Axial Length-Based Comparison of Clinical Characteristics and Visual Outcomes in Macular Pseudohole, Epiretinal Membrane Foveoschisis, and Lamellar Macular Hole

Axial Length-Based Comparison of Clinical Characteristics and Visual Outcomes in Macular Pseudohole, Epiretinal Membrane Foveoschisis, and Lamellar Macular Hole | 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 Axial Length-Based Comparison of Clinical Characteristics and Visual Outcomes in Macular Pseudohole, Epiretinal Membrane Foveoschisis, and Lamellar Macular Hole Noriko Kubota, Reo Sueno, Yosai Mori, Kazunori Miyata, Tomoyuki Kunishige, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7183858/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Oct, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 12 You are reading this latest preprint version Abstract Purpose To evaluate clinical and optical coherence tomography (OCT) findings and visual outcomes in patients with macular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) based on axial length (AL). Methods We retrospectively reviewed consecutive patients diagnosed with MPH, ERM-FS, and LMH who underwent vitrectomy and were followed for at least 6 months postoperatively. In each disease group, eyes were categorized into three groups based on AL; normal (< 24 mm), myopic (≥ 24 to < 26 mm), and highly myopic (≥ 26 mm). Analyzed factors included age, AL, preoperative and postoperative best-corrected visual acuity (BCVA), and OCT parameters such as the presence of inner and outer retinal cysts, epiretinal proliferation, and ellipsoid zone disruption. Results A total of 171 eyes from 170 patients (79 males and 91 females) were included: 74 eyes with MPH, 59 eyes with ERM-FS, and 38 eyes with LMH. Postoperative BCVA significantly improved in all AL groups across all disease types. In the MPH group, postoperative BCVA was significantly better in the highly myopic group than in the myopic group (p = 0.04). There were no significant differences in the frequency of the OCT findings among the AL groups in any of the diseases. However, the presence of outer cysts at 6 months postoperatively tended to be more frequent in the highly myopic group (p = 0.065). Conclusion Vitrectomy improved visual acuity in all AL groups across MPH, ERM-FS, and LMH. AL did not significantly affect the frequency of abnormal findings for the preoperative and postoperative OCT. axial length epiretinal membrane foveoschisis lamellar macular hole macular pseudohole visual outcome Figures Figure 1 Figure 2 Figure 3 Introduction Macular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) are distinct macular pathologies that can lead to visual impairment. Advances in optical coherence tomography (OCT) have enabled detailed characterization of these conditions and facilitated more accurate diagnoses [ 1 ]. Several studies have undertaken comparisons of the clinical features, prognostic factors and surgical outcomes of these diseases [ 2 – 6 ]. Axial length (AL) is an important anatomical parameter that influences retinal structure and vitreoretinal interface. In highly myopic eyes, elongation of the AL may lead to mechanical stresses and structural alterations, which may affect the development and progression of macular diseases [ 7 ]. Previous studies have reported differences in macular morphology and surgical outcomes between myopic and non-myopic eyes with regard to some macular diseases, including macular hole and diabetic retinopathy [ 8 , 9 ]. We previously reported that the AL in eyes with MPH, ERM-FS, and LMH was significantly longer than in eyes with idiopathic epiretinal membrane (ERM) [ 10 ]. Additionally, Miura et al. [ 11 ] reported favorable surgical outcomes following vitrectomy in highly myopic eyes with ERM, suggesting that myopia does not necessarily preclude visual improvement. However, comprehensive comparisons of clinical characteristics and visual outcomes among MPH, ERM-FS, and LMH across different AL groups remain limited. A better understanding of the influence of AL on these macular diseases may help refine surgical indicators and improve visual prognosis. Therefore, the purpose of this study was to compare the clinical characteristics, OCT findings, and visual outcomes in patients with MPH, ERM-FS, and LMH stratified by AL. Methods This retrospective study was reviewed and approved by the