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Predicting probability (%) of post operative visual success
Source publication
Data on the outcome of surgery facilitate informed preoperative patient counselling. Most studies on the outcome of surgery for idiopathic full thickness macular hole surgery have concentrated on rates of anatomical closure. The aim of this study was to identify factors predicting visual success (better than 20/40; 6/12 Snellen) following macular h...
Context in source publication
Context 1
... mathematical model of visual success (better than 20/40; 6/12 Snellen) is easy to apply clinically as it is based on 3 standard clinical measurements: age, visual acuity and OCT hole maximum minimum linear dimension (table 3). The predicted range of visual success varies from 2% in patients over 80 years of age with large holes and a presenting acuity of 6/60 or worse to 93% in subjects under 60 years of age with a presenting acuity of 20/80 or better and a hole of <350 microns MLD. ...
Similar publications
Purpose
This study aimed to define novel metrics for the area of the macular hole (MH) and the cysts placed around the hole using an optical coherence tomography (OCT) device.
Methods
This retrospective, cross-sectional study was conducted with 58 eyes of 56 patients. The patients were divided into two groups according to anatomic closure after su...
Citations
... vitreolysis. 1 2 4 Based on the size of the MH, some surgeons decide to perform the PPV with or without internal limiting membrane (ILM) peeling and with or without an inverted ILM-flap. [5][6][7][8] Therefore, accurate measurement of the MLD is essential for determining the appropriate management strategy in patients with aMH. However, MLD measurements are not automatically provided by current OCT devices but need to be determined manually by clinicians using a calliper tool integrated in the OCT device software. ...
Objective
To assess the interchangeability of minimum linear diameter (MLD) macular hole (MH) size measurements in high-density horizontal and radial scan modes in optical coherence tomography (OCT).
Methods and analysis
60 patients with a MH had repeat high-density OCT volume scans in a horizontal (30 µm interscan-spacing) and a radial (angular 3.75° interscan-spacing) mode, and the MLD was measured by five raters.
Results
There were no significant differences in the MLD measurements within the horizontal and the radial modes across repeat measurements of each rater in volume scan 1 (all p≥0.14 and p≥0.28, respectively), between volume scans 1 and 2 (all p≥0.14 and p≥0.69), among the raters (p=0.70 and p=0.60), and using all MLD measurements obtained in this study between primary and repeat measurements in volume scan 1 (p=0.10 and p=0.74) and between measurements obtained in volume scan 1 and 2 (p=0.21 and p=0.90).
There was a statistically significant difference of −10.05 µm between the mean MLD of all measurements in the horizontal (n=900) and in the radial (n=900) mode (427.91 (±187.01) vs 437.97 (±184.93) µm; p<0.001). However, the variability of these differences around the mean MLD was large (95% limits of agreement −77.31 to 57.21 µm). The mean difference between all horizontal and all radial MLD measurements in a MH was for MHs that had their widest MLD within 15° of the horizontal, vertical and diagonal meridians 0.77 (±13.88) µm, −34.43 (±55.22) µm and −10.39 (± 34.62) µm, respectively.
Conclusions
Horizontal scans systematically underestimate the maximum MLD if located vertically or diagonally; however, they have less intra-rater and inter-rater and inter-scan variability in MLD measurements as compared with radial scans. Therefore, the two scan modes are not interchangeable but rather complement each other. These results may be limited to the MLD range analysed (125–924 µm).
... Based on this, we hypothesized that the probability of MH closure was associated with the combined length of the distorted OPL on both sides of the macula, surpassing the total length of the MH lesion (Fig. 1C). The threshold value should theoretically be 1, indicating the fusion of Müller cell structure remnants at the OPL level [21]. This process is akin to a drawbridge, where if the planks on both sides align with the total length of the bridge, it can fully close. ...
Background
Herein, we developed a new index called the drawbridge index to predict surgical outcomes and assessed its value in guiding surgical decision-making for large macular holes (MHs) with diameters of 400–550 μm.
