PURPOSE:To compare the incidence and outcomes of postoperative epiretinal membrane (ERM) formation after fovea-sparing internal limiting membrane peeling (FSIP) and standard internal limiting membrane (ILM) peeling in eyes with myopic traction maculopathy (MTM). DESIGN:Multicenter, retrospective clinical cohort study (Schisis report no. 4). METHODS:Patients with MTM who underwent pars plana vitrectomy (PPV) at 10 institutions between June 2008 and July 2024, with at least 12 months of follow-up, were included. Postoperative ERM was identified on optical coherence tomography (OCT) and graded using the Govetto classification. The main outcomes were the 12-month incidence of postoperative ERM and postoperative visual outcomes. RESULTS:We included a total of 206 eyes (201 patients); 46 eyes treated with FSIP and 160 eyes treated with standard ILM peeling. Of the 206 eyes, postoperative ERM developed in 16 eyes (7.8%) at 12 months: 8 eyes (17.4%) in the FSIP group and 8 eyes (5.0%) in the standard ILM peeling group. The incidence of postoperative ERM was significantly higher in the FSIP group than in the standard ILM peeling group (P = .014), and univariable logistic regression analysis revealed that FSIP was significantly associated with postoperative ERM at 12 months (OR = 4.00, 95% CI = 1.39-11.55, P = .009). Of the 8 eyes with postoperative ERM after FSIP, 6 eyes showed stage 1 ERM and 2 eyes showed stage 2 ERM. Of the 8 eyes with postoperative ERM after standard ILM peeling, 7 eyes showed stage 1 ERM and 1 eye showed stage 2 ERM. No additional surgery was required for postoperative ERM during 12 months. Postoperative logarithm of minimum angle of resolution visual acuity at 12 months did not differ significantly between eyes with (0.50 ± 0.43) and without ERM (0.42 ± 0.52; P = .517). The incidence of postoperative macular hole (MH) was lower in the FSIP group (2.2%) than in the standard ILM peeling group (12.8%), although the difference was not statistically significant (P = .071). CONCLUSIONS:FSIP increased the incidence of postoperative ERM compared with standard ILM peeling, but most ERMs were subclinical and did not affect vision. Despite the elevated ERM risk, the potential benefit of FSIP in reducing postoperative macular hole formation may outweigh its drawbacks.

PURPOSE:To characterize the surgical management and outcomes of large high myopic macular holes (HMMHs). METHODS:Global multicenter retrospective case series of HMMHs with minimum linear diameter ≥ 400 µ m undergoing surgery between 2013 and 2023 with follow-up ≥ 3 months. The main outcome measure was the HMMH closure rate at postoperative Month 3. RESULTS:Four hundred and ninety-nine cases of 463 patients from 37 surgeons were included, with mean ± SD age 58.3 ± 12.2 years, 77.0% female, 77.4% primary, 22.6% refractory, and mean ± SD follow-up 18.8 ± 20.2 months. The mean ± SD (range) minimum linear diameter was 649 ± 280 (400, 2,759) µ m. Surgery techniques included 127 internal limiting membrane peels, 285 internal limiting membrane flaps, 19 amniotic membrane transplantations, 36 autologous retinal transplantations, and 32 others. The postoperative Month 3 closure rate for all cases was 72.4%. Closure rates significantly decreased with greater CLOSE Study Group size classification for HMMHs treated with internal limiting membrane peeling or internal limiting membrane flap ( P = 0.006) but not for HMMHs treated with amniotic membrane transplantations or autologous retinal transplantations ( P > 0.05). Visual acuity significantly increased from baseline to each follow-up time point among all eyes, with a final mean ± SD change in visual acuity of -0.29 (0.55) logMAR (+14.5 early treatment diabetic retinopathy study letters), which did not significantly differ by surgery type. CONCLUSION:High myopic macular hole closure rates are lower than those reported for macular holes in nonhighly myopic eyes, but most eyes can still achieve anatomical closure and meaningful visual acuity gains when treated with the appropriate technique.

