Impact of OCT scan-patterns in identifying morphological features of lamellar macular holes and macular pseudoholes

INTRODUCTION

The improvements of the optical coherence tomography(OCT) technique have enabled the investigators detailed morphological analysis of the vitreomacular interface diseases. Especially the OCT characteristics of the epiretinal membrane (ERM), lamellar macular hole (LMH) and macular pseudohole (MPH) have been reported frequently

. New concepts regarding the classification and nomenclature of the vitreomacular interface diseases are proposed

. Thus,LMH is characterised by the presence of irregular foveal contour, the presence of a foveal cavity with undermined edges and the apparent loss of foveal tissue

. MPH is defined by the presence of a foveal sparing ERM, a steepended foveal profile and an increased central retinal thickness

. Beside the visualisation and interpretation of the OCT-features, it became also evident, that the OCT-examination technique may have an influence on the detection of morphological features of the macula

.

The experienced retina specialists are using the appropriate OCT-scan pattern with high image quality. On the other hand,to our knowledge no evaluation of the OCT-scan patterns for the investigation of the OCT-features was performed in the specific field of LMH and MPH. The current evidence is only based on the anecdotal transfer of routine experience of the experts.

（3）個人學習賬戶。個人學習賬戶是最近法國推行的新的成人教育的重大舉措，是保障法國從業人員接受成人教育，促進公民終身學習的有力措施。該措施自2015年1月1日起開始實施，正式取代實施11年之久的個人培訓權利。個人學習賬戶規定，全職工作者每年享有24學時的免費帶薪培訓時間，該培訓時間可存入個人培訓賬戶中，可累計5年，共120學時。此外，個人培訓賬戶還承認另一種培訓時間的計算方式，即職工每年接受15學時的培訓，至多累計8年［8］。如果員工超出規定的時限，則個人學習賬戶的學時失效。

Statistical analysis of the features by different scan patterns is given in Table 2.

SUBJECTS AND METHODS

統一戰線是一些不同的階級、階層、政黨、集團、民族、國家等社會政治力量在共同利益的基礎上為實現共同目標而結成的聯盟［2］?！吨袊伯a黨統一戰線工作條例（試行）》（以下簡稱《條例》）規定，統一戰線是指中國共產黨領導的、以工農聯盟為基礎的，包括全體社會主義勞動者、社會主義事業建設者、擁護社會主義愛國者、擁護祖國統一和致力于中華民族偉大復興愛國者的聯盟［3］。統一戰線歷經多個階段的發展，堅持處理一致性與多樣性關系，在圍繞中心、服務大局和凝聚人心、匯聚力量中維護黨和國家安全。

This is a retrospective analysis of 100 consecutive eyes (100 patients). Patients diagnosed as ERM, LMH or MPH from March 2017 to July 2019 in the Department of Ophthalmology of the University Tuebingen were selected by screening of the digital chart archive. Inclusion criteria were the presence of at least three of the following OCT features: ERM, epiretinal proliferation, verticalization, intraretinal cystoid spaces,foveoschisis, irregular foveal contour, foveal cavity with undermined edges and ellipsoid line disruptions. Because of the low incidence of the pseudo-operculum in our cohort and possible intra- and interrater measurement differences of the central retinal thickness, these two features were not included into the analysis. Exclusion criteria were diseases affecting the posterior pole, such as advanced age-related macular degeneration, diabetic maculopathy, high myopia[＞-6.0 diopters (D)], choroidal neovascularization, retinal venous occlusions, uveitis, ocular trauma, retinal tear, previous intraocular surgery except for cataract extraction, retinal cryotherapy and laser photocoagulation. Eyes with ERMonly were also excluded. Forty-one eyes had LMH and 59 eyes had MPH. OCT was performed by the Spectralis OCT(Heidelberg Engineering GmbH, Heidelberg, Germany) and reviewed with the Heidelberg Eye Explorer (version 1.9.1.3.0)using the HRA/Spectralis Viewing Module (version 6.5.2.0).Primary outcome measurement was the detection frequency of the predetermined OCT findings in three different OCT scan patterns: 1) volume; 2) six radial scans (R6); and 3) vertical and horizontal radial (R2; extrapolated from the R6 pattern;Figure 1).

