Retinal Pigment Epitheliopathy after Macular Hole Surgery Lon S. Poliner, MD, Paul E. Tornambe, MD Background: Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and improve vision. This study evaluates the fluorescein angiographic changes that occur after macular hole surgery. Methods: Sixteen patients with stage III idiopathic macular holes underwent pars plana vitrectomy, removal of the posterior hyaloid, peeling of fine epiretinal sheets along the edges of the holes, and fluid-gas exchange. Preoperative fluorescein angiograms were performed, and best-corrected preoperative visual acuity was 20/200 or less in all eyes. Results: Postoperatively, the macular hole disappeared in 12 eyes (75%). In all 12 eyes, retinal pigment epithelial swelling was present, with a unique fluorescein angiographic appearance. This pattern slowly resolved over months, with gradual visual improvement but residual retinal pigment epithelial mottling. Systemic and periocular steroids had no significant impact on the process. Conclusion: The combination of prolonged intraocular gas contact and light exposure exceeding threshold for an already compromised macula appears to be responsible for this pigmentary pattern. Depending on the severity of the pigment epithelial alteration, this unique pattern may portend a guarded visual prognosis in affected patients undergoing successful macular hole repair. Ophthalmology 1992;99:1671-1677

Idiopathic macular holes most frequently affect women in their sixth and seventh decades of life, manifested by visual blurring and distortion, with median visual acuity of 20/200. 1 As the incidence of bilaterality can range from as low as 6%2 to as high as 22%,3 visual loss can be severely disabling. Abnormal vitreoretinal relationships appear to contribute to idiopathic macular hole formation. 4,5 Surgical intervention to relieve these tractional forces in patients with impending macular holes has been attempted,6.7 and a prospective clinical trial is being conducted. Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and improve vision. s In the current study, 16 eyes with idiopathic stage III macular holes were SUbjected to trans pars plana vitrecOriginally received: September 20, 1991. Revision accepted: May 14, 1992. From the Department of Ophthalmology, University of California, San Diego, Presented at the American Academy of Ophthalmology Annual Meeting, Anaheim, October 1991. Reprint requests to Lon S. Poliner, MD, Retina Consultants, San Diego, 12630 Monte Vista Rd, Suite 104, Poway, CA 92064.

tomy, engagement and removal of the posterior hyaloid, stripping of residual epiretinal sheets along the edges of the hole, total air-fluid exchange, followed by placement of a nonexpansile mixture of sulfur hexafluoride, and facedown positioning. In all eyes manifesting closure of the macular hole and resolution of the rim of subretinal fluid, swelling of the deeper retinal layers and retinal pigment epithelium was found. Fluorescein angiography in these eyes demonstrated a unique pattern of early hypofluorescence and later staining. In those eyes failing macular hole repair, this pattern was absent both clinically and angiographically. Although the etiology remains uncertain, the combination offace-down positioning with prolonged intraocular bubble contact and light exposure in an already compromised macula appear responsible. Retinal pigment epitheliopathy after macular hole surgery may portend a guarded visual prognosis in many affected patients.

Patients and Methods Sixteen patients with stage III idiopathic macular holes, as defined by Gass, 1 and best-corrected visual acuity less

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than or equal to 20/200 were evaluated over a 12-month period. The duration of symptoms of visual blurring and distortion ranged from 3 weeks to 14 months (Table I). At the initial examination, all eyes were subjected to biomicroscopic examination, contact lens examination, stereo fundus photography, and fluorescein angiography. In all cases, the surgical procedure was performed while the patient was under general anesthesia. A three-port trans pars plana vitrectomy was undertaken, followed by engagement of the posterior hyaloid. In the first three cases, the hyaloid was engaged with a membrane spatula, and gentle stripping was completed with a membrane pic. The hyaloid was engaged in the remaining 13 cases with active suction from a soft-tipped extrusion handpiece, as described by Kelly et al. 8 Epiretinal membranes were stripped with a barbed 20-gauge disposable needle. A fluid-air exchange then followed, and final flushing with 20% sulfurhexafluoride was performed. The patients then maintained strict face-down positioning postoperatively for a minimum of7 days. Follow-up visits were performed at 1 day, 5 days, 10 days, 3 weeks, 3 months, and 6 months. All patients were followed for a minimum of 12 months postoperatively.

