PMC7339408_01
Schistic splitting of the foveal walls between the outer plexiform layer (OPL) and Henle fiber layer (HFL) as a characteristic of tractional lamellar holes. The images show SD-OCT scans through the fovea and parafovea of 5 eyes of 5 patients. In c, e, f the months after the first visit (0) are indicated left of the images. a The presence of an operculum (arrowhead) may suggest that traction exerted by the posterior hyaloid removed the inner Muller cell layer from the foveola. The tissue of the foveal walls splitted between the OPL and HFL. b The scans were recorded at and 85 months after the first visit. The orientations of the scans are shown at the left side. The arrowhead indicates a tissue band with medium reflectivity extending from the center of the foveola to the edge of the elevated dorsal foveal wall. c Development of a tractional lamellar hole from a macular pseudohole. The orientations of the scans are shown above. Note the presence of epiretinal membranes (ERM) which bridged deep retinal folds in the fovea and parafovea. Note also that the fovea externa was not disrupted. d Circumpapillary scans recorded in the same eye 34.5 months after the first visit. The right image shows a part of the image at higher magnification. Note the schistic splitting between the OPL and ONL at various sites of the peripapillary retina which was associated with a disappearance of the ellipsoid zone (EZ) line. e Development of a lamellar hole by tractional detachment of the foveola from the retinal pigment epithelium (RPE) and subsequent disruption of the junction between the inner layer of the foveola and the nasal foveal wall. The disruption allowed a reattachment of the central outer nuclear layer (ONL) at the RPE and was associated with a schistic splitting of the foveal walls between the OPL and HFL. An ERM was present in the nasal parafovea. f Development of a tractional lamellar hole after disruption of the Muller cell cone. Scale bars, 200 microm. ELM: external limiting membrane; GCL: ganglion cell layer; ELM: external limiting membrane; INL: inner nuclear layer; IPL: inner plexiform layer; IZ: interdigitation zone; NFL: nerve fiber layer
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Fig1
SD-OCT images of the macular region of one eye of 14 patients with a tractional lamellar hole were investigated (Figs. 1a-f and 7a; 12 women, 2 men; mean +- S.D. age, 67.2 +- 8.9 years; range 45-76 years).
Schistic splitting of the foveal walls between the outer plexiform layer (OPL) and Henle fiber layer (HFL) in foveal pseudocysts (a-e), outer lamellar holes (f-h), and macular pseudoholes (j, k). The images show linear SD-OCT scans through the fovea and parafovea of 24 eyes of 24 patients. a Foveal pseudocysts which were likely produced by tangential traction exerted by epiretinal membranes (ERM). b-e Foveal pseudocysts which were produced by anteroposterior traction exerted by the partially detached posterior hyaloid. c Tractional development of a foveal pseudocyst. The months after the first visit (0) are indicated left of the images. Note the hyperreflectivity of the inner Muller cell layer of the foveola. d, e Regeneration of the foveal shape after relief of the vitreofoveal traction. f-h The outer lamellar holes were produced by vitreomacular traction exerted by the posterior hyaloid attached to the foveola. In f, the orientations of the scans are shown above. i-k Macular pseudoholes without (i) and with (j, k) a schistic splitting of the foveal walls. The scans in k were recorded at the first visit (0) and 6 months later. Pars plana vitrectomy with internal limiting membrane and ERM peeling was performed 2.5 months after the first visit. Scale bars, 200 microm. ELM: external limiting membrane; EZ: ellipsoid zone; GCL: ganglion cell layer; INL: inner nuclear layer; IPL: inner plexiform layer; IZ: interdigitation zone; NFL: nerve fiber layer; ONL: outer nuclear layer; RPE: retinal pigment epithelium
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Fig2
SD-OCT scans of the macular region of one eye of 16 further women (mean age, 65.8 +- 9.5 years; range 45-77 years; mean BCVA 0.60 +- 0.30, range, 0.12-1.00) showed foveal pseudocysts (Fig. 2a-e). Three women with an outer lamellar hole in one eye were investigated (Fig. 2f-h; mean age, 71.3 +- 13.0 years, range 61-86 years); the BCVA ranged from 0.35 to 0.80 (mean, 0.58 +- 0.22). SD-OCT images recorded in one eye of 5 patients revealed the presence of a macular pseudohole (Fig. 2i-K; 3 women, 2 men; mean age, 70.6 +- 7.2 years, range 59-77 years; mean BCVA 0.55 +- 0.18, range, 0.32-0.80).
