Macular Detachment – Causes, Diagnosis, Management and a Long-term Follow-up Based on a Case Series

Macular Detachment – Causes, Diagnosis, Management and a Long-term Follow-up Based on a Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Macular Detachment – Causes, Diagnosis, Management and a Long-term Follow-up Based on a Case Series Agnieszka Kudasiewicz-Kardaszewska, Małgorzata Ozimek, Karolina Bonińska, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7416799/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Macular detachment (MD) is a complex retinal disorder characterized by the separation of the neurosensory retina from the retinal pigment epithelium (RPE) within the macular region. Unlike rhegmatogenous retinal detachment (RRD), MD occurs without a visible retinal break and is primarily caused by vitreomacular traction (VMT), epiretinal membrane (ERM) formation, or myopic degeneration. Myopic tractional maculopathy (MTM) is a major contributing factor in highly myopic eyes, particularly in those with a staphyloma. The interplay between axial elongation, the stiffness of the internal limiting membrane (ILM), and progressive retinal thinning in MTM contributes to structural instability and detachment. However, MD is not exclusive to myopic eyes and can also develop in non-myopic individuals due to progressive tractional forces caused by VMT and/or ERM contraction. Material and methods: We analysed a group of 15 patients who underwent pars plana vitrectomy due to macular detachment. The following examinations were conducted preoperatively and at 10 days, 1 month, 3 months, 6 months, and 3 years postoperatively: Best-corrected visual acuity (BCVA), fundoscopic examination and optical coherence tomography (OCT) imaging. Axial length was assessed in all eyes preoperatively. Additionally, staging of myopic tractional maculopathy (MTM) and posterior staphyloma classification were evaluated in highly myopic cases. All patients underwent 23-gauge (23G) pars plana vitrectomy with ILM peeling and 20% sulphur hexafluoride (SF6) endo-tamponade. Follow-up assessments included BCVA measurement and evaluation of macular anatomical status. Results: Preoperative examinations identified MD causes as follows: VMT with ERM (8 eyes, 53.3%), myopic degeneration with MTM and posterior staphyloma (5 eyes, 33.3%) and VMT with macular neovascularisation (MNV) (2 eyes, 13.3%). Axial length in myopic eyes ranged from 25.81 mm to 29.0 mm, whereas in non-myopic eyes, it ranged from 21.34 mm to 24.18 mm. MTM stage 3 with type 1 or 2 staphyloma was noted in the myopic subgroup. Surgical success was achieved in 13 eyes (86.7%). However, two highly myopic eyes required reoperation with silicone oil tamponade due to macular re-detachment three months after the initial MD surgery. The macula remained attached following reoperation, even after subsequent silicone oil removal. Overall, BCVA improved in 10 eyes (66.7%), remained stable in 3 eyes (20%), and declined in 2 eyes (13.3%) over the 3-year follow-up. Conclusion. Long-term observations suggest that pars plana vitrectomy (PPV) with ILM peeling provides effective anatomical macular reattachment in MD. However, anatomical success does not always correlate with functional improvement. Cataract surgery in eyes with VMT syndrome may increase the risk of macular detachment, even in non-myopic individuals. VMT-related traction on the macula during ERM formation may cause MD in both myopic and non-myopic eyes. A weakened RPE pump in myopic retinas is an additional factor contributing to a poor prognosis for retinal reattachment and potential complications, even after uneventful vitrectomy. While PPV with ILM peeling remains an effective treatment for MD, it requires customised surgical approaches depending on the underlying aetiology. macular detachment (MD) pars plana vitrectomy ILM peeling vitreomacular traction epiretinal membrane macular neovascularisation (MNV) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Macular detachment (MD) is a complex ophthalmic condition characterised by the separation of the neurosensory retina from the retinal pigment epithelium (RPE) in the macular region, while the paracentral and peripheral retina often remains attached [ 1 ]. Unlike rhegmatogenous retinal detachment (RRD), where retinal breaks are one of the primary causes, MD occurs without a visible retinal break, indicating a distinct pathophysiology and aetiology. This condition poses a serious threat to central vision and, if left untreated, can significantly impair visual function and quality of life. Therefore, early diagnosis and timely intervention are crucial in preventing permanent vision loss. MD is primarily associated with tractional forces acting on the macula, often induced by vitreomacular traction (VMT) or epiretinal membrane (ERM) contraction [ 1 ]. An imbalance between the traction exerted by the vitreous gel on the internal limiting membrane (ILM) and the opposing forces, such as the RPE pump and interphotoreceptor matrix, is more commonly observed in MD compared to other types of retinal detachment [ 1 ]. Both antero-posterior and tangential traction from the vitreous cortex on the ILM can contribute to MD, especially in cases involving contracting epiretinal membranes (ERM) or vitreomacular traction syndrome (VMT) [ 2 , 3 ]. The tractional component is minimally visible on biomicroscopic examination of eyes with an ERM. It may be visualized in optical coherent tomography (OCT), but it is revealed intraoperatively during posterior vitreous detachment (PVD) in vitrectomy [ 3 – 5 ]. In highly myopic eyes with a staphyloma, the semidetached posterior hyaloid and the rigid internal limiting membrane are probably both responsible for MD [ 6 , 7 ]. The ILM's stiffness prevents the retina from conforming properly to underlying scleral curvature, particularly in the presence of staphyloma, where the retina is excessively stretched over an extremely concave scleral bulge. The detachment may be minimal e.g., perifoveal fluid cuffing in eyes with a macular hole, or widespread, spanning the staphyloma in highly myopic eyes [ 6 ]. In the latter case, the presence of the break (macular hole) is more likely to be secondary to the RD, not its cause [ 1 , 8 ]. Currently available literature describes central retinal detachment as a feature of highly myopic eyes [ 8 – 10 ]. In our case series MD developed as an excessive traction over the macular region regardless the presence of high myopia, which is one of the risk factors, but apparently not the only one. The diagnosis and management of MD require a comprehensive approach, including advanced imaging techniques such as optical coherence tomography (OCT). OCT provides detailed cross-sectional images of the retina, allowing precise identification of the underlying causes of detachment, such as VMT, ERM, and myopic degeneration. OCT is indispensable for planning surgical intervention and monitoring postoperative course and outcome [ 11 , 12 ]. Recently published revised OCT classification of myopic tractional maculopathy (MTM) supports treatment planning in the myopic but also in non-myopic cases.[ 13 ]. In myopic tractional maculopathy (MTM), which was present in all five myopic eyes in our study, the rigid ILM further restricts retinal mobility, contributing to schisis-like changes, foveoschisis, or full-thickness macular holes. MTM staging, as described in recent classifications, is crucial in guiding surgical decisions, particularly regarding ILM peeling and the potential need for macular buckling[ 14 , 15 ]. Surgical management of MD involves pars plana vitrectomy (PPV), a procedure that removes the vitreous gel and addresses the tractional forces. The addition of ILM peeling during PPV is crucial as it enhances retinal elasticity and promotes reattachment [ 6 ]. Application of blue or green dyes enhances proper visualization not only the membranes, but also of vitreous remnants attached to the retina. In our patients indocyanine green was used. With its negative staining of ERM and excellent tinting of the ILM and vitreous, ICG enables meticulous removal of all traction components from the retinal surface. Five per cent glucose as a solvent eliminates potential ICG toxicity to the retina [ 16 ]. Gas tamponade with 20% sulfur hexafluoride (SF6) and strict postoperative face-down positioning help to maintain retinal attachment during the healing process. The prognosis for CRD varies depending on the underlying cause and the timely initiation of appropriate treatment. While anatomical reattachment is often achievable, functional improvement in visual acuity may not always correlate with anatomical success. Retinal remodelling following the separation of the neuroretina from the RPE in the central region influences photoreceptor function [ 17 ]. Factors such as photoreceptor and RPE atrophy, particularly in cases involving myopia and age-related macular degeneration (AMD), can limit visual recovery [ 18 ]. Aim: The aim of our study was to present long-term results in management of macular detachment together with analysis of risk factors and their influence on final anatomical outcome and visual performance. Material and methods We retrospectively analysed 15 eyes from 15 patients who underwent pars plana vitrectomy (PPV) for macular detachment (MD). Surgical procedures were performed in Prof. Zagorski Eye Surgery Centers in Nowy Sącz and Nałęczów between Jan 2021-Dec 2021. The surgeries were done by two experienced vitreoretinal surgeons. The study group included 8 females and 7 males, with a mean age of 68 years (range 52–86 years). Patients were selected based on the diagnosis of MD confirmed through comprehensive ophthalmic examinations, including best corrected visual acuity (BCVA), fundus examination with colour fundus photograph, and optical coherence tomography (OCT). Inclusion criteria were a primary diagnosis of MD and necessity for surgical intervention. Exclusion criteria included any prior retinal surgery and inadequate follow-up. Detailed preoperative assessments included BCVA measurement with the use of Snellen charts, fundus examination with slit-lamp biomicroscopy with + 90D lens to evaluate the extent and nature