Ethics Committee of Nippon Medical School (ID: M-2023-161) in accordance with the ethical review processes utilized at our institution [ 12 ]. Patients provided written consent for their information to be stored in the hospital’s database and to be used for research purposes. This study was performed according to the tenets of the Declaration of Helsinki. Patient Data and OCT Analysis This study retrospectively reviewed the medical records of consecutive patients with MPH, ERM-FS, and LMH who underwent vitrectomy between April 2020 and December 2023 and who were followed-up for at least 6 months postoperatively. Exclusion criteria included patients with a previous history of vitreoretinal surgery, ophthalmic disorders, except for mild cataract, retinal vascular disease, uveitis, and trauma. Clinical details collected from the medical records included patients’ age, gender, and best-corrected visual acuity (BCVA). Patients were diagnosed with each disease based on the spectral-domain (SD) OCT findings (Spectralis version 1.8.6.0, Heidelberg Engineering GmbH, Heidelberg, Germany) and the updated criteria that were established by an international panel of vitreoretinal experts in 2020. 1 After the diagnosis of each disease, eyes were classified into three groups based on the AL; normal group (AL < 24 mm), myopic group (AL ≥ 24 to < 26 mm), and highly myopic group (AL ≥ 26 mm) in all three groups (MPH, ERM-FS and LMH). The anatomical features examined included the presence of retinal cysts, disruption of the ellipsoid zone (EZ), and epiretinal proliferation (EP). The inner and outer retinal cysts were identified as the hyporeflective spaces in the inner nuclear layer (INL) and in Henle’s fiber layer (HFL) and/or the outer plexiform layer (OPL), respectively. The disruption of the EZ was identified as an irregularity of the EZ line within a 1 mm diameter at the fovea. These OCT parameters were evaluated preoperatively and at 3 and 6 months postoperatively. BCVA was measured before and after surgery using a standard Japanese decimal visual acuity chart at a distance of 5 meters. For statistical analyses, the decimal values were converted to the logarithm of the minimal angle of resolution (logMAR) units. The AL was measured by ultrasonography (AL-4000, Tomey Corporation, Nagoya, Japan). Surgical Procedures All patients under local anesthesia underwent 25-gauge pars plana vitrectomy performed by two vitreoretinal surgeons (F.O., Y.M.). After complete posterior vitreous detachment and vitrectomy, 0.1–0.2 mL of 0.025% brilliant blue G solution was gently injected over the macula and then washed out using irrigation solution. After the ERM was peeled, 0.1 mL of the brilliant blue G solution was applied to the macular area. Subsequently, we then completely peeled the remaining internal limiting membrane (ILM) within an area approximately equal to the vertical extent of the optic disc. In cases with EP, ILM was peeled toward the fovea following ERM removal, and then inverted on the fovea. The EP was embedded into the fovea defect with ILM. After removing the lens by phacoemulsification, an intraocular lens was then implanted when required, followed by vitrectomy. Statistical Analysis The mean scores and standard deviations were calculated for age, AL, and the preoperative and postoperative BCVA. The difference between the preoperative and postoperative BCVA was analyzed by Wilcoxon’s signed-rank test. Spearman’s rank correlation test was used to examine the correlation between the preoperative and postoperative BCVA. A Kruskal-Wallis test was used to compare the difference among the AL groups. The analyses of the categorical data in the cross tables, such as distribution of the AL groups and the presence of inner and outer retinal cysts, EP, and EZ disruption were analyzed using Fisher’s exact test. All tests of association were considered statistically significant if p < 0.05. The analyses were carried out using SPSS Statistics (version 29.0, IBM). Results A total of 170 patients (79 males and 91 females) with a mean age of 71.7 ± 7.8 years (mean ± SD) were included. Among these, 74 eyes met the criteria for MPH, 59 eyes for ERM-FS, and 38 eyes for LMH. Based on the AL, eyes were classified into three groups: normal, myopic, and highly myopic eyes. Table 1 summarizes the number of eyes, age, preoperative and postoperative