OCT examination protocol included R6, through the fovea and a volume scan centered on the fovea. Length of the radial scans was 4 mm. The volume scan had the dimension of 15°×5° with the average of minimum 25 A-scans and a distance of 63 μm between the scans. The OCT scan patterns were examined twice by one observer who was blinded to the clinical information of the patients. Twenty randomly selected cases were examined by an experienced consultant and the intrarater and interrater agreement ratios were analyzed.

Of the total 8 predetermined features, the maximal detection frequency was found by the volume pattern as 4.45±1.45.The frequency of the R6 and R2 revealed 4.35±1.47 and 3.70±1.59, respectively. Regarding the statistical significance of total frequencies, whereas R2 was inferior to the other patterns (

＜0.001), R6 and volume patterns were comparable(

=0.312). The distribution of the feature detection rates based on the OCT scan patterns, and their interquartile values are shown in Table 1.

Statistical Analysis Data were analyzed using IBM SPSS Statistics premium 23 V. The kappa statistic was used to test intrarater and interrater reliability. Friedman statistical test was used to detect the features depending on the type of scanning method. Post hoc analysis with Wilcoxon signed-rank tests was conducted with a Bonferroni correction applied, resulting in a significance level set at

0.017. The frequency of features detected by three scan patterns was measured by inter quartile range (IQR) and the comparison was made by McNemar’s statistical test.

The statistical evaluation of ERM was not applicable since this feature was detected in almost all eyes by the three different OCT patterns. Statistical analysis showed that R2 was inferior to R6 and volume patterns in detecting foveal cavity with undermined edges and irregular foveal contour, which are criteria for LMH. Epiretinal proliferation and ellipsoid line disruptions, both optional feature for the diagnosis of LMH,were similarly often in all scans patterns. R2 was also inferiorin detecting verticalization and intraretinal cystoid spaces, the mandatory features for the diagnoses of MPH. In comparison to R6 and volume, R2 was less sensitive in detecting foveoschisis,which is one mandatory feature for ERM foveoschisis.

RESULTS

Of the 100 patients, 66 were female and 34 males. The mean age ±SD was 70.50±7.33y (range 49-89y). Fifty-five eyes were right and 45 left.

Terminology of the Features ERM had been characterized as increasing reflectivity on the surface of the retina

. Epiretinal proliferation is a thick homogenous layer of moderately reflective material between the inner border of the internal limiting membrane and the retinal nerve fiber layer

.Verticalization was considered as a deep foveal pit

.Foveoschisis was defined if hyperreflective tissue bridges along wider hyporeflective spaces between the outer nuclear and outer plexiform layers at the fovea

, which was termed as schitic cavity

, schitic separation/appearance before

.Intraretinal cystoid spaces are small, well-circumscribed hyporeflective areas in the inner plexiform layer

. Irregular foveal contour is the presence of the irregularities of the foveal surface

. Foveal cavity with undermined edges has recently been described

as the angle between the retinal surface and the edge of the hole less than 90° which was formerly known as a wide, mostly round edged intraretinal, homogeneous,hyporeflective cavitation between the inner and outer retina

.Ellipsoid line disruption is defined as any interruption or blurring of this line

, which was formerly named as ellipsoid layer disruption

.

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In summary, volume and R6 patterns were comparable for epiretinal proliferation, verticalization, foveoschisis and foveal cavity with undermined edges. R2 was inferior to both patterns in revealing verticalization, foveoschisis, irregular foveal contour, and foveal cavity with undermined edges;and additionally, to the volume pattern for intraretinal cystoid spaces (Figures 2-4).

Ethical Approval Approval of the Institutional Ethic Committee of the University of Tuebingen was obtained before the analysis of the data (Project 685/2020BO). The study has been performed in accordance with the Declaration of Helsinki.

年輕父母缺乏家庭教育的經驗，所以從一開始就要學做家庭教育的“有心人”，悉心了解和掌握家庭教育的基本情況。……