of the detachment and OCT imaging to identify the presence of vitreomacular traction (VMT), epiretinal membrane (ERM), and other relevant pathological features such as macular neovascularisation (MNV) and myopic degeneration. In highly myopic patients the stage of myopic tractional maculopathy (MTM) was additionally assessed. In all five myopic eyes, OCT confirmed the presence of central posterior staphyloma, a hallmark feature associated with myopic tractional maculopathy (MTM). These cases exhibited features such as macular schisis, foveoschisis, and varying degrees of outer retinal layer thinning. To further characterize the structural changes, axial length measurements were recorded for all eyes, and for myopic eyes MTM staging was assigned according to recently published classification (tabl.2) [ 13 , 14 ]. Type of staphyloma was also described at table 2. [ 19 ] These additional data points allowed for a more precise correlation between anatomical abnormalities and surgical outcomes. All patients underwent 23-gauge (23G) pars plana vitrectomy with core vitrectomy with the use of triamcinolone acetonide (TA) to enhance vitreous visualisation( Vitreal S, Fidia Pharma) and peripheral thorough shaving of the vitreous base to prevent future traction. ILM peeling was performed using vital dye - indocyanine green (ICG) diluted in 5%glucose as a solvent - to stain the ILM and facilitate its visualisation and peeling. ICG was kept on the retina 30 seconds before removal with the vitrector. In highly myopic eyes with posterior staphyloma, extra care was taken during ILM peeling due to increased retinal fragility and biomechanical instability. These retinas required double staining with prolonged time (1–1,5 minutes) for ICG to stay over the retina to facilitate visualisation. ICG was removed either with the use of the vitrector as above or passively by the flute-needle. Peeling encompasses ERM and traction removal and after re-staining removal of ILM itself. When retina was extremely thin and stretched over the staphyloma fovea sparring peeling was done to prevent iatrogenic damage to the fovea. 20% sulphur hexafluoride (SF6) gas was used as an endo-tamponade agent to provide temporary internal pressure, supporting the reattached retina. Postoperative face-down positioning was maintained for 3–5 days to ensure effective gas tamponade of the macula. In this study, all five myopic eyes had central posterior staphyloma and developed macular detachment over the staphyloma due to myopic degeneration and tractional forces (MTM - stage 3 b or c) [ 13 , 19 ]. The altered retinal contour over the concave scleral bulge contributed to the complexity of surgical intervention, necessitating careful handling of the ILM and vitreous removal to minimize additional traction. The rigidity of the ILM in these cases required meticulous peeling techniques with double staining with ICG with prolonged time (1–1,5 minutes) to achieve adequate relaxation of the macular tissue and ensure retinal reattachment. Postoperative evaluations were conducted in 10 days, 1 month, 3 months, 6 months, and 3 years (36 months) after surgery. These evaluations included BCVA measurement (decimal values were subsequently converted to logMAR scale), fundoscopy with colour fundus photographs, captured with an ultra-wide-field fundus camera (EIDON, Centervue, ICare, Germany) and OCT imaging to monitor the macular anatomy during the healing process and detect any residual or recurrent pathologies. In cases where postoperative complications were noted, further interventions were performed. For eyes with concurrent MNV, anti-VEGF injections (aflibercept 2mg/0,1ml) were administered postoperatively to control neovascular activity and associated subretinal fluid. Two eyes developed macular re-detachment due to secondary holes formation close to the staphyloma edge. Re-detachment was noted three months after initial surgery in both instances. Patients were referred immediately to the Department of Ophthalmology of Jonscher Public Hospital in Łódź, Poland as an ophthalmic emergency. Re-vitrectomy with silicone oil tamponade was performed there. 1000 si silicone oil was applied in both instances as longer tamponade. Oil was removed after three subsequent months. Data were analysed to assess both anatomical and functional outcomes. The primary outcome measures included the rate of anatomical reattachment of the macula and changes in BCVA. Secondary outcomes included the incidence of postoperative complications and any need for additional treatments. Results Patient Demographics and Preoperative Findings A total of 15 eyes from 15 patients were included in this study, consisting of 8 females and 7 males, with a mean age of 68 years (range 52–86 years). Among these, 5 eyes (33.3%) had high myopia with posterior staphyloma and myopic tractional maculopathy (MTM). The axial length in myopic eyes ranged from 25,81mm to 29.0 mm . MTM staging was determined for all myopic cases using recently proposed classification[13], and the posterior staphyloma type was categorized according to newest OCT-based classification [20]. Preoperative OCT examination revealed vitreomacular traction (VMT) and epiretinal membranes (ERM) in 8 eyes (53.3%). The macular detachment developed due to excessive vitreomacular traction (Fig. 1) and contracted epiretinal membrane lifting the central retina (Fig. 2). In 2 cases MD appeared shortly after uneventful cataract surgery (fig.2). Five eyes (33.3%) exhibited macular detachment over the posterior staphyloma. MTM staging revealed 1 eye with stage 3A, 2 eyes with stage 3B and 2 eyes with stage 3C (table 2). Two eyes (13.3%) had macular detachment due to VMT with concurrent active MNV. (Fig. 4). The causes of MD and the corresponding number of eyes are summarised in Table 1. Table 1. MD causes based on clinical and OCT examination Cause of MD Number of eyes VMT+ERM, non-myopic 8 MTM+ERM 5 VMT+MNV, non-myopic 2 N=15 Table 2. Axial Length, Myopic Traction Maculopathy (MTM) Stage, and Best Corrected Visual Acuity (BCVA) Change Over Time Following Surgery (values rounded to 2 nd place) **BCVA decreased compared to preoperative values - cause of failure depicted in last column *** BCVA temporarily worsened in 3 rd month due to reRD operated subsequently with oil. No ALX (mm) MTM stage[13] Type of staphyloma [19] Preop BCVA 10 days BCVA 1 month BCVA 3 months BCVA 6 months BCVA 3 years BCVA Cause of failure 1 25,81 3A Type2 2.7 1.0 0.7 3.0*** 1.0 1.0 reRD 2 28,12 3B Type1 1.0 1.3 1.0 1.0 1.0 0.7 3 29,01 3C Type1 1.0 1.3 1.0 2.7*** 0.7 1.3** reRD 4 27,12 3B Type1 2.7 2.7 1.3 1.0 1.0 1.0 5 26,54 3B Type2 1.49 1.49 2.0 2.0 1.49 1.49 6 22,01 n/a n/a 1.3 1.3 1.4 1.52 1.7 1.7** MNV 7 22,38 n/a n/a 1.3 1.0 1.3 0.7 0.49 1.3 MNV 8 24,01 n/a n/a 3.0 1.0 0.52 1.3 0.1 0.1 9 23,23 n/a n/a 3.0 0.92 0.7 0.49 0.22 0.22 10 21,34 n/a n/a 1.49 2.1 1.3 1.0 1.0 1.0 11 22,00 n/a n/a 1.7 1.0 0.7 0.52 0.3 0.3 12 22,47 n/a n/a 1.3 1.3 1.0 0.7 0.52 0.7 13 21,08 n/a n/a 0.7 0.52 0.7 1.0 1.3 1,3** Dry AMD 14 22,47 n/a n/a 2.7 1.0 0.7 0.4 0.4 0.52 15 24,18 n/a n/a 2.0 2.0 1.7 3.0 2.0 2.0 Myopic eyes – no 1-5. MTM stage acc to Parolini et al. [13] Eyes with VMT and MNV no 6-7. Pars plana vitrectomy (PPV) with ILM peeling was performed in all eyes. In two highly myopic cases with deep staphyloma and MTM stage 3B or higher , adjunct macular buckling was considered but ultimately not performed. Neovascularization in MNV cases was managed postoperatively with anti-VEGF therapy . Intra-operative success was achieved in all eyes, with reattachment of the macula observed immediately post-surgery. Anatomical reattachment: was maintained in 13 eyes (86.7%) without further intervention. Two cases (13.3%) with high myopia developed macular re-detachment 3 months after initial surgery due to the formation of secondary holes. These cases were successfully managed with re-vitrectomy and 1000 si silicone oil tamponade, with stable reattachment observed after oil removal. Visual acuity improved in 10 eyes (66.7%), in 3 eyes (20%) remained at the same level and worsened in 2 eyes (13,3%) by the 6-month follow-up. Subsequent three years (36 months) observation indicated BCVA improvement although variability across conditions was noted (see table. 2 and table 3). BCVA results are summarised in Table 3 and depicted at Figure 5. Table 3. Best corrected visual acuity (BCVA) in log MAR scale obtained preoperatively, and postoperatively at 10 days, 1 months, 3 months, 6 months and 36 months, per condition. Mean VA values for the whole cohort are depicted in the last column; values are rounded to 2 nd place. Time Myopia VMT_ERM VMT_MNV Mean preop 1.78 1.99 1.3 1.69 10 d 1.56 1.23 1.15 1.31 1 m 1.2 0.91 1.35 1.15 3 m 1.94 1.05 1.11 1.37 6 m 1.04 0.73 1.1 0.96 3 years (36m) 1.1 0.77 1.5 1.12 BCVA results in detail can be described as follows. In five high myopia cases preoperative visual acuity was the poor (Log MAR ~1.78). Significant improvements were observed by 10 days (~1.56) and 1 month (~1.20). A temporary regression was noted at 3 months (~1.94), followed by recovery to the best recorded value at 6 months (~1.04); with further stabilization in 3 rd year of observation ((~1.10). In eight, non-myopic, VMT+ERM case preoperative acuity was the worst overall (Log MAR ~1.99). Postoperative recovery showed substantial gains by 10 days (~1.23) and 1 month (~0.91). Despite minor fluctuations at 3 months (~1.05), sustained improvement was observed at 6 months (~0.73), and remained good in 3 rd year, indicating excellent long-term recovery. Finally in two cases with VMT+MNV preoperative acuity was moderate (Log MAR ~1.30). Visual acuity improved gradually at 10 days (~1.15) and stabilised around 1.10 by 3 and 6 months. A decline to 1.50 was observed at the 3-year follow-up, likely reflecting the influence of macular neovascularisation. In summary significant gains were observed across all conditions within the first 1–3 months post-treatment. Long-term improvements were sustained by 6 months, with VMT+ERM showing the most notable recovery. Variability was observed, particularly for myopia and VMT+ERM, at 3 months. Third year follow-up revealed sustained improvement of BCVA, although variability was noted among the conditions. 