Methods
A total of 48 eyes with large MHs (diameters of 400 to 550 μm), which had undergone vitrectomy with internal limiting membrane (ILM) peeling, were included and retrospectively analyzed. Based on optical coherence tomography images, base diameter, minimum linear diameter, the macular hole index (MHI), diameter hole index (DHI), and traction hole index (THI) were measured and calculated. The drawbridge index was calculated using the software ImageJ. It was determined by calculating the sum of the arm lengths extending from the break point of the outer plexiform layer (OPL) to the retinal pigment epithelium (RPE) on both sides of the macular hole, as well as the sum of the lengths from the starting point of the distorted OPL to the RPE in the vertical direction, and the difference between them then dividing by base diameter. The effectiveness of these predictive indices in prognosing “closed” versus “not closed” outcomes, and their correlation with outcome indicators, including best-corrected visual acuity, central foveal thickness, and ellipsoid zone defect length, was assessed. Furthermore, the area under the receiver operating characteristic curve (AUC) and a cutoff value were calculated for the drawbridge index. In the second part, a total of 21 patients were enrolled in the validation group, and the drawbridge index was utilized to guide surgical decisions for the ILM techniques.
Results
Significant differences were observed between the “closed” and “not closed” groups using the drawbridge index (P < 0.05). The drawbridge index was significantly correlated with postoperative best-corrected visual acuity, ellipsoid zone defect, and central foveal thickness. It exhibited an AUC value of 0.92, and the cutoff value of 1.03 demonstrated a sensitivity of 87.50% and a specificity of 80.00%. Assisted by the drawbridge index, a 100% closure rate was achieved in patients in the validation group.
Conclusion
The drawbridge index may be reliable and useful for making surgical decisions regarding ILM manipulation for large MHs.
... 17 Smaller MH sizes, including base diameter, minimum linear diameter, and MH inner opening, have been associated with higher incidences of MH closure and better visual outcomes postoperatively. [25][26][27][28] Additionally, a higher MH index, defined as the maximum height to base diameter of the hole, correlates with better postoperative BCVA. 29,30 Further, a larger preoperative photoreceptor inner segment/outer segment defect area and a smaller macular density ratio (measured as the ratio of the reflectivity of the central to the peripheral macula) have been linked to greater improvement in BCVA postoperatively. ...
... 19,21 For MH specifically, younger age at presentation, duration of symptoms, and better preoperative VA are wellknown predictors of postoperative success and are examples of data that could be added in automated models. 25,28,30 The predictive power of socioeconomic factors has also been explored, with Afro-Caribbean ethnicity and uninsured status found to be independently associated with surgical failure. 34,35 Future studies could explore the benefits of such integration further, potentially enhancing the robustness of predictive models by incorporating a wider range of clinical parameters. ...
Optical coherence tomography (OCT) is a non-invasive imaging modality essential for macular hole (MH) management. Artificial intelligence (AI) algorithms could be applied to OCT to garner insights for MH prognosis and outcomes. The objective was to review literature assessing automated image analysis algorithms in predicting postoperative outcomes for MH patients based on OCT images. A narrative search of all available published studies in peer-reviewed journals was conducted up to June 2023 following PRISMA guidelines. Three hundred sixty-eight publications underwent screening, with 14 selected for full-text review and seven determined as relevant. In MH status prediction, AI models achieved an area under the curve (AUC) of 83.6% to 98.4%. For postoperative visual acuity prediction, algorithm performance ranged from AUCs of 57% to 85%. In conclusion, novel AI algorithms were found to be predictive for postoperative MH status and postoperative visual acuity. More research in larger populations should be conducted to gauge the value of these novel algorithms in a real-world setting.
[Ophthalmic Surg Lasers Imaging Retina 2025;56:372–377.]