Table 2. Operating Time for 16 Study Eyes Undergoing Macular Hole Surgery Patient No. 1 2 3

4 5 6 7 8 9 10 11 12 13 14 15 16

Operating Time* 65 min 79 min 67 min 94 min 69 min 58 min 106 min 76 min 85 min 109 min 79 min 115 min 75 min 66 min 102 min 91 min

• Operating time denotes surgical time from first incision to closure.

Results Of 16 eyes with stage III idiopathic macular holes and best-corrected visual acuity of20/200 or less, the macular hole flattened in 12 eyes (75%). The rim of subretinal fluid surrounding the macular hole was absent on the first postoperative visit in all successfully repaired eyes. The edges of the macular hole were ill-defined during this early Table 1. Preoperative Characteristics of 16 Study Eyes Before Macular Hole Surgery Patient No.

Age (yrs)

Initial Visual Acuity

Hole Duration

Lens Status

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

61 67 63 70

20/ 200 20/400 CF 2 ft 20/ 400 20/ 200 20/200 20/400 20/200 20/400 20/400 CF 2 ft 20/400 20/ 400 20/200 20/ 400 20/400

4 mos 13 mos 11 mos 12 mos 6 mos 3 mos 3 wks 3 mos 14 mos 8 mos 6 mos 1 mo 14 mos 4 mos 5 mos IOmos

Pseudophakic Phakic Pseudophakic Pseudophakic Pseudophakic Pseudophakic Phakic Pseudophakic Phakic Pseudophakic Phakic Phakic Pseudophakic Phakic Phakic Pseudophakic

CF

=

72 63 68 74 79 64

77 79 67

60 73 78 counting fingers.

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postoperative period. No eyes successfully repaired with this technique subsequently developed a recurrent macular hole. In 4 eyes (25%), the macular hole did not improve postoperatively, and the rim of subretinal fluid persisted. In those 12 eyes that had macular hole resolution, a unique clinical and angiographic appearance was documented. In 3 eyes, an arcuate pattern of deep retinal and retinal pigment epithelial swelling was noted on the first postoperative visit at 5 days. The intraocular gas bubble precluded fluorescein angiographic evaluation until 10 days after surgery. Fluorescein angiography demonstrated early hypofluorescence and late staining, with more widespread involvement than that suspected on clinical examination. The arcuate pattern of swelling resolved slowly with minimal visual impairment. In nine eyes, the pigment epitheliopathy was much more diffuse with involvement of the entirety of the macula. Central scotomata were present, and angiographic evaluations indicated widespread hypo fluorescence and late staining. Because of diffuse involvement and poor visual function, three patients were managed with periocular and systemic steroid therapy, but no significant improvement in visual outcome occurred in comparison with patients managed with observation alone. The severity of retinal pigment epithelial swelling in these eyes was graded on the basis of area of involvement in the following manner: grade I, less than 1 disc diameter of swelling; grade II, 1 to 2 disc diameters of swelling; grade III, more than 2 disc diameters of swelling. The retinal pigment epithelial pattern was not correlated with the preoperative lens status (Table I) or the duration of the surgical procedure and resultant light exposure (Table 2). Final visual outcome was correlated

Poliner and Tornambe . RPE after Macular Hole Surgery with the severity of retinal pigment epithelial swelling (Table 3). In those eyes failing macular hole repair, postoperative swelling of the deep retina and retinal pigment epithelium was not noted. Fluorescein angiography postoperatively did not demonstrate early hypofluorescence or late leakage. The macular hole and subretinal fluid remained stable with no change in best-corrected visual acuity postoperatively. In reviewing the surgical procedure performed for these four eyes failing repair, there was no difference in operating time or extent of dissection compared with eyes successfully repaired (Table 2).

Selected Case Reports Case 1. A 63-year-old woman presented with a 4-week history of visual blurring in her right eye. Best-corrected visual acuity was 20/400 in the right eye and 20/25 in the left, with a stage III, idiopathic macular hole on the right. During the next 10 months, visual blurring and distortion in the right eye increased, and visual acuity declined to counting fingers at 2 feet. Because of increasing visual disability, the patient requested attempted surgical repair of the macular hole. While the patient was under general anesthesia, a three-port vitrectomy was performed, and the posterior hyaloid was engaged with a membrane spatula along the superotemporal arcade. No extrusion device was used to engage the hyaloid, and the infusion bottle was not elevated at any time during the procedure. The fiberoptic endoilluminator was held at least 6 mm from the retinal surface throughout the procedure. Fine diaphanous membranes were present beneath the posterior hyaloid and removed with a barbed 20-gauge needle. By the conclusion of the procedure, the macular hole appeared considerably smaller in diameter. The rim of subretinal fluid flattened during the fluid-air exchange, and 20%

Table 3. Postoperative Characteristics of 16 Study Eyes After Macular Hole Surgery Patient No.