11 eyes (73,3%) had stable or improved BCVA. Decreased BCVA was noted in 4 eyes (26,7%). Two of them had progression of neovascular AMD and 2 were myopes with RD development after initial surgery. Across the groups the best gain was in ERM-VMT non-myopic group, the poorest in VMT-MNV group, with significant influence of AMD on the long-term result. BCVA after 3 years in myopic eyes also revealed significant improvement compared to preoperative values. The findings demonstrate the effectiveness of the surgical intervention in improving visual acuity, with case-specific recovery trajectories and good long-term outcomes (fig.5.). Due to the small sample size, subgroup analyses were limited; future studies with larger cohorts are needed. Statistical analysis based on t-Paired test showed overall significant BCVA improvement postoperatively (p<0,05), but condition specific analysis indicated consistent improvements for VMT+ERM, variable improvements for Myopia, and mixed results for VMT+MNV. Discussion The findings from our study contribute to the growing body of evidence regarding the pathophysiology, surgical management, and outcomes of macular detachment. Our series of 15 cases highlights the complexity of MD and underlines the importance of individualised management based on the aetiology and anatomical characteristics. The study identifies MD as a feature not only myopic, but also non-myopic eyes. In our study, only five out of 15 eyes were highly myopic. High myopia is a well-recognized risk factor for MD due to structural and biomechanical features of the eye. In such eyes with posterior staphyloma the retina is stretched over the extremely concave scleral bulge and stiff ILM does not allow the retinal tissue to adhere properly to the eye wall. The rigid ILM in these eyes prevents the retina from conforming to the underlying scleral curvature ([ 6 ]). Additionally, the reduced efficacy of the RPE pump in myopic eyes contributes to the accumulation of subretinal fluid and hinders retinal reattachment [ 18 ] The incomplete posterior vitreous detachment (PVD) observed intraoperatively in myopic eyes is another critical factor. Dynamic tractional forces exerted by the semidetached posterior hyaloid can initiate or worsen retinal detachment. Our findings align with those reported previously, which described similar mechanisms in myopic foveoschisis and MD [ 10 ]. Furthermore, pars plana vitrectomy (PPV) in these cases is particularly challenging due to the difficulty in visualizing the posterior vitreous. Even with the use of triamcinolone acetonide (TA), the poor contrast between the crystals and the hypopigmented retina and choroid complicates the removal of the posterior hyaloid [ 21 ]. One may try to use indocyanine green (ICG) to stain vitreous in such cases [ 16 , 22 ]. ILM peeling usually needs re-staining and the dye should be kept longer over the central retina to make the structures clearly visible. The myopic retina is much thinner than the healthy one and more prone to re-detachment, that is why the surgery should be done by an experience vitreoretinal surgeon. [ 22 ]. In our case series 2 eyes, which developed re-detachment were from the myopic sub-group. Intraoperatively, ILM peeling in myopic eyes posed unique challenges due to increased retinal fragility. Our findings align with reports suggesting that peeling techniques must be adapted based on MTM severity, with a greater need for re-staining in highly myopic eyes and sometimes fovea sparring method [ 8 , 23 , 24 ]. While macular buckling has been proposed as an alternative approach for advanced MTM stages, it was not performed in our series due to surgical complexity and patient considerations. For advanced MTM cases with significant posterior staphyloma depth, macular buckling has been proposed as an alternative to ILM peeling alone [ 25 , 26 ]. This technique supports the posterior pole by counteracting the tractional forces exerted by the concave sclera, reducing the risk of post-vitrectomy retinal re-detachment. Posterior scleral contraction techniques, including scleral shortening or hydrogel scleral implants, have also been explored to reduce axial length and improve retinal stabilization in myopic eyes [ 27 – 29 ]. While these techniques are not yet widely adopted, they may represent future advancements in MD management. It was suggested that RD development is connected to the dynamic traction exerted on the retina by incompletely detached posterior vitreous [ 1 ]. Eight eyes in our study were non-myopic and presented with tractional forces primarily due to VMT (Fig. 1) or/and ERM (Fig. 2 ). Excessive adhesion between the posterior vitreous cortex and the macula resulted in localized traction that detached the central retina. There was no break. The role of vitreoschisis in the formation of ERM and its contribution to tractional forces has been extensively documented in the literature [ 30 – 32 ]. Our study reinforces the importance of addressing these pathological changes during surgery to achieve successful reattachment. The surgical elimination of VMT and ERM via ERM and ILM peeling was a critical step in all cases. Peeling the ERM and ILM not only removes the tractional component but also enhances retinal elasticity, facilitating re-attachment [ 23 ]. The procedure is technically demanding, particularly in eyes with thin retinas or pre-existing macular atrophy. Our findings are consistent with previous studies that emphasize the need for meticulous surgical technique and the use of appropriate staining agents such as indocyanine green (ICG) to enhance visibility during ILM peeling[ 16 ]. In two cases from the VMT/ERM group (tabl.3) MD developed shortly after cataract surgery (Fig. 2 ). The replacement of the natural lens with a much thinner intraocular lens (IOL) increases the space available for vitreous movement, amplifying tractional forces on the macula [ 33 ]. This phenomenon highlights the importance of preoperative evaluation of the vitreoretinal interface in patients undergoing cataract surgery, particularly those with predisposing conditions such as VMT or ERM. Such patients would eventually need closer and longer follow-up with OCT examination after cataract removal [ 17 , 34 ]. In two eyes, MD had mixed origin—there was vitreomacular traction pulling on the central retina, but there was also MNV which, by fluid production, separated the macula from the eye wall (Fig. 4 ). The tractional element was eliminated by PPV and MNV was treated postoperatively with anti-VEGFs. Such eyes unfortunately have poorer prognoses, but elimination of tractional component usually facilitates further anti-VEGF therapy [ 35 , 36 ] It was suggested previously, that tractional forces may cause the pharmacological resistance to anti-VEGF treatment in these patients [ 36 ]. Removal of traction may improve the effect of anti-VEGF therapy and maintain the functional vision [ 37 ]. Additionally, the vitreo-macular traction removal may facilitate oxygenation, decrease of oedema and inflammation within the macula affected by AMD [ 35 ]. Traction removal seemed to enhance drug effectiveness in our two cases, reflected in BCVA stabilisation over time (Fig. 5 ). PPV with ERM and ILM peeling was a method of choice in all eyes to re-attach the central retina in our case series. Removal of the vitreous and all its abnormal connections to the central retina eliminates tractional component [ 5 , 11 , 38 ]. ILM peeling makes the retina more elastic and easier to re-attach [ 6 ]. To give interphotoreceptor matrix environment to re-establish its normal connections we used gas tamponade (SF6) and position the patients strictly face-down for at least 3–5 days. Retina remained attach in 13 eyes after the procedure. In two eyes 3 months postoperatively, re-detachment developed due to secondary holes formation, but reoperation with silicone oil managed it successfully. These findings underscore the need for long-term monitoring and individualized postoperative care to optimize outcomes. It is important to address visual performance after anatomical re-attachment of the central retina [ 39 ]. Looking to the preoperative BCVA data one notice that before surgery BCVA was poor or very poor (see Tables 2 and 3 .). VA improved after macular attachment but not in all instances. VA decreased with time due to the natural progression of AMD in 3 cases. It was comparable with previously published data, and it is worthy to stress that elimination of tractional component seemed to be helpful with further control of AMD [ 35 , 37 , 40 ]. In two myopic eyes with subsequent re-RD the VA deterioration in 3rd month was due to the detachment. However, there wasn’t much improvement of the visual performance post reattachment of the retina, probably due to structural changes related to the re-RD itself, such as retinal atrophy, tissue remodelling and apoptosis of photoreceptors [ 39 , 41 ]. Overall functional improvement in our material was not high but stable with time (see Table 2.). Variability was noted across the conditions (Fig. 5 .). Future Directions Our findings highlight several areas for further research. The development of advanced imaging techniques to better visualize the vitreoretinal interface and guide surgical interventions is critical. Additionally, exploring adjunctive pharmacological treatments to enhance the efficacy of surgical procedures and address underlying RPE dysfunction could improve outcomes. Long-term studies investigating the natural history of CRD and the impact of emerging therapies, such as gene therapy and regenerative approaches, are also warranted. Conclusions Long-term observations suggest that pars plana vitrectomy (PPV) with ILM peeling provides effective anatomical macular re-attachment in MD. However, anatomical success does not always correlate with functional improvement. Cataract surgery in eyes with VMT syndrome may increase the risk of macular detachment, even in non-myopic individuals. VMT-related traction on the macula during ERM formation may cause MD in both myopic and non-myopic eyes. A weakened RPE pump in myopic retinas is an additional factor contributing to a poor prognosis for retinal reattachment and