... 19,[22][23][24] The postoperative closure rate and visual outcome following MH surgeries depends on preoperative MH diameter. 25 Previous reports indicated a lower success rate for conventional MH surgery techniques for MHs with a diameter greater than 400 μm. 26 Moreover, MHs larger than 650 μm have been associated with a poorer prognosis. ...
Purpose
To investigate the outcome of primary idiopathic extra-large full-thickness macular holes (FTMH) treated with a modified autologous neurosensory retinal transplantation (ART) adjuncted by bevacizumab (BCZ) injection.
Methods
In this retrospective interventional case series, five consecutive patients with primary extra-large chronic FTMHs were investigated. The ART procedure included internal limiting membrane (ILM) peeling of both donor and macular hole (MH) areas, placement of the harvested tissue under the edges of MH and use of silicone oil tamponade.
Results
The median age was 64 (60–77) years. The first patient developed choroidal neovascularization one month after surgery, which was treated with BCZ injections. Subsequent patients received injection of BCZ (1.25 mg/0.05 mL) into the silicone oil at the end of the initial surgery. At the last follow-up, complete anatomical closure of the MH was achieved in all patients. With the exception of the first patient, all other patients achieved either a final ellipsoid zone (EZ) defect of zero (three cases) or a reduction to 100 μm (one case). The external limiting membrane (ELM) was completely reconstructed in all of patients. All patients demonstrated an improvement in best corrected distant visual acuity (BCDVA) one month after ART surgery, which was sustained throughout the follow-up period (12–42 months). The median LogMAR BCDVA at baseline was 1.4 (1.3–1.4) which decreased to 1.1(1.0–1.1) (P = 0.041) at the first month and 1.0 (0.7–1.2) (P = 0.043) at the last follow-up.
Conclusions
The use of ART surgery accompanied by BCZ injection appears to be an effective method for primary extra-large chronic FTMHs.
... In comparison with earlier reports, our study showed that poor preoperative visual acuity contributed to a poorer visual acuity at 6 months in our study, as well as in many other reports [28,29]. Furthermore, our study uniquely identified the significance of specific OCT-derived metrics, offering new insights into the predictors of visual outcomes. ...
Objectives: To develop a machine learning logistic regression algorithm that can classify patients with an idiopathic macular hole (IMH) into those with good or poor vison at 6 months after a vitrectomy. In addition, to determine its accuracy and the contribution of the preoperative OCT characteristics to the algorithm. Methods: This was a single-center, cohort study. The classifier was developed using preoperative clinical information and the optical coherence tomographic (OCT) findings of 43 eyes of 43 patients who had undergone a vitrectomy. The explanatory variables were selected using a filtering method based on statistical significance and variance inflation factor (VIF) values, and the objective variable was the best-corrected visual acuity (BCVA) at 6 months postoperation. The discrimination threshold of the BCVA was the 0.15 logarithm of the minimum angle of the resolution (logMAR) units. Results: The performance of the classifier was 0.92 for accuracy, 0.73 for recall, 0.60 for precision, 0.74 for F-score, and 0.84 for the area under the curve (AUC). In logistic regression, the standard regression coefficients were 0.28 for preoperative BCVA, 0.13 for outer nuclear layer defect length (ONL_DL), −0.21 for outer plexiform layer defect length (OPL_DL) − (ONL_DL), and −0.17 for (OPL_DL)/(ONL_DL). In the IMH form, a stenosis pattern with a narrowing from the OPL to the ONL of the MH had a significant effect on the postoperative BCVA at 6 months. Conclusions: Our results indicate that (OPL_DL) − (ONL_DL) had a similar contribution to preoperative visual acuity in predicting the postoperative visual acuity. This model had a strong performance, suggesting that the preoperative visual acuity and MH characteristics in the OCT images were crucial in forecasting the postoperative visual acuity in IMH patients. Thus, it can be used to classify MH patients into groups with good or poor postoperative visual acuity, and the classification was comparable to that of previous studies using deep learning.