PURPOSE:To determine whether tractional inner retinal changes, including schisis of the retinal nerve fiber layer (sRNFL) and internal limiting membrane (ILM) tears, represent a surgically irreversible stage of the epiretinal membrane (ERM). DESIGN:Retrospective study. PARTICIPANTS:Patients who underwent vitrectomy with ERM and ILM peeling. METHODS:Visual acuity and metamorphopsia were assessed at baseline and at 1, 3, 6, and 12 months after operation, whereas retinal sensitivity was evaluated at baseline and 3 and 12 months after operation. Metamorphopsia was quantified using M-CHARTS, and retinal sensitivity was measured within the central 10° of the macula using microperimetry. Visual outcomes were compared between eyes with and without sRNFL and ILM tears. MAIN OUTCOME MEASURES:Visual acuity, metamorphopsia, and retinal sensitivity at 12 months and their changes from baseline. RESULTS:Among 129 eyes (129 patients), sRNFL was observed in 62 eyes (48%) and ILM tears in 49 eyes (38%), all of which co-occurred with sRNFL. Eyes with sRNFL or ILM tears had worse baseline visual function across all 3 parameters, greater central foveal thickness, and a more advanced ERM stage (all P < 0.01). However, visual function in eyes with sRNFL or ILM tears significantly improved (P < 0.001), resulting in comparable postoperative outcomes regardless of their presence. Multivariate analyses showed that baseline visual function independently predicted postoperative visual acuity (β = 0.292, P = 1.5 × 10-4), metamorphopsia (β = 0.251, P = 0.017), and retinal sensitivity (β = 0.422, P = 4.9 × 10-4), excluding sRNFL or ILM tears. In functional changes, sRNFL remained independently associated with greater improvements in visual acuity (β = -0.144, P = 5.9 × 10-4) and retinal sensitivity (β = 1.140, P = 0.028), whereas ILM tears were associated only with visual acuity improvement (β = -0.167, P = 1.0 × 10-4) after adjusting for age, sex, and phacovitrectomy. CONCLUSIONS:Schisis of the RNFL and ILM tears represent extrafoveal tractional markers in ERM and do not necessarily indicate irreversible visual dysfunction. Recovery patterns may differ across visual function domains with increasing inner retinal tractional changes, whereas visual acuity may remain recoverable even in eyes with advanced traction. These findings may help inform prognostic counseling before surgery. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

PURPOSE:The aim of this study was to report the case of paracentral acute middle maculopathy (PAMM) associated with pulmonary arterial hypertension (PAH), and to highlight its potential as an early indicator of systemic hypoxemia. METHODS:This is a case report. RESULTS:A 76-year-old Japanese woman presented with bilateral visual disturbances and was found to have PAMM lesions on optical coherence tomography. Her initial best-corrected visual acuity (BCVA) was 20/25 in both eyes. Over the three-year follow-up, recurrent PAMM lesions appeared in various retinal locations, coinciding with progressive visual decline and worsening cardiopulmonary function. The patient experienced repeated hospitalizations due to systemic deterioration. After the initiation of home oxygen therapy, no new PAMM lesions were observed during follow-up; however, progressive vascular dropout in the central macula led to irreversible vision loss. Her BCVA declined to 20/200 in the right eye and 20/30 in the left eye at the last visit. CONCLUSION:The definitive diagnosis of PAH requires invasive testing and is therefore frequently delayed. This case suggests that PAMM may serve as a useful ocular indicator prompting early systemic evaluation. Recognizing PAMM lesions could facilitate earlier diagnosis and intervention in patients with underlying hypoxemic conditions such as PAH.