potential complications, even after uneventful vitrectomy. While PPV with ILM peeling remains an effective treatment for MD, it requires customised surgical approaches depending on the underlying aetiology. Future Perspectives Advancements in imaging technologies, such as ultra-high-resolution OCT, could improve preoperative planning and intraoperative decision-making. Furthermore, the integration of pharmacological adjuncts to enhance RPE function and prevent atrophic changes may improve long-term visual outcomes. Ongoing research into regenerative therapies and biomaterials for retinal repair offers hope for better outcomes in cases of chronic MD. Final Remarks Our findings reinforce the importance of individualized management strategies for MD, guided by a thorough understanding of its diverse aetiology and pathophysiology. While PPV with ILM peeling remains the cornerstone of surgical treatment, addressing the broader biological and biomechanical challenges is essential for optimizing both anatomical and functional outcomes. Continued advancements in surgical techniques and adjunctive therapies hold the potential to further improve the prognosis for patients with MD. Abbreviations MD= macular detachment, ILM =internal limiting membrane, ICG = indocyanine green Declarations Ethics approval and consent to participate: The study adhered to the tenets of the Declaration of Helsinki. According to Polish national regulations ( Ustawa o Prawach Pacjenta i Rzeczniku Praw Pacjenta , Dz.U. 2009 nr 52 poz. 417), retrospective studies using anonymised patient data do not require formal ethics committee or Institutional Review Board (IRB) approval. Therefore, approval by a local IRB was waived. Informed consent to participate was obtained from all of the participants in the study Consent for publication: Not applicable according to national regulations (Ustawa o Prawach Pacjenta i Rzeczniku Praw Pacjenta Dz. U. 2009 nr 52 po. 417) Availability of data and materials: The datasets generated and analysed during this study are available from the corresponding author upon reasonable request. Competing interests: The authors declare no competing interests. Funding: No external funding was received for this research. Authors’ contributions: Agnieszka Kudasiewicz-Kardaszewska – manuscript structure, writing, data evaluation Małgorzata Ozimek – data evaluation, manuscript writing, literature review Karolina Bonińska – data and figure collection, manuscript review Ferenc Kuhn – manuscript review, surgical expertise Sławomir Cisiecki – team leadership, data evaluation, final review Acknowledgements: Not applicable. References Kuhn F, Aylward B. Rhegmatogenous retinal detachment: a reappraisal of its pathophysiology and treatment. Ophthalmic Res. 2014;51:15–31. https://doi.org/10.1159/000355077 . Gandorfer A, Rohleder M, Kampik A. Epiretinal pathology of vitreomacular traction syndrome. Br J Ophthalmol. 2002. https://doi.org/10.1136/bjo.86.8.902 . 86. Yamada N, Kishi S. Tomographic features and surgical outcomes of vitreomacular traction syndrome. Am J Ophthalmol. 2005. https://doi.org/10.1016/j.ajo.2004.08.055 . 139. Duker JS, Kaiser PK, Binder S, De Smet MD, Gaudric A, Reichel E, et al. 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Comparison of macular buckling and vitrectomy for the treatment of macular schisis and associated macular detachment in high myopia: a randomized clinical trial. Acta Ophthalmol. 2020;98. https://doi.org/10.1111/aos.14260 . Zheng L, Pan A, Zhu S, Wu Y, Dong L, Xue A. Posterior scleral contraction to treat recurrent or persistent macular detachment after previous vitrectomy in highly myopic eyes. Retina. 2019;39. https://doi.org/10.1097/IAE.0000000000002217 . Ye J, Wu Y, Zhu S, Dong L, Qu J, Lu F, EVALUATION OF THE EFFICACY OF POSTERIOR SCLERAL CONTRACTION IN THE TREATMENT OF MACULAR HOLE WITH RETINAL DETACHMENT IN HIGH MYOPIA, et al. Retina. 2021;41. https://doi.org/10.1097/IAE.0000000000003126 . Ye J, Pan AP, Zhu S, Zheng L, Lu F, Xue AQ. Posterior Scleral Contraction to Treat Myopic Foveoschisis in Highly Myopic Eyes. Retina. 2021;41. https://doi.org/10.1097/IAE.0000000000002997 . Sebag J. Vitreoschisis. Graefe’s Archive for Clinical and Experimental Ophthalmology. 2008;246. https://doi.org/10.1007/s00417-007-0743-x Sebag J, Gupta P, Rosen RR, Garcia P, Sadun AA. Macular holes and macular pucker: The role of vitreoschisis as imaged by optical coherence tomography/scanning laser ophthalmoscopy. Trans Am Ophthalmol Soc. 2007;105. Gupta P, Yee KMP, Garcia P, Rosen RB, Parikh J, Hageman GS, et al. Vitreoschisis in macular diseases. Br J Ophthalmol. 2011;95. https://doi.org/10.1136/bjo.2009.175109 . Carpineto P, Ciciarelli V, Borrelli E, Aharrh-Gnama A, Mastropasqua R. EPIRETINAL MEMBRANE in EYES with VITREOMACULAR TRACTION. Retina. 2019;39. https://doi.org/10.1097/IAE.0000000000002546 . Murphy G, Owasil R, Kanavati S, Ashena Z, Nanavaty MA. Preoperative fundoscopy versus optical coherence tomography to detect occult maculopathy during cataract surgery preassessment. Eye (Basingstoke). 2023;37. https://doi.org/10.1038/s41433-022-02027-0 . Schulze S, Hoerle S, Mennel S, Kroll P. Vitreomacular traction and exudative age-related macular degeneration. Acta Ophthalmol. 2008;86. https://doi.org/10.1111/j.1755-3768.2008.01210.x . Xie P, Zheng X, Yu Y, Ye X, Hu Z, Yuan D, et al. Vitreomacular adhesion or vitreomacular traction may affect antivascular endothelium growth factor treatment for neovascular age-related macular degeneration. Br J Ophthalmol. 2017;101. https://doi.org/10.1136/bjophthalmol-2017-310155 . Robison CD, Krebs I, Binder S, Barbazetto IA, Kotsolis AI, Yannuzzi LA, et al. Vitreomacular Adhesion in Active and End-Stage Age-related Macular Degeneration. Am J Ophthalmol. 2009;148. https://doi.org/10.1016/j.ajo.2009.01.014 . McDonald HR, Johnson RN, Schatz H. Surgical Results in the Vitreomacular Traction Syndrome. Ophthalmology. 1994;101. https://doi.org/10.1016/S0161-6420(94)31158-4 . Fisher SK, Lewis GP, Linberg KA, Verardo MR. Cellular remodeling in mammalian retina: Results from studies of experimental retinal detachment. Prog Retin Eye Res. 2005;24. https://doi.org/10.1016/j.preteyeres.2004.10.004 . Mojana F, Cheng L, Bartsch DUG, Silva GA, Kozak I, Nigam N, et al. The Role of Abnormal Vitreomacular Adhesion in Age-related Macular Degeneration: Spectral Optical Coherence Tomography and Surgical Results. Am J Ophthalmol. 2008;146. https://doi.org/10.1016/j.ajo.2008.04.027 . de Souza CF, Kalloniatis M, Polkinghorne PJ, McGhee CNJ, Acosta ML. Functional and anatomical remodeling in human retinal detachment. Exp Eye Res. 2012;97. https://doi.org/10.1016/j.exer.2012.02.009 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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MD with VMT. (57 y, female)\u003c/p\u003e\n\u003cp\u003eA. Preoperative image- note enormous VMT lifting entire macula, BCVA = HM\u003c/p\u003e\n\u003cp\u003eB. Postoperative image – macula attached; BCVA 3 years after surgery 0,6.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7416799/v1/a6bab982a85235184527109a.png"},{"id":92844014,"identity":"74b6b949-e290-4c00-8a7d-6f028234797d","added_by":"auto","created_at":"2025-10-06 09:21:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":490848,"visible":true,"origin":"","legend":"\u003cp\u003eMD in 86 year old female patient, who developed 10 days after uneventful cataract surgery (mature cataract, prior cataract extraction fundus not visible). BCVA before and after cataract surgery 0,05.\u003c/p\u003e\n\u003cp\u003eA. preoperative picture and OCT showing VMT+ERM lifting the macula\u003c/p\u003e\n\u003cp\u003eB. preoperative picture and OCT – detached macula and contracting ERM on top\u003c/p\u003e\n\u003cp\u003eC. Postoperative picture – macula attached 3 months postop, remaining subretinal fluid (SRF) still present; BCVA=0,05\u003c/p\u003e\n\u003cp\u003eD. 3 years after PPV+ILM peeling+SF6 macula still attached, but no functional improvement due to macular atrophy (arrow).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7416799/v1/8c2c4056b193535e1e293b40.png"},{"id":92844007,"identity":"50ad5f71-f680-44a5-9c50-1c963ea681a2","added_by":"auto","created_at":"2025-10-06 09:21:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":732677,"visible":true,"origin":"","legend":"\u003cp\u003eMyopic foveoschis in 71-year-old female. MD developed due to contraction of ERM over posterior staphyloma resulting in deterioration of VA to 0,2. History of high myopia, cataract extraction 3 years earlier. This is the patient’s better eye (BCVA prior MD was 0,6, reading vision was full)\u003c/p\u003e\n\u003cp\u003eA. Fundus photograph preop. – note hazy reflectance from central retina\u003c/p\u003e\n\u003cp\u003eB. OCT image preop. – ERM lifting central retina stretched over posterior staphyloma, stage 3 B (acc to Parolini et al.)\u003c/p\u003e\n\u003cp\u003eC. Fundus Photograph postop. (12 months) – note change in macular region appearance\u003c/p\u003e\n\u003cp\u003eD. OCT image postop. (12 months) – note the remnants of subretinal fluid, retina almost completely fills in the scleral bulge, BCVA =0,5, with full reading vision\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7416799/v1/462ff2f9d288aecb0a7e4dfa.png"},{"id":92844010,"identity":"12bf9a21-4359-43b6-b72c-70d63fb0833b","added_by":"auto","created_at":"2025-10-06 09:21:23","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":535983,"visible":true,"origin":"","legend":"\u003cp\u003eVMT+CNV. 72 year ogled male.\u003c/p\u003e\n\u003cp\u003eA. Preoperatively two components lifting macula – VMT and MNV with subretinal fluid production. BCVA=0,05; patient during anti-VEGF therapy with bevacizumab. Tractional component indicated by arrow.\u003c/p\u003e\n\u003cp\u003eB. 3 years and after 10 bevacizumab and 10 aflibercept injections, BCVA= 0,05 due to scarring process. Despite of remaining SRF central retina remains attached.