... Gupta et al. [37] and Meng et al. [38] reported that the final BCVA was affected by the preoperative BCVA in eyes with closed macular holes. Lee et al. [18] also reported that improvement in BCVA, after surgery, was affected by the baseline BCVA along with follow-up duration after surgery and MLD. ...
... Gupta et al. [37] also reported that the hole size was a significant predictor of visual success. They concluded that the shorter the distance, the faster and better the recovery due to the lower need for horizontal stretching force to reapproximate. ...
Purpose
To develop a novel external limiting membrane (ELM) and ellipsoid zone (EZ) restoration-based grading system after successful macular hole surgery (MHS) and to evaluate EZ as a structural biomarker for the final visual outcome.
Methods
In a tertiary care center-based retrospective study, 34 consecutive cases of successful MHS for full-thickness macular holes (FTMHs) were included. Spectral domain optical coherence tomography (SD-OCT) cross-sectional analysis was performed on preoperative and postoperative data of weeks 1, 4, 12, and 24, respectively. Sequential measurements of FTMH size, ELM and EZ defect were performed using the caliper function of SD-OCT. MHS was uniquely graded as grade 0: persistence of ELM and EZ defect; grade 1: partial or complete restoration of ELM with shortening of EZ defect; and grade 2: complete restoration of ELM and EZ. Data were statistically analyzed on Statistical Package for the Social Sciences software-version 24.
Results
MHS was graded as grade 0 ( n = 8), grade 1 ( n = 15), and grade 2 ( n = 11). Best corrected visual activity (BCVA) was found to be 1.13 ± 0.19 in grade 0, 0.59 ± 0.09 in grade 1, and 0.26 ± 0.06 in grade 2. One-way analysis of variance showed improvement in final BCVA among the three grades ( P < 0.001) Postoperative visual acuity and residual EZ defect had a statistically significant linear correlation ( r = 0.899, P < 0.001). EZ was found to be an excellent structural biomarker for final BCVA (area under the curve = 0.99).
Conclusion
Successful MHS is associated with better visual outcomes in eyes with restored EZ. ELM restoration preceded EZ regeneration. MHS novel grading system is physician friendly, incorporates pathoanatomic aspects, and correlates well with visual outcomes.
... In 2009, Gupta et al. reported 93% anatomical and 42% functional success rates in cases with a minimum hole diameter of less than 400 microns. Conversely, for cases with a minimum hole diameter larger than 400 microns, the anatomical and functional success rates decreased to 42% and 20%, respectively [9]. ...
Purpose: To evaluate the effects of preoperative hole structure and size on postoperative anatomical and functional success in patients with macular holes and determine the changes in retinal layers using optical coherence tomography (OCT).
Methods: This study included 48 eyes of 45 patients who underwent surgery with the diagnosis of macular hole between January 1, 2013, and August 1, 2019, and were followed up for at least six months in the postoperative period.
Results: Forty-five patients, 23 (51.1%) female and 22 (48.9%) male, were included in the study.
There was a statistically significant difference between the preoperative visual acuity and the postoperative third-month and sixth-month visual acuity values. After surgery, visual acuity significantly increased for up to six months. When examining the relationship between hole edge parameters and preoperative visual acuity, a negative correlation was detected between the minimum hole diameter, basal hole diameter and the visual acuities measured at the postoperative. The macular hole index (MHI) and The tractional hole index (THI) had a positive correlation with the postoperative visual acuities.
The assessment of the effect of the integrity of the outer limiting membrane (OLM) and the ellipsoid zone (EZ) on postoperative visual acuity at the third and sixth months revealed that visual acuity was higher in patients with OLM and/or EZ integrity at these evaluation times.
Conclusion: The surgical closure of macular holes provides anatomical and functional recovery. This study showed that the minimum hole diameter and basal hole diameter, as well as MHI and THI, among the edge parameters measured by preoperative OCT, had a significant effect on functional success.