1 2 3 4 5 6

7 8 9

10 11

12 13

14 15 16 NA

=

Outcome

Severity

Therapy

Final Visual Acuity

Success Failure Success Success Failure Success Success Success Failure Failure Success Success Success Success Success Success

Grade 3 NA Grade 1 Grade 2 NA Grade 3 Grade 3 Grade 3 NA NA Grade 3 Grade 1 Grade 3 Grade 3 Grade 1 Grade 2

Steroids None None None None None None Steroids None None Steroids None None None None None

20/100 20/ 200 20/30 20/80 20/200 20/100 20/100 20/80 20/400 20/400 20/200 20/40 20/200 20/80 20/25 20/70

not applicable.

sulfur hexafluoride was flushed through the globe at the conclusion of the procedure. The patient ~as positioned face down as much as possible for the first 7 days. On the fifth postoperative day, visual acuity was still counting fingers, with pinhole improvement to 20/200 in the right eye. An arcuate area of swelling involving the deep retina and retinal pigment epithelium was noted nasal to fixation, but the intraocular gas bubble precluded angiographic evaluation. A fine diaphanous glial membrane across the edges of the hole was noted and no rim of subretinal fluid was present (Fig I A). By the tenth postoperative day, visual acuity had improved to 20/100, and the arcuate area of swelling had begun to diminish (Fig I B). With 24 months offollow-up, best-corrected visual acuity in the right eye improved to 20/30 and the nasal swelling gradually diminished with subsequent retinal pigment epithelial mottling. Approximately 10 months after macular hole repair in the right eye, the patient presented with visual blurring and distortion involving the left eye. An idiopathic stage III macular hole was identified, with best-corrected visual acuity of 20/80. Visual acuity rapidly decreased to 20/200 in the left eye, and the patient elected to undergo attempted repair of the macular hole. Asofttipped extrusion handpiece was used to engage the posterior hyaloid in the superonasal quadrant. The infusion bottle was not raised, and the posterior hyaloid was engaged and gently stripped from the posterior pole. A diaphanous preretinal membrane was removed with a barbed 20-gauge needle, and a fluidair exchange was performed, followed by an exchange with 20% sulfur hexafluoride. The patient was positioned face down as much as possible for the first 7 days. On the fifth postoperative day, visual acuity was 20/400 in the left eye, but the patient had the subjective complaint of a central scotoma. Diffuse central swelling involving the deeper layers ofthe retina and the retinal pigment epithelium was present, and the edges of the hole could still be faintly visualized. The rim of sub retinal fluid, however, was not evident (Fig IC). Fluorescein angiography performed 10 days after surgery showed early hypofluorescence (Fig 10) with diffuse late staining of the retinal pigment epithelium (Fig I E). Because of the diffuse nature of the swelling in the deeper retina and retinal pigment epithelium, systemic steroid therapy was begun (Prednisone 60 mg daily with a rapid taper), but no significant reduction in the swelling or improvement in vision occurred. Best-corrected visual acuity improved to 20/100 with pigment mottling 15 months postoperatively. Case 2. A 67-year-old woman presented with a 2-month history of visual distortion in her left eye. On examination, visual acuity was 20/20 in the right eye and 20/ I00 in the left with a stage III idiopathic macular hole on the left. Over the next 12 months, visual function declined to 20/400, and the visual distortion became more pronounced. The patient wished to pursue surgical intervention in the hope of reducing the visual distortion. While the patient was under general anesthesia, a three-port vitrectomy was undertaken, and the edge of the posterior hyaloid was engaged in the superonasal quadrant with a soft-tipped extrusion handpiece. The hyaloid was gently stripped posteriorly without difficulty, and a diaphanous membrane was removed with a barbed 20-gauge needle. There were no petechial hemorrhages encountered, and the macular hole flattened well with a fluid-air exchange. An exchange with 20% sulfur hexafluoride was undertaken, and the patient was placed face down as much as possible for the first 7 days. On the tenth postoperative day, visual acuity was 20/400 in the left eye, but the patient was aware of a pronounced central scotoma. Diffuse swelling involving the deeper layers of the retina and retinal pigment epithelium was noted involving the macula. Fluorescein angiography showed hypofluorescence in early frames of the angiogram (Fig 2A) and late staining (Fig