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7416799/v1/e320efacc6d1eedafa9d1c3d.png"},{"id":92845918,"identity":"755fea1a-3d6e-4969-9c30-5ca279720f49","added_by":"auto","created_at":"2025-10-06 09:37:23","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":116170,"visible":true,"origin":"","legend":"\u003cp\u003eBCVA changes with time. (p\u0026lt;0,05)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7416799/v1/224d4162799e811b6338e657.png"},{"id":100406095,"identity":"44c621fa-2b54-4c94-8572-5bf79b9f13f0","added_by":"auto","created_at":"2026-01-16 12:39:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3073488,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7416799/v1/60bad0a4-ccb8-490c-a483-902bc3ee1d28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eMacular Detachment – Causes, Diagnosis, Management and a Long-term Follow-up Based on a Case Series\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMacular detachment (MD) is a complex ophthalmic condition characterised by the separation of the neurosensory retina from the retinal pigment epithelium (RPE) in the macular region, while the paracentral and peripheral retina often remains attached [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Unlike rhegmatogenous retinal detachment (RRD), where retinal breaks are one of the primary causes, MD occurs without a visible retinal break, indicating a distinct pathophysiology and aetiology. This condition poses a serious threat to central vision and, if left untreated, can significantly impair visual function and quality of life. Therefore, early diagnosis and timely intervention are crucial in preventing permanent vision loss.\u003c/p\u003e\u003cp\u003eMD is primarily associated with tractional forces acting on the macula, often induced by vitreomacular traction (VMT) or epiretinal membrane (ERM) contraction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. An imbalance between the traction exerted by the vitreous gel on the internal limiting membrane (ILM) and the opposing forces, such as the RPE pump and interphotoreceptor matrix, is more commonly observed in MD compared to other types of retinal detachment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBoth antero-posterior and tangential traction from the vitreous cortex on the ILM can contribute to MD, especially in cases involving contracting epiretinal membranes (ERM) or vitreomacular traction syndrome (VMT) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe tractional component is minimally visible on biomicroscopic examination of eyes with an ERM. It may be visualized in optical coherent tomography (OCT), but it is revealed intraoperatively during posterior vitreous detachment (PVD) in vitrectomy [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In highly myopic eyes with a staphyloma, the semidetached posterior hyaloid and the rigid internal limiting membrane are probably both responsible for MD [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The ILM's stiffness prevents the retina from conforming properly to underlying scleral curvature, particularly in the presence of staphyloma, where the retina is excessively stretched over an extremely concave scleral bulge.\u003c/p\u003e\u003cp\u003eThe detachment may be minimal e.g., perifoveal fluid cuffing in eyes with a macular hole, or widespread, spanning the staphyloma in highly myopic eyes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the latter case, the presence of the break (macular hole) is more likely to be secondary to the RD, not its cause [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Currently available literature describes central retinal detachment as a feature of highly myopic eyes [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our case series MD developed as an excessive traction over the macular region regardless the presence of high myopia, which is one of the risk factors, but apparently not the only one.\u003c/p\u003e\u003cp\u003eThe diagnosis and management of MD require a comprehensive approach, including advanced imaging techniques such as optical coherence tomography (OCT). OCT provides detailed cross-sectional images of the retina, allowing precise identification of the underlying causes of detachment, such as VMT, ERM, and myopic degeneration. OCT is indispensable for planning surgical intervention and monitoring postoperative course and outcome [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Recently published revised OCT classification of myopic tractional maculopathy (MTM) supports treatment planning in the myopic but also in non-myopic cases.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In myopic tractional maculopathy (MTM), which was present in all five myopic eyes in our study, the rigid ILM further restricts retinal mobility, contributing to schisis-like changes, foveoschisis, or full-thickness macular holes. MTM staging, as described in recent classifications, is crucial in guiding surgical decisions, particularly regarding ILM peeling and the potential need for macular buckling[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSurgical management of MD involves pars plana vitrectomy (PPV), a procedure that removes the vitreous gel and addresses the tractional forces. The addition of ILM peeling during PPV is crucial as it enhances retinal elasticity and promotes reattachment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Application of blue or green dyes enhances proper visualization not only the membranes, but also of vitreous remnants attached to the retina. In our patients indocyanine green was used. With its negative staining of ERM and excellent tinting of the ILM and vitreous, ICG enables meticulous removal of all traction components from the retinal surface. Five per cent glucose as a solvent eliminates potential ICG toxicity to the retina [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Gas tamponade with 20% sulfur hexafluoride (SF6) and strict postoperative face-down positioning help to maintain retinal attachment during the healing process.\u003c/p\u003e\u003cp\u003eThe prognosis for CRD varies depending on the underlying cause and the timely initiation of appropriate treatment. While anatomical reattachment is often achievable, functional improvement in visual acuity may not always correlate with anatomical success. Retinal remodelling following the separation of the neuroretina from the RPE in the central region influences photoreceptor function [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Factors such as photoreceptor and RPE atrophy, particularly in cases involving myopia and age-related macular degeneration (AMD), can limit visual recovery [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAim: The aim of our study was to present long-term results in management of macular detachment together with analysis of risk factors and their influence on final anatomical outcome and visual performance.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eWe retrospectively analysed 15 eyes from 15 patients who underwent pars plana vitrectomy (PPV) for macular detachment (MD). Surgical procedures were performed in Prof. Zagorski Eye Surgery Centers in Nowy Sącz and Nałęcz\u0026oacute;w between Jan 2021-Dec 2021. The surgeries were done by two experienced vitreoretinal surgeons. The study group included 8 females and 7 males, with a mean age of 68 years (range 52\u0026ndash;86 years). Patients were selected based on the diagnosis of MD confirmed through comprehensive ophthalmic examinations, including best corrected visual acuity (BCVA), fundus examination with colour fundus photograph, and optical coherence tomography (OCT). Inclusion criteria were a primary diagnosis of MD and necessity for surgical intervention. Exclusion criteria included any prior retinal surgery and inadequate follow-up.\u003c/p\u003e\u003cp\u003eDetailed preoperative assessments included BCVA measurement with the use of Snellen charts, fundus examination with slit-lamp biomicroscopy with +\u0026thinsp;90D lens to evaluate the extent and nature of the detachment and OCT imaging to identify the presence of vitreomacular traction (VMT), epiretinal membrane (ERM), and other relevant pathological features such as macular neovascularisation (MNV) and myopic degeneration. In highly myopic patients the stage of myopic tractional maculopathy (MTM) was additionally assessed. In all five myopic eyes, OCT confirmed the presence of central posterior staphyloma, a hallmark feature associated with myopic tractional maculopathy (MTM). These cases exhibited features such as macular schisis, foveoschisis, and varying degrees of outer retinal layer thinning. To further characterize the structural changes, axial length measurements were recorded for all eyes, and for myopic eyes MTM staging was assigned according to recently published classification (tabl.2) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Type of staphyloma was also described at table 2. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] These additional data points allowed for a more precise correlation between anatomical abnormalities and surgical outcomes.\u003c/p\u003e\u003cp\u003eAll patients underwent 23-gauge (23G) pars plana vitrectomy with core vitrectomy with the use of triamcinolone acetonide (TA) to enhance vitreous visualisation( Vitreal S, Fidia Pharma) and peripheral thorough shaving of the vitreous base to prevent future traction. ILM peeling was performed using vital dye - indocyanine green (ICG) diluted in 5%glucose as a solvent - to stain the ILM and facilitate its visualisation and peeling. ICG was kept on the retina 30 seconds before removal with the vitrector. In highly myopic eyes with posterior staphyloma, extra care was taken during ILM peeling due to increased retinal fragility and biomechanical instability. These retinas required double staining with prolonged time (1\u0026ndash;1,5 minutes) for ICG to stay over the retina to facilitate visualisation. ICG was removed either with the use of the vitrector as above or passively by the flute-needle. Peeling encompasses ERM and traction removal and after re-staining removal of ILM itself. When retina was extremely thin and stretched over the staphyloma fovea sparring peeling was done to prevent iatrogenic damage to the fovea. 20% sulphur hexafluoride (SF6) gas was used as an endo-tamponade agent to provide temporary internal pressure, supporting the reattached retina. Postoperative face-down positioning was maintained for 3\u0026ndash;5 days to ensure effective gas tamponade of the macula.