... Macular hole occurs unilaterally in 80% of cases [3,7,8]. Vitrectomy is the surgical method of choice for the treatment of full-wall macular holes, with an anatomical success rate of 85-100% [9][10][11][12]. The use of vitrectomy with removal of the inner retinal limiting membrane (ILM) has now become the method of choice in the treatment of MH, and most authors report achieving closure of the hole with the success of 90-98% [13,14]. ...
... Summing up, the postoperative visual acuity of patients with a macular hole was influenced by the patient's age, initial size of the hole, and duration of symptoms. In the case of a macular hole, the duration of this pathology affects the size of the hole, which in turn has predictive significance for parameters assessing retinal function after surgery [9,28,29]. In our patients with MH, the longer duration of the disease resulted in an increase in hole size parameters, which correlated with worse postoperative distance and near visual acuity, as well as retinal sensitivity in the macula. ...
Purpose of the study
The purpose of the study was to compare the morphological and functional results of the studied patients with idiopathic macular hole treated with a one-stage method (phacovitrectomy) and combined cataract and vitrectomy surgery.
Material and methods
The study included 33 patients (33 eyes) with idiopathic macular hole treated at the Department of Retina and Vitreous Surgery in Lublin. Twenty-one eyes were surgically treated with phacovitrectomy (Group 1 MH). Twelve patients underwent two-stage, combined treatment with removal of the lens in the first stage and vitrectomy in the second (Group 2 MH). The assignment of patients to groups was random. All patients underwent 23-gauge sutureless vitrectomy with removal of the internal limiting membrane (internal limiting membrane peeling). SF6 gas was used as an intraocular tamponade at an isovolumetric concentration of 20% and face down position recommendation for 7 days. Cataract surgery was performed using the phacoemulsification method with an incision in the transparent part of the cornea with intracapsular, posterior chamber implantation of a monofocal lens. A 12-month observation period was established, measured from the date of vitrectomy performance, and in the case of a combined procedure, this period was extended by the time between each stage of treatment. At subsequent check-ups, the subjects underwent a complete ophthalmological examination, which included: best corrected distance visual acuity and best corrected near visual acuity, assessment of the anterior and posterior segments, in a slit lamp, measurement of retinal sensitivity in the macula using microperimetry, the Amsler test and optical coherence tomography examination of the macula.
Results
In patients of the total studied group, an improvement in the best-corrected visual distance and near acuity was obtained, and in 88% retinal sensitivity in the macula was also achieved. In the group of patients subjected to phacovitrectomy (Group 1 macular hole) with an average minimum hole diameter of 487.48 µm before the procedure, after a one-year follow-up the mean best corrected distance visual acuity was 0.57 and best corrected near visual acuity 0.51, with macular retinal sensitivity of 26.65 dB. However, in the group of patients subjected to combined cataract and vitrectomy, an average minimum hole diameter of 521.58 µm 12 months after trans pars plana vitrectomy was performed as well as an average best corrected distance visual acuity of 0.64, best corrected near visual acuity of 0.5, and retinal sensitivity in the macula of 25.98 dB. There were no statistically significant differences between phacovitrectomy and the combined procedures in terms of the improvement in the values of distance and near visual acuity and macular retinal sensitivity 12 months after trans pars plana vitrectomy. A statistically significant improvement in retinal sensitivity in the macula was observed in Group 1 macular hole during the 12-month follow-up, while in the combined procedure group the improvement was not statistically significant.
Conclusions
Vitrectomy is an effective method of treating maculopathy in the form of macular hole. Morphological and functional improvement was noted in all patients, regardless of the treatment method used. There were no statistically significant differences between phacovitrectomy and the combined procedure in terms of the improvement achieved in the values of distance visual acuity parameters, near vision and retinal sensitivity in the macula 12 months after trans pars plana vitrectomy. A common feature of patients with worse results on individual variables was a longer duration of the disease and a larger size of the hole prior vitrectomy.