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Poliner and Tornambe . RPE after Macular Hole Surgery Top left, Figure lAo Fundus photograph of a 63-year-old woman 5 days status post vitrectomy, posterior hyaloid removal, and fluid-gas exchange for a stage III idiopathic macular hole of the right eye. An arcuate area of swelling involving the deep retina and retinal pigment epithelium is present. Top right, Figure lB. By the tenth day status post vitrectomy, visual acuity is now 20/100 and the swelling has begun to resolve. Second row left, Figure Ie. On the fifth day status post vitrectomy, posterior hyaloid removal, and fluid-gas exchange for a stage III idiopathic macular hole of the left eye, diffuse central swelling involving the deeper layers of the retina and retinal pigment epithelium was present (grade 3). The edges of the hole could still be faintly visualized. Second row right, Figure lD. Results of fluorescein angiographic evaluation performed 10 days after surgery showed early hypofluorescence in the left eye. Third row left, Figure IE. Results of fluorescein angiographic evaluation performed 10 days after surgery showed late diffuse staining in the left eye. Third row right, Figure 2A. Fundus photograph of a 67-year-old woman 10 days status post vitrectomy, posterior hyaloid removal, and fluid-gas exchange for a stage III idiopathic macular hole. Results of fluorescein angiography showed early hypofluorescence in the left eye (grade 3). Bottom left, Figure 2B. Results of fluorescein angiographic evaluation performed 10 days after surgery showed later diffuse staining in the left eye. Bottom right, Figure 2e. By 3 weeks after surgery, deep retinal and retinal pigment epithelial swelling had diminished, and retinal pigment epithelial mottling was present. (

2B). By the third postoperative week, mottling of the retinal pigment epithelium was present centrally (Fig 2C), and the patient believed her central scotoma was beginning to fade. Bestcorrected visual acuity, however, is 20/200 14 months after surgery with central pigment mottling.

Discussion A stage III macular hole represents a fully developed fullthickness macular hole with vitreofoveal separation, as classified by Gass. 1 Visual acuity is usually in the range of 20170 to 20/400, and in most cases the diameter of the hole is approximately 500 /-Lm. Changes that can occur in long-standing macular holes include epiretinal membrane contraction around the edge of the hole and depigmentation of the retinal pigment epithelium in the areas of the hole and surrounding rim of subretinal fluid. Pigment epithelial changes often are more evident angiographically than biomicroscopically. In observing 158 eyes with evolving or completed idiopathic macular holes, Johnson and Gass4 believed that prefoveal vitreous cortex contraction was the likely cause of idiopathic macular holes. Gass 5 also suggested that tangential traction from the posterior vitreous surface may be causative in the formation of macular holes. Smiddy et al 6 performed pars plana vitrectomy in 15 patients with visual loss and clinical features suggestive of impending macular holes. Of these 15 eyes, 12 (80%) failed to progress to a full-thickness macular hole with minimum follow-up of 15 months. In a study undertaken by Jost et aI/ 15 eyes at risk for macular hole formation underwent vitrectomy in an attempt to prevent macular hole formation. Full-thickness macular holes failed to develop in 10 of II eyes with stage I macular holes. To determine whether surgical intervention may reduce the risk of formation of full-thickness macular holes, a controlled, randomized clinical trial is under way. Although idiopathic macular holes were previously considered untreatable, Kelly and Wendel 8 found that surgical techniques designed to relieve tractional forces