\u003c/p\u003e\u003cp\u003eIn this study, all five myopic eyes had central posterior staphyloma and developed macular detachment over the staphyloma due to myopic degeneration and tractional forces (MTM - stage 3 b or c) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The altered retinal contour over the concave scleral bulge contributed to the complexity of surgical intervention, necessitating careful handling of the ILM and vitreous removal to minimize additional traction. The rigidity of the ILM in these cases required meticulous peeling techniques with double staining with ICG with prolonged time (1\u0026ndash;1,5 minutes) to achieve adequate relaxation of the macular tissue and ensure retinal reattachment. Postoperative evaluations were conducted in 10 days, 1 month, 3 months, 6 months, and 3 years (36 months) after surgery. These evaluations included BCVA measurement (decimal values were subsequently converted to logMAR scale), fundoscopy with colour fundus photographs, captured with an ultra-wide-field fundus camera (EIDON, Centervue, ICare, Germany) and OCT imaging to monitor the macular anatomy during the healing process and detect any residual or recurrent pathologies. In cases where postoperative complications were noted, further interventions were performed. For eyes with concurrent MNV, anti-VEGF injections (aflibercept 2mg/0,1ml) were administered postoperatively to control neovascular activity and associated subretinal fluid. Two eyes developed macular re-detachment due to secondary holes formation close to the staphyloma edge. Re-detachment was noted three months after initial surgery in both instances. Patients were referred immediately to the Department of Ophthalmology of Jonscher Public Hospital in Ł\u0026oacute;dź, Poland as an ophthalmic emergency. Re-vitrectomy with silicone oil tamponade was performed there. 1000 si silicone oil was applied in both instances as longer tamponade. Oil was removed after three subsequent months.\u003c/p\u003e\u003cp\u003eData were analysed to assess both anatomical and functional outcomes. The primary outcome measures included the rate of anatomical reattachment of the macula and changes in BCVA. Secondary outcomes included the incidence of postoperative complications and any need for additional treatments.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Demographics and Preoperative Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 15 eyes from 15 patients were included in this study, consisting of 8 females and 7 males, with a mean age of 68 years (range 52\u0026ndash;86 years). Among these, 5 eyes (33.3%) had \u003cstrong\u003ehigh myopia with posterior staphyloma\u003c/strong\u003e and myopic tractional maculopathy (MTM). The axial length in myopic eyes ranged from \u003cstrong\u003e25,81mm to 29.0 mm\u003c/strong\u003e. MTM staging was determined for all myopic cases using recently proposed classification[13], and the posterior staphyloma type was categorized according to newest OCT-based classification [20].\u003c/p\u003e\n\u003cp\u003ePreoperative OCT examination revealed vitreomacular traction (VMT) and epiretinal membranes (ERM) in 8 eyes (53.3%). The macular detachment developed due to excessive vitreomacular traction (Fig. 1) and contracted epiretinal membrane lifting the central retina (Fig. 2). In 2 cases MD appeared shortly after uneventful cataract surgery (fig.2). Five eyes (33.3%) exhibited macular detachment over the posterior staphyloma. \u003cstrong\u003eMTM staging revealed 1 eye with stage 3A, 2 eyes with stage 3B and 2 eyes with stage 3C (table 2). Two\u0026nbsp;\u003c/strong\u003eeyes (13.3%) had macular detachment due to VMT with concurrent active MNV. (Fig. 4). The causes of MD and the corresponding number of eyes are summarised in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1. MD causes based on clinical and OCT examination\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003eCause of MD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003eNumber of eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003eVMT+ERM, non-myopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003eMTM+ERM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003eVMT+MNV, non-myopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003eN=15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Axial Length, Myopic Traction Maculopathy (MTM) Stage, and Best Corrected Visual Acuity (BCVA) Change Over Time Following Surgery (values rounded to 2\u003csup\u003end\u003c/sup\u003e place)\u003c/p\u003e\n\u003cp\u003e**BCVA decreased compared to preoperative values - cause of failure depicted in last column\u003c/p\u003e\n\u003cp\u003e*** BCVA temporarily worsened in 3\u003csup\u003erd\u003c/sup\u003e month due to reRD operated subsequently with oil.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"747\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eALX (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMTM stage[13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eType of staphyloma\u003c/p\u003e\n \u003cp class=\"MsoNormal\" align=\"center\"\u003e\u003cspan lang=\"EN-GB\"\u003e[19]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePreop\u003c/p\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10 days\u003c/p\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3 years\u003c/p\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eCause of failure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e25,81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eType2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3.0***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003ereRD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e28,12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eType1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e29,01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eType1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.7***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.3**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003ereRD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e27,12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eType1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e26,54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eType2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e22,01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.7**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eMNV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e22,38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eMNV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e24,01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e23,23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e21,34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e22,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e22,47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e21,08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1,3**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eDry AMD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e22,47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e24,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMyopic eyes \u0026ndash; no 1-5. MTM stage acc to Parolini et al. [13]\u003c/p\u003e\n\u003cp\u003eEyes with VMT and MNV no 6-7.\u003c/p\u003e\n\u003cp\u003ePars plana vitrectomy (PPV) with ILM peeling was performed in all eyes. In \u003cstrong\u003etwo highly myopic cases with deep staphyloma and MTM stage 3B or higher\u003c/strong\u003e, adjunct \u003cstrong\u003emacular buckling\u003c/strong\u003e was considered but ultimately not performed. \u003cstrong\u003eNeovascularization in MNV cases was managed postoperatively with anti-VEGF therapy\u003c/strong\u003e. Intra-operative success was achieved in all eyes, with reattachment of the macula observed immediately post-surgery. Anatomical reattachment: was maintained in 13 eyes (86.7%) without further intervention. Two cases (13.3%) with high myopia developed macular re-detachment 3 months after initial surgery due to the formation of secondary holes. These cases were successfully managed with re-vitrectomy and 1000 si silicone oil tamponade, with stable reattachment observed after oil removal.\u003c/p\u003e\n\u003cp\u003eVisual acuity improved in 10 eyes (66.7%), in 3 eyes (20%) remained at the same level and worsened in 2 eyes (13,3%) by the 6-month follow-up. Subsequent three years (36 months) observation indicated BCVA improvement although variability across conditions was noted (see table. 2 and table 3). BCVA results are summarised in Table 3 and depicted at Figure 5.\u003c/p\u003e\n\u003cp\u003eTable 3. Best corrected visual acuity (BCVA) in log MAR scale obtained preoperatively, and postoperatively at 10 days, 1 months, 3 months, 6 months and 36 months, per condition. Mean VA values for the whole cohort are depicted in the last column; values are rounded to 2\u003csup\u003end\u003c/sup\u003e place.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eMyopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eVMT_ERM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eVMT_MNV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003epreop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e10 d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e6 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3 years (36m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBCVA results in detail can be described as follows. In five high myopia cases preoperative visual acuity was the poor (Log MAR ~1.78). Significant improvements were observed by 10 days (~1.56) and 1 month (~1.20). A temporary regression was noted at 3 months (~1.94), followed by recovery to the best recorded value at 6 months (~1.04); with further stabilization in 3\u003csup\u003erd\u003c/sup\u003e year of observation ((~1.10). In eight, non-myopic, VMT+ERM case preoperative acuity was the worst overall (Log MAR ~1.99). Postoperative recovery showed substantial gains by 10 days (~1.23) and 1 month (~0.91). Despite minor fluctuations at 3 months (~1.05), sustained improvement was observed at 6 months (~0.73), and remained good in 3\u003csup\u003erd\u003c/sup\u003e year, indicating excellent long-term recovery. Finally in two cases with VMT+MNV preoperative acuity was moderate (Log MAR ~1.30). Visual acuity improved gradually at 10 days (~1.15) and stabilised around 1.10 by 3 and 6 months. A decline to 1.50 was observed at the 3-year follow-up, likely reflecting the influence of macular neovascularisation. In summary significant gains were observed across all conditions within the first 1\u0026ndash;3 months post-treatment. Long-term improvements were sustained by 6 months, with VMT+ERM showing the most notable recovery. Variability was observed, particularly for myopia and VMT+ERM, at 3 months. Third year follow-up revealed sustained improvement of BCVA, although variability was noted among the conditions. 