PURPOSE:Anatomic restoration after vitrectomy for lamellar macular hole (LMH) is not always achieved. However, the impact of unresolved LMH on visual outcomes remains unclear. We evaluated postoperative outcomes in eyes with unresolved LMH and postoperative full-thickness macular hole (FTMH) to reassess the meaning of anatomic success after LMH surgery. DESIGN:Multicenter, retrospective cohort study. SUBJECTS:One hundred sixty-six consecutive eyes of 166 patients who underwent vitrectomy for LMH. METHODS:Anatomic success was defined as restoration of foveal configuration, whereby the postoperative OCT findings no longer met the diagnostic criteria for LMH. Postoperative anatomic outcomes were classified as anatomic success, unresolved LMH (including both persistent or recurrent LMH), or postoperative FTMH. MAIN OUTCOME MEASURES:Incidence and risk factors of unresolved LMH and postoperative FTMH, and best-corrected visual acuity (BCVA). RESULTS:Anatomic success was achieved in 141 eyes (84.9%), whereas 14 eyes (8.4%) had unresolved LMH and 11 eyes (6.6%) progressed to FTMH during follow-up (mean, 17.8 months). At 12 months, BCVA was significantly worse in eyes with unresolved LMH than in those with anatomic success (0.24 ± 0.24 vs. 0.09 ± 0.19 logarithm of the minimum angle of resolution [LogMAR]; P = 0.041). Internal limiting membrane (ILM) peeling was significantly associated with a reduced risk of unresolved LMH (odds ratio [OR], 0.011; 95% confidence interval [CI], 0.002-0.062; P < 0.001). Postoperative FTMH was significantly associated with epiretinal proliferation (P = 0.018), thinner preoperative central foveal thickness (P = 0.017), and no ILM peeling (P = 0.001). Multivariable analysis confirmed that ILM peeling was an independent factor preventing postoperative FTMH (OR, 0.080; 95% CI, 0.010-0.620; P = 0.001). Postoperative FTMH achieved closure in 9 eyes (82%) with additional treatment or observation, whereas the final BCVA was significantly worse in eyes that developed FTMH than in those with anatomic success (0.50 ± 0.32 vs. 0.12 ± 0.20 LogMAR; P < 0.001). CONCLUSIONS:Although most eyes achieved anatomic success after vitrectomy for LMH, approximately 15% developed unresolved LMH or postoperative FTMH, both of which were associated with the absence of ILM peeling. Because anatomic failure was associated with poorer visual outcomes, foveal restoration on OCT may represent a more clinically meaningful anatomic endpoint after LMH surgery. FINANCIAL DISCLOSURE(S):The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retinal neovascularization (RNV) is a vision threatening development in diabetic retinopathy (DR). Vision loss associated with RNV is preventable with timely intervention, making RNV clinical screening and monitoring a priority. Optical coherence tomography (OCT) angiography (OCTA) provides high-resolution imaging and high-sensitivity detection of RNV lesions. With recent commercial devices introducing widefield OCTA imaging to the clinic, the technology stands to improve early detection of RNV pathology. However, to meet clinical requirements, these imaging capabilities must be combined with effective RNV detection and quantification, but existing algorithms for OCTA images are optimized for conventional, i.e., narrow, fields of view. Here, we present a novel, to our knowledge, approach for RNV diagnosis and staging on widefield OCT/OCTA. Unlike conventional methods dependent on multi-layer retinal segmentation, our model reframes RNV identification as a direct binary localization task. Our fully automated approach was trained and validated on 634 widefield scans (17 & times; 17 to 26 & times; 21 mm) collected from multiple devices at multiple clinics. Our method achieved a device-dependent area under curve (AUC) ranging from 0.96 to 0.99 for RNV diagnosis, and mean intersection over union (IOU) ranging from 0.76 to 0.88 for segmentation. We also demonstrate our method's ability to monitor lesion growth longitudinally. Our results indicate that deep learning-based analysis for widefield OCTA images could offer a valuable means for improving RNV screening and management. (c) 2026 Optica Publishing Group under the terms of the Optica Open Access Publishing Agreement

