopathy and eyes with prior vitrectomy were excluded from the study.

Statistical methods

Preoperative data included age, gender, right or left eye, stage of macular hole, symptom duration, best corrected visual acuity (BCVA) in LogMAR units, length of the COST line defect, as well as length of the EZ and ELM defects were recorded. Heidelberg's Spectralis optical coherence tomography (OCT) was used to obtain images of the foveal area and lengths of COST line defect, EZ defect, and ELM defect were measured preoperatively and at 1 month, 3 months, and 6 months after surgery. The pattern of recovery of the photoreceptor layers was observed as complete recovery, incomplete recovery, or disrupted.


  Results Top


In this study, 28 patients who underwent macular hole surgery were analyzed. A total of 73.5% patients were above 60 years of age, and age of presentation ranged from 50 to 77 years. The mean age of presentation was 65.11 years. Seventeen (60.7%) of the study participants were females. Of the 28 patients, 2 had stage 2 Full Thickness Macular Hole (FTMH), 15 had stage 3 FTMH, and 11 had stage 4 FTMH.

The preoperative COST defect ranged from 67 microns to 1128 microns with a mean of 499.5 microns. There was a significant correlation between preoperative COST defect and preoperative BCVA (P < 0.002). Increased size of preoperative COST defect was associated with a reduced visual acuity [Figure 1].
Figure 1: Correlation between preoperative COST line defect and preoperative BCVA

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There was a significant correlation between preoperative COST defect and postoperative BCVA (P < 0.001). Increased size of preoperative COST defect was associated with a significantly reduced postoperative visual acuity [Figure 2].
Figure 2: Correlation between preoperative COST line defect and postoperative BCVA

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The preoperative BCVA ranged from 1.0 to 0.30 logMAR units, with a mean of 0.7 logMAR units. The postoperative BCVA ranged from 0.7 to 0.0 logMAR units, with a mean of 0.35 logMAR units. This show that there was a significant improvement in the visual acuity after macular hole surgery (P < 0.001) [Figure 3].
Figure 3: Change in BCVA

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Of the study participants, 13 showed complete recovery compared to 12 with incomplete and 2 with disrupted recovery of the photoreceptors [Figure 4].
Figure 4: Pattern of photoreceptor recovery

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The patients with a significantly improved visual acuity of 0.17 had a complete photoreceptor recovery compared to a postoperative visual acuity of 0.47 with incomplete and postoperative visual acuity of 0.61 with disrupted photoreceptor recovery [Figure 5].
Figure 5: Correlation between postoperative BCVA and pattern of recovery of the photoreceptors

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Thirteen patients with a mean preoperative COST line defect of 303.8 microns had a complete photoreceptor recovery; 12 with a mean preoperative COST line defect of 632.7 had incomplete recovery whereas only 3 patients with mean preoperative COST line defect of 815 microns had disrupted photoreceptor recovery [Figure 6].
Figure 6: Correlation between preoperative COST line defect and pattern of photoreceptor recovery

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Thirteen patients with a mean preoperative ELM defect of 232.6 microns had a complete photoreceptor recovery; 12 with a mean preoperative ELM defect of 498.8 had incomplete recovery whereas only 3 patients with mean preoperative ELM defect of 583.3 microns had disrupted photoreceptor recovery [Figure 7].
Figure 7: Correlation between preoperative ELM defect and pattern of photoreceptor recovery

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  Discussion Top


Our study showed that the preoperative length of COST line defect, EZ, and ELM defects were strongly related with the postoperative visual acuity as well as the pattern of recovery of photoreceptors at 6 months postoperatively [Figure 8].
Figure 8: (a-f) COST line and ELM defect and pattern of recovery

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It is known that the photoreceptors continuously add and shed discs of the outer segments. This renewal of the outer segment has been suggested to be related to the recovery of the length of the foveal photoreceptor outer segments.[1],[2],[3],[4],[5]

The integrity of the ELM line, the junction between the inner segment and the Müller cells, was reported to be another important morphologic structure of the photoreceptor microstructure that was related to the visual acuity in patients after macular hole closure [6] and macula retinal reattachment. A continuous ELM has been considered to be a sign of intact photoreceptor cell bodies and Müller cells, and the IS/OS junction rarely recovered without a recovery of the ELM. However, our results suggest that postoperative visual acuity was significantly correlated with the length of COST line defect as well as ELM defect. The recovered COST line was observed only in eyes with an intact EZ and ELM. The eyes with complete recovery of the photoreceptor layer had visual acuity of 0.17 (6/9-6/6) at 6 months post successful macular hole closure compared to the eyes with incomplete and disrupted pattern of photoreceptor recovery, which had a poorer visual acuity of 0.47 (6/18) and 0.61 (6/36), respectively.

Further, in our study the eyes with a mean preoperative COST line defect of 303.8 microns had a complete photoreceptor recovery compared to a mean preoperative COST line defect of 632.7 with incomplete recovery, whereas the mean preoperative COST line defect of 815 microns had disrupted photoreceptor recovery.