... There has been, therefore, interest in identifying factors that predict the extent of visual recovery in patients undergoing MH surgery. The size of the MH is a well-established predictive factor, and previous studies have shown that larger MHs have lower anatomical success rates and worse visual prognosis [1][2][3][4][5]. There are various methods to estimate MH size, but the minimum horizontal diameter is the most commonly used parameter because it is simple to measure, holds greater prognostic relevance than other metrics (i.e., base diameter), and is at the foundation of the current staging system [6,7]. ...
Purpose
To test the hypothesis that optical coherence tomography (OCT) choroidal hypertransmission width (CHW) is a prognostic biomarker in idiopathic macular hole (MH) surgery
Methods
Retrospective cohort study of consecutive patients undergoing successful pars plana vitrectomy for idiopathic MH. We collected demographic, clinical, and OCT variables at the preoperative and last available visits. Two investigators assessed the following OCT parameters: MH minimum diameter, base diameter, CHW, ellipsoid zone, and external limiting membrane status (absent vs. present). Delta CHW was calculated as the difference between CHW and MH minimum diameter. Linear models were used to investigate factors associated with postoperative best-corrected visual acuity (BCVA) and BCVA change.
Results
Thirty-six eyes (36 patients) with a median (interquartile range (IQR)) follow-up of 9 (8–11) months were included. The median BCVA (IQR) improved from 0.75 (1–0.6) logMAR preoperatively to 0.2 (0.6–0.1) logMAR at the last visit (p < 0.001). Preoperative MH minimum diameter (for a 10-μm increase, estimate (standard error (SE)): 0.009 (0.003) logMAR, p = 0.003), base diameter (for a 10-μm increase, 0.003 (0.001) logMAR, p = 0.032), CHW (for a 10-μm increase, 0.008 (0.002) logMAR, p < 0.001), and delta CHW (for a 10-μm increase, 0.013 (0.005) logMAR, p = 0.009) were significantly associated with postoperative BCVA. The proportion of variance explained was the highest for MH CHW (R² 0.35), followed by minimum MH diameter (R² 0.24), delta CHW (R² 0.19), and MH base diameter (R² 0.14). None of the study variables was associated with delta BCVA.
Conclusion
Preoperative CHW is associated with postoperative visual acuity in patients undergoing successful idiopathic MH surgery and may be a useful OCT prognostic biomarker.
... Macular holes (MHs) are vertical full-thickness defects of the neurosensorial retina in the fovea. Various factors have been shown to affect the visual acuity (VA) after the operation, namely the patient's age, size of the MH, duration of the symptoms, pre-operative VA, and vascular density of the fovea [24]. In clinical practice, pre-operative VA is an indicative factor for prognosis, often considered the strongest predictor of postoperative VA [25]. ...
Artificial intelligence (AI) studies are increasingly reporting successful results in the diagnosis and prognosis prediction of ophthalmological diseases as well as systemic disorders. The goal of this review is to detail how AI can be utilized in making diagnostic predictions to enhance the clinical setting. It is crucial to keep improving methods that emphasize clarity in AI models. This makes it possible to evaluate the information obtained from ocular imaging and easily incorporate it into therapeutic decision-making procedures. This will contribute to the wider acceptance and adoption of AI-based ocular imaging in healthcare settings combining advanced machine learning and deep learning techniques with new developments. Multiple studies were reviewed and evaluated, including AI-based algorithms, retinal images, fundus and optic nerve head (ONH) photographs, and extensive expert reviews. In these studies, carried out in various countries and laboratories of the world, it is seen those complex diagnoses, which can be detected systemic diseases from ophthalmological images, can be made much faster and with higher predictability, accuracy, sensitivity, and specificity, in addition to ophthalmological diseases, by comparing large numbers of images and teaching them to the computer. It is now clear that it can be taken advantage of AI to achieve diagnostic certainty. Collaboration between the fields of medicine and engineering foresees promising advances in improving the predictive accuracy and precision of future medical diagnoses achieved by training machines with this information. However, it is important to keep in mind that each new development requires new additions or updates to various social, psychological, ethical, and legal regulations.