PURPOSE:To identify the risk factors and predictive cutoff values for new-onset microscotoma after vitrectomy with internal limiting membrane peeling for epiretinal membrane. METHODS:This retrospective study included patients who underwent vitrectomy with epiretinal membrane and internal limiting membrane peeling. Visual acuity, metamorphopsia, and visual field (Humphrey Field Analyzer 10-2 program) were evaluated preoperatively and at 3 to 6 months and 12 months postoperatively. New-onset microscotoma was defined as any test points decreasing from ≥10 dB preoperatively to <10 dB at 3 months to 6 months. Risk factors, vulnerable regions, and preoperative threshold cutoff values for new-onset microscotoma were analyzed. RESULTS:New-onset microscotoma was observed in 31 (17.8%) of 174 eyes (174 patients; 67.7 ± 8.2 years). Visual acuity and metamorphopsia improved significantly at 12 months postoperatively (both P < 0.0001). A multivariate analysis identified glaucoma (odds ratio = 8.18), secondary epiretinal membrane (odds ratio = 4.45), indocyanine green usage (odds ratio = 3.70), and male sex (odds ratio = 2.46) as significant risk factors. Vulnerable regions corresponded to the temporal and inferior macula ( P < 0.01). The overall preoperative threshold cutoff value was 27.5 dB (area under the curve = 0.85, P < 0.001), whereas in eyes with glaucoma (n = 18), it was 26.5 dB (area under the curve = 0.90, P < 0.001). Both analyses demonstrated a negative predictive value exceeding 99%. CONCLUSION:The identified risk factors, vulnerable regions, and cutoff values may guide preoperative patient counseling and development of safe strategies to prevent postoperative microscotoma. The high negative predictive values highlight reliable identification of low-risk areas, contributing to internal limiting membrane peeling approach optimization.

Epiretinal proliferation (EP) is associated with poor visual and anatomical outcomes in eyes with macular holes (MHs). A preoperative cross-sectional OCT can detect EP; however, We observed that some cases with intraoperatively visible EP showed no evidence of EP on preoperative OCT. This study assessed the discrepancy between EP observed by OCT and during surgery. We defined OCT-EP as epiretinal materials with homogeneous medium reflectivity observed in cross-sectional OCT. We defined surgical-EP as yellowish tissues contiguous to the hole during the membrane peeling. We detected the surgical-EP by also assessing the internal limiting membrane staining pattern using Brilliant Blue G (BBG) and preretinal abnormal tissue (PAT) using en face OCT. We included 110 eyes. Intraoperative observations revealed surgical-EP in 30 (27

To evaluate visual outcomes after vitrectomy based on preoperative visual acuity (VA) in eyes with myopic traction maculopathy (MTM) and explore the optimal timing for surgery. Patients who underwent vitrectomy for MTM were categorized into four groups: preoperative vision of 20/25 or better (V1), worse than 20/25 to 20/50 (V2), 20/60 to 20/200 (V3), and worse than 20/200 (V4). The primary outcome was the postoperative VA at 12 months. We included 193 eyes: V1 (12 eyes), V2 (77 eyes), V3 (83 eyes), and V4 (21 eyes). Postoperative VA significantly correlated with preoperative VA (R2 = 0.400, P < 0.001). Postoperative logarithm of the minimum angle of resolution VA was the best in V1 and worst in V4 (V1, 0.10 ± 0.26; V2, 0.19 ± 0.26; V3, 0.54 ± 0.44; and V4, 0.92 ± 0.54; P < 0.001). Visual improvement was highest in V4 and lowest in V1 (V1, 0.04 ± 0.26; V2, -0.12 ± 0.25; V3, -0.18 ± 0.41; and V4, -0.36 ± 0.44; P = 0.001). At 12 months, 83.3

This case report discusses a diagnosis of posterior lenticonus with intralenticular cracks found during a school vision screening in a girl aged 8 years referred for decreased visual acuity in the left eye.