In this study, we found that the length of the COST line, EZ, and ELM defect was significantly correlated with visual acuity at each postoperative period. Chang et al.[2] suggested that the length of the IS/OS junction was not correlated with visual acuity after macular hole surgery because the IS/OS defect occurred in edematous retinal areas. Oh et al.[7] reported that the shape of IS/OS junction defect area was round and regular before macular hole surgery but turned irregular after surgery. They found that the postoperative area of the IS/OS defect was more strongly correlated with the BCVA than the length of the defect measured by linear-based raster scans because of the irregular shape of the IS/OS defect area after surgery.

Reconstruction of the foveal ELM line in the early postoperative period can help to predict subsequent restoration of the foveal photoreceptor layer and the potential for better visual outcomes. Ooka et al.[6] reported that the preoperative IS/OS or ELM line defect was significantly associated with the postoperative foveal sensitivity detected by microperimetry but not significantly associated with the postoperative BCVA. Thus, they estimated the postoperative sensitivity at 6 months from the preoperative length of the IS/OS junction and ELM line defects, but the postoperative BCVA could not be predicted.[6]

On the preoperative SD-OCT image, the edge of a macular hole was elevated with a surrounding cuff of subretinal fluid. Within the elevated outer retina around the macular hole, the back-reflection of the IS/OS line was reduced, whereas the visibility of the ELM line was retained.[6] Hangai et al.[8] reported that the ELM back-reflecting line could be used to delineate the photoreceptor inner and outer segment reflectivity within the elevated outer retina around the macular hole. However, the length of the ELM line defect is affected by the height of the elevated retina around the macular hole. Consequently, an evaluation of both the IS/OS junction and the ELM line may not accurately indicate the status of the preoperative foveal photoreceptor microstructures in patients with macular hole.

In our study, we found that the length of the COST line defect was greater than the length of the EZ defect and the ELM defect in the preoperative SD-OCT images. We have not evaluated the effect of the fluid cuff on the SD-OCT signals of the COST line around the macular hole.

However, we assume that when the preoperative factor to predict postoperative visual recovery in SD-OCT findings was considered, the COST line defect had an advantage because it was minimally affected by the fluid cuff as a result of the significantly larger COST line defect compared with the fluid cuff.


  Conclusion Top


Our study showed that the preoperative quantitative measurements of the photoreceptor COST line defects, EZ defects, as well as the ELM defects showed that the recovery of the photoreceptor layer was significantly correlated with the BCVA after macular hole surgery. In addition, the preoperative COST line defect may be able to predict visual acuity as well as the pattern of recovery of the photoreceptors after successful macular hole closure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baba T, Yamamoto S, Arai M, Arai E, Sugawara T, Mitamura Y, et al. Correlation of visual recovery and presence of photoreceptor inner/outer segment junction in optical coherence images after successful macular hole repair. Retina 2008;28:453-8.  Back to cited text no. 1
    
2.
Chang LK, Koizumi H, Spaide RF. Disruption of the photoreceptor inner segment-outer segment junction in eyes with macular holes. Retina 2008;28:969-75.  Back to cited text no. 2
    
3.
Lee JE, Lee SU, Jea SY, Choi HY, Oum BS. Reorganization of photoreceptor layer on optical coherence tomography concurrent with visual improvement after macular hole surgery. Korean J Ophthalmol 2008;22:137-42.  Back to cited text no. 3
    
4.
Haritoglou C, Neubauer AS, Reiniger IW, Priglinger SG, Gass CA, Kampik A. Long-term functional outcome of macular hole surgery correlated to optical coherence tomography measurements. Clin Exp Ophthalmol 2007;35:208-13.  Back to cited text no. 4
    
5.
Guérin CJ, Lewis GP, Fisher SK, Anderson DH. Recovery of photoreceptor outer segment length and analysis of membrane assembly rates in regenerating primate photoreceptor outer segments. Invest Ophthalmol Vis Sci 1993;34:175-83.  Back to cited text no. 5
    
6.
Ooka E, Mitamura Y, Baba T, Kitahashi M, Oshitari T, Yamamoto S. Foveal microstructure on spectral-domain optical coherence tomographic images and visual function after macular hole surgery. Am J Ophthalmol 2011;152:283-90.  Back to cited text no. 6
    
7.
Oh J, Smiddy WE, Flynn HW Jr, Gregori G, Lujan B. Photoreceptor inner/outer segment defect imaging by spectral domain OCT and visual prognosis after macular hole surgery. Invest Ophthalmol Vis Sci 2010;51:1651-8.  Back to cited text no. 7
    
8.
Hangai M, Ojima Y, Gotoh N, Inoue R, Yasuno Y, Makita S, et al. Three-dimensional imaging of macular holes with high-speed optical coherence tomography. Ophthalmology 2007;114:763-73.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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