on the edges of the hole, followed by intraocular gas tamponade and face-down positioning, resulted in flattening of the hole in 58% of patients. Complications related to the surgical procedure included mottling of the retinal pigment epithelium, identified on clinical examination in several patients, which was associated with limited visual improvement. Fluorescein angiography was not performed postoperatively in this consecutive series of patients to determine the frequency and severity of retinal pigment epithelial alterations evident angiographically. In the current study, 16 eyes with idiopathic stage III macular holes were subjected to trans pars plana vitrectomy, engagement and removal of the posterior hyaloid, stripping of residual epiretinal membranes, and total fluid-air exchange, followed by placement of a nonexpansile mixture of sulfur hexafluoride. With successful repair of the macular hole and collapse of the rim of subretinal fluid, swelling of the deeper retinal layers and retinal pigment epithelium was discovered. Fluorescein angiography in these 12 eyes demonstrated a unique pattern of early hypofluorescence and late staining. In those eyes failing macular hole repair, the pigment epitheliopathy was absent both clinically and angiographically. In a histopathologic analysis of 22 full-thickness macular holes, Guyer et al 9 found that 16 (73%) had epiretinal membranes, 15 (68%) had cystoid macular edema, and 3 (17%) were sealed by fibroglial and retinal pigment epithelial hyperplasia. In addition, photoreceptor atrophy was present in all eyes with macular holes. The extent of photoreceptor atrophy ranged from 200 to 750 /-Lm from the margin of the hole. Resolution of the cystoid macular edema and reattachment of the adjacent macular retina may explain the visual improvement in some patients successfully undergoing repair of full-thickness macular holes. The degeneration of photoreceptors and retinal pigment epithelial atrophy in long-standing macular holes may explain the lack of visual improvement in many of these patients. The lack of deep retinal and pigment epithelial swelling in eyes failing surgical repair, however, suggests that photoreceptor degeneration alone is not the

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cause of the retinal pigment epithelial disturbance. In those eyes failing repair, progressive photoreceptor degeneration continues, but the angiographic appearance is unchanged. Photic toxicity is a well-recognized complication of intraocular surgery, with most case reports emphasizing microscopic-induced retinal and retinal pigment epithelial lesions. 10.11 Although many cases of retinal phototoxicity from microscopic light sources have been published, the pathologic results are often subtle and symptomatology is frequently rare. The lesions tend to be round and emulate the shape of the filament incorporated within the microscopic light source. In an afoveate nocturnal owl monkey, Fuller et al 12 produced ophthalmoscopic and irreversible histologic lesions after illumination from a stationary intravitreal fiberoptic light. A central oval of outer retinal and retinal pigment epithelial damage was generated with surrounding halos of hyperpigmentation and hypopigmentation. On fluorescein angiography, significant staining of the pigment epithelium and outer retina occurred within 24 hours. Meyers and Bonner!3 measured the light output of 19- and 20-gauge endoilluminators, calculated their retinal irradiance values, and compared these data with the retinal damage threshold from intravitreal fiberoptic light in the adult owl monkey. Although the calculated retinal irradiance values 2 mm from the retina for the 19- and 20-gauge endoilluminators exceeded threshold for the owl monkey in 1 minute or less, at 6 mm from the retina, the calculated retinal irradiance values appear to be safe. During vitrectomy, endoilluminators are usually held 5 to 7 mm from the retina unless an illuminated pic is used, and the illuminated area changes as the surgeon moves the light source. In the current study, although the retinal pigment epithelial changes resemble previously described macular phototoxic lesions, no illuminated light pics were used, and conscious attempts were made to keep the light source at least 6 mm from the retinal surface. In addition, the initial dissection of the posterior hyaloid was begun superonasal to fixation, well away from the macular hole and fixation. The surgical time also was considerably less than that required for macular pucker removal, which requires more stationary macular illumination, yet this pattern of retinal pigment epithelial swelling has not been frequently noted after macular pucker surgery. Delayed resorption of subretinal fluid also may be potentially responsible for the postoperative appearance in the deep retina and retinal pigment epithelium. Longstanding accumulations of subretinal fluid may give rise to poor retinal pigment epithelium pump function and subsequent retinal pigment epithelial swelling with successful flattening of the macular hole. However, despite postoperative visual complaints, delayed resorption in patients after scleral buckling!4 or pneumatic retinopexy!5 rarely give rise to long-term retinal pigment epithelial alteration. Acute loss of central and paracentral vision with diffuse and patchy whitening of the outer retina has been described in patients after cataract surgery!6 and vitrectomy