11 eyes (73,3%) had stable or improved BCVA. Decreased BCVA was noted in 4 eyes (26,7%). Two of them had progression of neovascular AMD and 2 were myopes with RD development after initial surgery. Across the groups the best gain was in ERM-VMT non-myopic group, the poorest in VMT-MNV group, with significant influence of AMD on the long-term result. BCVA after 3 years in myopic eyes also revealed significant improvement compared to preoperative values. The findings demonstrate the effectiveness of the surgical intervention in improving visual acuity, with case-specific recovery trajectories and good long-term outcomes (fig.5.). Due to the small sample size, subgroup analyses were limited; future studies with larger cohorts are needed.\u003c/p\u003e\n\u003cp\u003eStatistical analysis based on t-Paired test showed overall significant BCVA improvement postoperatively (p\u0026lt;0,05), but condition specific analysis indicated consistent improvements for VMT+ERM, variable improvements for Myopia, and mixed results for VMT+MNV.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from our study contribute to the growing body of evidence regarding the pathophysiology, surgical management, and outcomes of macular detachment. Our series of 15 cases highlights the complexity of MD and underlines the importance of individualised management based on the aetiology and anatomical characteristics. The study identifies MD as a feature not only myopic, but also non-myopic eyes.\u003c/p\u003e\u003cp\u003eIn our study, only five out of 15 eyes were highly myopic. High myopia is a well-recognized risk factor for MD due to structural and biomechanical features of the eye. In such eyes with posterior staphyloma the retina is stretched over the extremely concave scleral bulge and stiff ILM does not allow the retinal tissue to adhere properly to the eye wall. The rigid ILM in these eyes prevents the retina from conforming to the underlying scleral curvature ([\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]). Additionally, the reduced efficacy of the RPE pump in myopic eyes contributes to the accumulation of subretinal fluid and hinders retinal reattachment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] The incomplete posterior vitreous detachment (PVD) observed intraoperatively in myopic eyes is another critical factor. Dynamic tractional forces exerted by the semidetached posterior hyaloid can initiate or worsen retinal detachment. Our findings align with those reported previously, which described similar mechanisms in myopic foveoschisis and MD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, pars plana vitrectomy (PPV) in these cases is particularly challenging due to the difficulty in visualizing the posterior vitreous. Even with the use of triamcinolone acetonide (TA), the poor contrast between the crystals and the hypopigmented retina and choroid complicates the removal of the posterior hyaloid [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. One may try to use indocyanine green (ICG) to stain vitreous in such cases [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. ILM peeling usually needs re-staining and the dye should be kept longer over the central retina to make the structures clearly visible. The myopic retina is much thinner than the healthy one and more prone to re-detachment, that is why the surgery should be done by an experience vitreoretinal surgeon. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our case series 2 eyes, which developed re-detachment were from the myopic sub-group. Intraoperatively, ILM peeling in myopic eyes posed unique challenges due to increased retinal fragility. Our findings align with reports suggesting that peeling techniques must be adapted based on MTM severity, with a greater need for re-staining in highly myopic eyes and sometimes fovea sparring method [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. While macular buckling has been proposed as an alternative approach for advanced MTM stages, it was not performed in our series due to surgical complexity and patient considerations.\u003c/p\u003e\u003cp\u003eFor advanced MTM cases with significant posterior staphyloma depth, macular buckling has been proposed as an alternative to ILM peeling alone [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This technique supports the posterior pole by counteracting the tractional forces exerted by the concave sclera, reducing the risk of post-vitrectomy retinal re-detachment. Posterior scleral contraction techniques, including scleral shortening or hydrogel scleral implants, have also been explored to reduce axial length and improve retinal stabilization in myopic eyes [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. While these techniques are not yet widely adopted, they may represent future advancements in MD management.\u003c/p\u003e\u003cp\u003eIt was suggested that RD development is connected to the dynamic traction exerted on the retina by incompletely detached posterior vitreous [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Eight eyes in our study were non-myopic and presented with tractional forces primarily due to VMT (Fig.\u0026nbsp;1) or/and ERM (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Excessive adhesion between the posterior vitreous cortex and the macula resulted in localized traction that detached the central retina. There was no break. The role of vitreoschisis in the formation of ERM and its contribution to tractional forces has been extensively documented in the literature [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Our study reinforces the importance of addressing these pathological changes during surgery to achieve successful reattachment.\u003c/p\u003e\u003cp\u003eThe surgical elimination of VMT and ERM via ERM and ILM peeling was a critical step in all cases. Peeling the ERM and ILM not only removes the tractional component but also enhances retinal elasticity, facilitating re-attachment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The procedure is technically demanding, particularly in eyes with thin retinas or pre-existing macular atrophy. Our findings are consistent with previous studies that emphasize the need for meticulous surgical technique and the use of appropriate staining agents such as indocyanine green (ICG) to enhance visibility during ILM peeling[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn two cases from the VMT/ERM group (tabl.3) MD developed shortly after cataract surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The replacement of the natural lens with a much thinner intraocular lens (IOL) increases the space available for vitreous movement, amplifying tractional forces on the macula [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This phenomenon highlights the importance of preoperative evaluation of the vitreoretinal interface in patients undergoing cataract surgery, particularly those with predisposing conditions such as VMT or ERM. Such patients would eventually need closer and longer follow-up with OCT examination after cataract removal [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn two eyes, MD had mixed origin\u0026mdash;there was vitreomacular traction pulling on the central retina, but there was also MNV which, by fluid production, separated the macula from the eye wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The tractional element was eliminated by PPV and MNV was treated postoperatively with anti-VEGFs. Such eyes unfortunately have poorer prognoses, but elimination of tractional component usually facilitates further anti-VEGF therapy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] It was suggested previously, that tractional forces may cause the pharmacological resistance to anti-VEGF treatment in these patients [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Removal of traction may improve the effect of anti-VEGF therapy and maintain the functional vision [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Additionally, the vitreo-macular traction removal may facilitate oxygenation, decrease of oedema and inflammation within the macula affected by AMD [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Traction removal seemed to enhance drug effectiveness in our two cases, reflected in BCVA stabilisation over time (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePPV with ERM and ILM peeling was a method of choice in all eyes to re-attach the central retina in our case series. Removal of the vitreous and all its abnormal connections to the central retina eliminates tractional component [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. ILM peeling makes the retina more elastic and easier to re-attach [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To give interphotoreceptor matrix environment to re-establish its normal connections we used gas tamponade (SF6) and position the patients strictly face-down for at least 3\u0026ndash;5 days. Retina remained attach in 13 eyes after the procedure. In two eyes 3 months postoperatively, re-detachment developed due to secondary holes formation, but reoperation with silicone oil managed it successfully. These findings underscore the need for long-term monitoring and individualized postoperative care to optimize outcomes.