Optical coherence tomography (OCT) has revolutionized the diagnosis and management of macular holes (MHs). Before OCT, physicians relied on slit-lamp biomicroscopy and angiographic findings, which were often insufficient for differentiating subtle pathologies. By enabling cross-sectional visualization of the retina, OCT has confirmed vitreomacular traction as a key factor in MH formation and supports the safety of surgical intervention. Quantitative OCT parameters have allowed the development of prognostic biomarkers, while spectral-domain OCT has further improved assessment by revealing postoperative photoreceptor integrity, with restoration of the ellipsoid zone and external limiting membrane correlating with visual recovery. OCT imaging under intraocular gas has enabled early confirmation of MH closure, allowing OCT-guided face-down positioning protocols that reduce postoperative burden without compromising outcomes. En face OCT and three-dimensional volumetric analysis have uncovered new biomarkers, such as preretinal abnormal tissue and inner retinal fluid volume, which aid in surgical planning and visual prognosis. Structural changes, such as dissociation of the optic nerve fiber layer and epiretinal proliferation (EP), are also better understood through OCT, thereby influencing decisions on internal limiting membrane peeling and EP preservation. OCT has not only revolutionized the diagnosis and classification of MHs but also continues to shape their surgical management, bringing us closer to optimizing visual recovery through personalized and data-driven approaches.

PURPOSE:To evaluate the efficacy of internal limiting membrane (ILM) peeling on the anatomic and visual outcomes of pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with grade C proliferative vitreoretinopathy (PVR). DESIGN:Multicenter, interventional, clinical cohort study. SUBJECTS:Consecutive patients who underwent PPV for grade C PVR with a minimum of 6-month follow-up. METHODS:We compared the anatomic and visual outcomes of grade C PVR surgery after vitrectomy with PVR membrane peeling plus, or without, ILM peeling, in patients treated at 6 institutions between January 2015 and January 2022. Internal limiting membrane peeling was performed within the macula, arcade to arcade, or beyond the arcades (extended ILM peeling). MAIN OUTCOME MEASURES:Single surgery anatomic success at 3 months and 6 months with versus without ILM peeling. RESULTS:We included a total of 370 eyes (370 patients); 157 eyes (42.4%) treated with ILM peeling were compared with 213 eyes (57.6%) treated without ILM peeling. Mean follow-up was 23.2 ± 13.9 months. No differences were noted in baseline characteristics or surgical techniques. Single surgery anatomic success was significantly higher in the ILM peeling group (86.6% vs. 73.2% at 3 months [P = 0.002] and 75.2% vs. 65.3% at 6 months [P = 0.041], respectively). The retinal reattachment rate under fluid without tamponade was significantly higher in the ILM peeling group at 6 months (68.8% vs. 51.6%, P < 0.001). Both groups showed visual improvement after surgery (both P < 0.001). However, the ILM peeling group showed significantly better visual acuity and visual improvement (1.11 ± 0.70 vs. 1.29 ± 0.80 [P = 0.020] and 0.48 ± 0.77 vs. 0.24 ± 0.90 [P = 0.018], respectively). The ILM peeling group had significantly fewer subsequent vitreoretinal surgeries (P = 0.002), including subsequent epiretinal membrane surgeries (8.9% vs. 17.8%, P = 0.015). No ILM peeling was associated with more posterior breaks when the retina redetached (P = 0.045). Multivariable regression analysis showed that extended ILM peeling was significantly associated with higher likelihood of retinal reattachment without tamponade (under fluid) at 6 months and better final visual acuity (P = 0.040 and 0.031, respectively). CONCLUSIONS:Internal limiting membrane peeling, particularly extended ILM peeling, for RRD with grade C PVR resulted in superior anatomic and visual outcomes compared with vitrectomy without ILM peeling in this study. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.