Cavitations of the foveal pit in the lower foveal walls as a characteristic of degenerative lamellar macular holes in 6 eyes of 6 patients. The months after the first visit (0) are indicated above or left of the images. Yellow and pink arrowheads indicate lamellar hole-associated epiretinal proliferation (LHEP). The arrows indicate tissue bands of medium reflectivity which connect glial cells in the center of the foveola with LHEP at the inner surface of the foveal walls. a-d Radial scans of four cases of a degenerative lamellar macular hole. The orientations of the SD-OCT scans are shown at the left side. The blue arrowhead in a indicates the adherence of a membrane to the temporal parafovea. e Development of a degenerative lamellar hole. f Development of a full-thickness macular hole from a lamellar hole. Scale bars, 200 microm. ELM, external limiting membrane; EZ, ellipsoid zone; GCL, ganglion cell layer; HFL, Henle fiber layer; INL, inner nuclear layer; IPL, inner plexiform layer; IZ, interdigitation zone; NFL, nerve fiber layer; ONL, outer nuclear layer; OPL, outer plexiform layer; RPE, retinal pigment epithelium
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Fig3
Twenty-two patients with a degenerative lamellar hole in one eye were investigated (Figs. 3a-f, 4a-f, 5, and 7b; 10 women, 12 men; mean age, 72.7 +- 7.9 years, range 52-87 years; mean BCVA 0.66 +- 0.16 range, 0.30-0.90).
In degenerative lamellar holes, Muller cells in the foveola are connected to the middle part of lamellar macular hole-associated epiretinal proliferation (LHEP) at the inner surface of the foveal walls. The images show SD-OCT scans through the fovea and parafovea of 6 eyes of 6 patients. The orientations of the scans are shown at the left side. The blue arrowheads indicate LHEP. The yellow arrowheads indicate vitreomacular adhesions. In the smaller images at the right side, the middle part of LHEP is indicated by yellow color, cells of the Muller cell cone are indicated by green color, and the posterior hyaloid is indicated by pink color. Scale bars, 200 microm. ELM, external limiting membrane; ERM: epiretinal membrane; EZ: ellipsoid zone; GCL: ganglion cell layer; HFL: Henle fiber layer; INL: inner nuclear layer; IPL: inner plexiform layer; IZ: interdigitation zone; NFL: nerve fiber layer; ONL: outer nuclear layer; OPL: outer plexiform layer; RPE: retinal pigment epithelium
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Fig4
Twenty-two patients with a degenerative lamellar hole in one eye were investigated (Figs. 3a-f, 4a-f, 5, and 7b; 10 women, 12 men; mean age, 72.7 +- 7.9 years, range 52-87 years; mean BCVA 0.66 +- 0.16 range, 0.30-0.90).
Example of a full-thickness macular hole with lamellar macular hole-associated epiretinal proliferation (LHEP) at the inner surface of the foveal walls. The images show SD-OCT scans through the fovea and parafovea of the right eye of a 76 year-old man. The orientations of the scans are shown at the left side. The arrowheads indicate LHEP. In the smaller images at the right side, the middle part of LHEP is indicated by yellow color, and cells of the Muller cell cone are indicated by green color. Scale bars, 200 microm. ELM: external limiting membrane; ERM: epiretinal membrane; EZ: ellipsoid zone; GCL: ganglion cell layer; HFL: Henle fiber layer; INL: inner nuclear layer; IPL: inner plexiform layer; IZ: interdigitation zone; NFL: nerve fiber layer; ONL: outer nuclear layer; OPL: outer plexiform layer; RPE: retinal pigment epithelium
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Fig6
In addition, one eye of a 76 year-old man with a FTMH was investigated (Fig. 6; BCVA, 0.7).
Comparison of schistic and degenerative cavitations in tractional and degenerative lamellar holes, respectively. The images show linear SD-OCT scans through the fovea of 18 eyes of 18 patients. a Tractional lamellar holes. b Degenerative lamellar holes. The arrows indicate the levels of the widest lateral extensions of schistic (a) and degenerative cavitations (b). The arrowheads indicate morphological connections between Muller cells in the foveola and lamellar macular hole-associated epiretinal proliferation. Scale bars, 200 microm. ELM: external limiting membrane; ERM: epiretinal membrane; EZ: ellipsoid zone; GCL: ganglion cell layer; HFL: Henle fiber layer; INL: inner nuclear layer; IPL: inner plexiform layer; IZ: interdigitation zone; NFL: nerve fiber layer; ONL: outer nuclear layer; OPL: outer plexiform layer; RPE: retinal pigment epithelium
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Fig7
SD-OCT images of the macular region of one eye of 14 patients with a tractional lamellar hole were investigated (Figs. 1a-f and 7a; 12 women, 2 men; mean +- S.D. age, 67.2 +- 8.9 years; range 45-76 years).