\u003c/p\u003e\u003cp\u003eIt is important to address visual performance after anatomical re-attachment of the central retina [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Looking to the preoperative BCVA data one notice that before surgery BCVA was poor or very poor (see Tables\u0026nbsp;2 and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.). VA improved after macular attachment but not in all instances. VA decreased with time due to the natural progression of AMD in 3 cases. It was comparable with previously published data, and it is worthy to stress that elimination of tractional component seemed to be helpful with further control of AMD [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In two myopic eyes with subsequent re-RD the VA deterioration in 3rd month was due to the detachment. However, there wasn\u0026rsquo;t much improvement of the visual performance post reattachment of the retina, probably due to structural changes related to the re-RD itself, such as retinal atrophy, tissue remodelling and apoptosis of photoreceptors [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Overall functional improvement in our material was not high but stable with time (see Table\u0026nbsp;2.). Variability was noted across the conditions (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e.).\u003c/p\u003e\u003cp\u003eFuture Directions\u003c/p\u003e\u003cp\u003eOur findings highlight several areas for further research. The development of advanced imaging techniques to better visualize the vitreoretinal interface and guide surgical interventions is critical. Additionally, exploring adjunctive pharmacological treatments to enhance the efficacy of surgical procedures and address underlying RPE dysfunction could improve outcomes. Long-term studies investigating the natural history of CRD and the impact of emerging therapies, such as gene therapy and regenerative approaches, are also warranted.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eLong-term observations suggest that pars plana vitrectomy (PPV) with ILM peeling provides effective anatomical macular re-attachment in MD. However, anatomical success does not always correlate with functional improvement.\u003c/p\u003e\u003cp\u003eCataract surgery in eyes with VMT syndrome may increase the risk of macular detachment, even in non-myopic individuals. VMT-related traction on the macula during ERM formation may cause MD in both myopic and non-myopic eyes.\u003c/p\u003e\u003cp\u003eA weakened RPE pump in myopic retinas is an additional factor contributing to a poor prognosis for retinal reattachment and potential complications, even after uneventful vitrectomy.\u003c/p\u003e\u003cp\u003eWhile PPV with ILM peeling remains an effective treatment for MD, it requires customised surgical approaches depending on the underlying aetiology.\u003c/p\u003e\u003cp\u003eFuture Perspectives\u003c/p\u003e\u003cp\u003eAdvancements in imaging technologies, such as ultra-high-resolution OCT, could improve preoperative planning and intraoperative decision-making. Furthermore, the integration of pharmacological adjuncts to enhance RPE function and prevent atrophic changes may improve long-term visual outcomes. Ongoing research into regenerative therapies and biomaterials for retinal repair offers hope for better outcomes in cases of chronic MD.\u003c/p\u003e\u003cp\u003eFinal Remarks\u003c/p\u003e\u003cp\u003eOur findings reinforce the importance of individualized management strategies for MD, guided by a thorough understanding of its diverse aetiology and pathophysiology. While PPV with ILM peeling remains the cornerstone of surgical treatment, addressing the broader biological and biomechanical challenges is essential for optimizing both anatomical and functional outcomes. Continued advancements in surgical techniques and adjunctive therapies hold the potential to further improve the prognosis for patients with MD.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMD= macular detachment, ILM =internal limiting membrane, ICG = indocyanine green\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cbr\u003eThe study adhered to the tenets of the Declaration of Helsinki. According to Polish national regulations (\u003cem\u003eUstawa o Prawach Pacjenta i Rzeczniku Praw Pacjenta\u003c/em\u003e, Dz.U. 2009 nr 52 poz. 417), retrospective studies using anonymised patient data do not require formal ethics committee or Institutional Review Board (IRB) approval. Therefore, approval by a local IRB was waived.\u003c/p\u003e\n\u003cp\u003eInformed consent to participate was obtained from all of the participants in the study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cbr\u003eNot applicable according to national regulations \u003cem\u003e(Ustawa o Prawach Pacjenta i Rzeczniku Praw Pacjenta Dz. U. 2009 nr 52 po. 417)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and analysed during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No external funding was received for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAgnieszka Kudasiewicz-Kardaszewska\u003c/strong\u003e – manuscript structure, writing, data evaluation\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMałgorzata Ozimek\u003c/strong\u003e – data evaluation, manuscript writing, literature review\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKarolina Bonińska\u003c/strong\u003e – data and figure collection, manuscript review\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFerenc Kuhn\u003c/strong\u003e – manuscript review, surgical expertise\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSławomir Cisiecki\u003c/strong\u003e – team leadership, data evaluation, final review\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKuhn F, Aylward B. 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Exp Eye Res. 2012;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.exer.2012.02.009\u003c/span\u003e\u003cspan address=\"10.1016/j.exer.2012.02.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"macular detachment (MD), pars plana vitrectomy, ILM peeling, vitreomacular traction, epiretinal membrane, macular neovascularisation (MNV)","lastPublishedDoi":"10.21203/rs.3.rs-7416799/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7416799/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Macular detachment (MD) is a complex retinal disorder characterized by the separation of the neurosensory retina from the retinal pigment epithelium (RPE) within the macular region. Unlike rhegmatogenous retinal detachment (RRD), MD occurs without a visible retinal break and is primarily caused by vitreomacular traction (VMT), epiretinal membrane (ERM) formation, or myopic degeneration. Myopic tractional maculopathy (MTM) is a major contributing factor in highly myopic eyes, particularly in those with a staphyloma. The interplay between axial elongation, the stiffness of the internal limiting membrane (ILM), and progressive retinal thinning in MTM contributes to structural instability and detachment. However, MD is not exclusive to myopic eyes and can also develop in non-myopic individuals due to progressive tractional forces caused by VMT and/or ERM contraction.\u003c/p\u003e\u003cp\u003eMaterial and methods: We analysed a group of 15 patients who underwent pars plana vitrectomy due to macular detachment. The following examinations were conducted preoperatively and at 10 days, 1 month, 3 months, 6 months, and 3 years postoperatively: Best-corrected visual acuity (BCVA), fundoscopic examination and optical coherence tomography (OCT) imaging. Axial length was assessed in all eyes preoperatively. Additionally, staging of myopic tractional maculopathy (MTM) and posterior staphyloma classification were evaluated in highly myopic cases. All patients underwent 23-gauge (23G) pars plana vitrectomy with ILM peeling and 20% sulphur hexafluoride (SF6) endo-tamponade. Follow-up assessments included BCVA measurement and evaluation of macular anatomical status.\u003c/p\u003e\u003cp\u003eResults: Preoperative examinations identified MD causes as follows: VMT with ERM (8 eyes, 53.3%), myopic degeneration with MTM and posterior staphyloma (5 eyes, 33.3%) and VMT with macular neovascularisation (MNV) (2 eyes, 13.3%). Axial length in myopic eyes ranged from 25.81 mm to 29.0 mm, whereas in non-myopic eyes, it ranged from 21.34 mm to 24.18 mm. MTM stage 3 with type 1 or 2 staphyloma was noted in the myopic subgroup. Surgical success was achieved in 13 eyes (86.7%). However, two highly myopic eyes required reoperation with silicone oil tamponade due to macular re-detachment three months after the initial MD surgery. The macula remained attached following reoperation, even after subsequent silicone oil removal. Overall, BCVA improved in 10 eyes (66.7%), remained stable in 3 eyes (20%), and declined in 2 eyes (13.3%) over the 3-year follow-up.\u003c/p\u003e\u003cp\u003eConclusion. Long-term observations suggest that pars plana vitrectomy (PPV) with ILM peeling provides effective anatomical macular reattachment in MD. However, anatomical success does not always correlate with functional improvement.\u003c/p\u003e\u003cp\u003eCataract surgery in eyes with VMT syndrome may increase the risk of macular detachment, even in non-myopic individuals. VMT-related traction on the macula during ERM formation may cause MD in both myopic and non-myopic eyes.\u003c/p\u003e\u003cp\u003eA weakened RPE pump in myopic retinas is an additional factor contributing to a poor prognosis for retinal reattachment and potential complications, even after uneventful vitrectomy. While PPV with ILM peeling remains an effective treatment for MD, it requires customised surgical approaches depending on the underlying aetiology.\u003c/p\u003e","manuscriptTitle":"Macular Detachment – Causes, Diagnosis, Management and a Long-term Follow-up Based on a Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-06 09:21:17","doi":"10.21203/rs.3.rs-7416799/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c72d1dc-388f-4270-a4b3-a7de15672788","owner":[],"postedDate":"October 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-24T11:39:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-06 09:21:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7416799","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7416799","identity":"rs-7416799","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}