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with scleral buckling. 17 Later clearing of the retinal whitening occurs with mottling of the retinal pigment epithelium and partial recovery of the central visual field. The postulated mechanism for this diffuse pattern of whitening is elevated intraocular pressure sufficient to obstruct the choroidal blood flow,18 occurring during the use of volume-reducing devices before cataract surgery, during phacoemulsification, or during closed vitrectomy. The clinical picture is that of immediate postoperative whitening of the posterior pole and subsequent pigment epithelial atrophy and clumping. The retinal whitening however is widespread, involving the posterior one third of the fundus. After macular hole surgery, the pigment epitheliopathy tends to be less diffuse. In addition, in the current study, intraocular pressure was not raised during the procedure, and infusion bottle height was carefully monitored. Despite these proposed etiologies for the deep retinal and retinal pigment epithelial swelling described in this consecutive series, none at present appear to adequately explain the absence of any macular disturbance in those eyes that failed attempted repair. The combination offacedown positioning with prolonged intraocular gas contact and light exposure exceeding threshold for an already compromised macula seems responsible. Prolonged intraocular gas contact may compromise choriocapillaris perfusion through mechanical compression. Oxidative byproducts from intraocular light exposure may be responsible for the retinal pigment epithelial lesions as the intraocular gas bubble may sequester such byproducts within the macula with face-down positioning. Despite concerted efforts to limit light exposure during the surgical procedure, this clinical and angiographic pattern was present in all eyes successfully repaired. Depending on the severity of the pigment epithelial changes, this unique pattern may portend a guarded prognosis in many affected patients undergoing successful repair.

References I. Gass JDM. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol 1988; 106:629-39. 2. McDonnell PJ, Fine SL, Hillis AI. Clinical features of idiopathic macular cysts and holes. Am J Ophthlamol 1982;93: 777-86. 3. Bronstein MA, Trempe CL, Freeman HM. Fellow eyes of eyes with macular holes. Am J Ophthlamol 1981;92:75761. 4. Johnson RN, Gass JDM. Idiopathic macular holes: observations, stages of formation, and implications for surgical intervention. Ophthalmology 1988;95:917-24. 5. Gass JDM. Stereoscopic Atlas of Macular Disease: Diagnosis and Treatment, 3rd ed. Vol. 2. St. Louis: CV Mosby, 1987;676-93. 6. Smiddy WE, Michels RG, Glaser BM, de Bustros S. Vitrectomy for impending idiopathic macular holes. Am J Ophthalmol 1988; 105:371-6. 7. Jost BF, Hutton WL, Fuller 00, et al. Vitrectomy in eyes at risk for macular hole formation. Ophthalmology 1990;97: 843-7.

Po liner and Tornambe . RPE after Macular Hole Surgery 8. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991; 109:654-9. 9. Guyer DR, Green WR, de Bustros S, Fine SL. Histopathologic features of idiopathic macular holes and cysts. Ophthalmology 1990;97: 1045-51. 10. Ross WHo Light-induced maculopathy. Am J Ophthlamol 1984;98:488-93. 11. Michels M, Sternberg P Jr. Operating microscope-induced retinal phototoxicity: pathophysiology, clinical manifestations and prevention. Surv Ophthlamol 1990;34:237-52. 12. Fuller D, Machemer R, Knighton RW. Retinal damage produced by intraocular fiber optic light. Am J Ophthlamol 1978;85:519-37. 13. Meyers SM, Bonner RF. Retinal irradiance from vitrectomy endoilluminators. Am J Ophthalmol 1982;94:26-9.

14. Robertson DM. Delayed absorption of subretinal fluid after scleral buckling procedures. Am J OphthalmoI1979;87:5764. 15. Chan CK, Wessels IF. Delayed subretinal fluid absorption after pneumatic retinopexy. Ophthalmology 1989;96: 16911700. 16. Gass JDM, Parrish R. Outer retinal ischemic infarctionnewly recognized complication of cataract extraction and closed vitrectomy. Part 1. A case report. Ophthlamology 1982;89: 1467-71. 17. Diamond JG, Kaplan HJ. Uveitis: effect of vitrectomy combined with lensectomy. Ophthalmology 1979;86: 13207. 18. Parrish R, Gass JDM, Anderson DR. Outer retinal ischemic infarction-a newly recognized complication of cataract extraction and closed vitrectomy: Part 2. An animal model. Ophthalmology 1982;89: 1472-7.

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Retinal pigment epitheliopathy after macular hole surgery.

Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and i...
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