BCVA, and preoperative OCT parameters in all eyes. The distribution of eyes in each group was as follows: In the MPH group, 33 eyes (44.6%) were classified as normal, 23 eyes (31.1%) as myopic, and 18 eyes (24.3%) as highly myopic. In the ERM-FS group, 25 eyes (42.3%) were classified as normal, 22 eyes (37.3%) as myopic, and 12 eyes (20.3%) as highly myopic. In the LMH group, 15 eyes (39.5%) were classified as normal, 14 eyes (36.8%) as myopic, and 9 eyes (23.7%) as highly myopic. There were no significant differences in the distribution of the AL groups among the three disease types. Regarding preoperative OCT parameters, EZ disruption was observed significantly more frequently in eyes with LMH versus in those with MPH and ERM-FS (p < 0.05). Postoperatively, EZ disruption was more frequently observed in LMH at both 3 months (p < 0.005) and at 6 months (p < 0.05). Additionally, outer cysts were more frequently observed in ERM-FS at 3 months postoperatively (p < 0.05) and tended to be more frequent in ERM-FS at 6 months (p = 0.069). Across all disease groups, patients in the highly myopic group were significantly younger than those in the normal group (p < 0.001 in MPH, p < 0.01 in ERM-FS, and p < 0.01 in LMH). Preoperative BCVA did not significantly differ among the AL groups in any of the three diseases, while that of the eyes in the highly myopic group tended to be worse in the ERM-FS group (p = 0.07). In the MPH group, postoperative BCVA was significantly better in the highly myopic group as compared with the myopic group. Table 1 Clinical characteristics and preoperative optical coherence tomography (OCT) parameters of patients with macular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) classified by axial length Axial Length (mm) normal < 24 myopic ≥ 24 to < 26 highly myopic ≥ 26 p MPH Number of eyes 33 (44.6%) 23 (31.1%) 18 (24.3%) Age (years ± SD) 72.7 ± 7.0* 70.7 ± 6.9 66.4 ± 5.1‡ < 0.001 Preoperative BCVA 0.277 ± 0.27 0.361 ± 0.26 0.242 ± 0.21 0.13 Postoperative BCVA 0.058 ± 0.17 0.112 ± 0.18* -0.010 ± 0.15* < 0.05 Preoperative OCT parameters EP 9 (21.2%) 5 (21.7%) 2 (11.1%) 0.42 Outer cyst 9 (27.3%) 0 (0%) 3 (16.7%) 0.264 Inner cyst 5 (15.2%) 5 (21.7%) 3 (16.7%) 0.924 EZ disruption 7 (21.2%) 4 (17.4%) 3 (16.7%) 1 ERM-FS Number of eyes 25 (42.3%) 22 (37.3%) 12 (20.3%) Age (years ± SD) 72.3 ± 6.1* 69.1 ± 7.3 67.5 ± 6.7* 0.01 Preoperative BCVA 0.216 ± 0.46 0.331 ± 0.43 0.420 ± 0.45 0.07 Postoperative BCVA 0.028 ± 0.37 0.041 ± 0.46 0.177 ± 0.49 0.52 Preoperative OCT parameters EP 4 (16.0%) 6 (27.3%) 4 (33.3%) 0.45 Outer cyst 25 (100%) 22 (100%) 12 (100%) Inner cyst 5 (20.0%) 7 (31.2%) 4 (33.3%) 0.596 EZ disruption 7 (28.0%) 5 (22.7%) 3 (25.0%) 0.927 LMH Number of eyes 15 (39.5%) 14 (36.8%) 9 (23.7%) Age (years ± SD) 72.3 ± 8.7* 71.8 ± 6.9 64.7 ± 7.3† <0.01 Preoperative BCVA 0.284 ± 0.22 0.383 ± 0.34 0.421 ± 0.50 0.82 Postoperative BCVA 0.120 ± 0.19 0.136 ± 0.18 0.120 ± 0.45 0.15 Preoperative OCT parameters EP 9 (60.0%) 10 (71.4%) 4 (44.4%) 0.49 Outer cyst 7 (46.7%) 9 (64.3%) 5 (55.6%) 0.71 Inner cyst 3 (20.0%) 3 (21.4%) 2 (22.2%) 1 EZ disruption 9 (60.0%) 5 (35.7%) 3 (33.3%) 0.412 MPH = macular pseudohole, ERM-FS = epiretinal membrane, LMH = lamellar macular hole, BCVA = best-corrected visual acuity, OCT = optical coherence tomography, EP = epiretinal proliferation, EZ = ellipsoid zone Values are presented as the mean ± standard deviation. Significantly different from the other groups (*p < 0.05, †p < 0.01, ‡p < 0.001, Kruskal-Wallis test) A significant correlation between the preoperative and postoperative BCVA was observed in the normal group of the MPH (Fig. 1 A; p < 0.01, r = 0.47), whereas no significant correlations were found in the myopic or highly myopic groups. No significant correlations between the preoperative and postoperative BCVA were observed in any of the AL groups within the ERM-FS. In the LMH, a significant correlation between the preoperative and postoperative BCVA was observed in the myopic group (Fig. 1 B; p < 0.05, r = 0.59). Figure 2 presents the percentages of the preoperative and postoperative (at 3 and 6 months) OCT findings in each of the AL groups for MPH (Fig. 2 A), ERM-FS (Fig. 2 B), and LMH (Fig. 2 C). Across all diseases, there were no significant differences in the frequency of the OCT findings among the AL groups. However, in LMH, the presence of outer retinal cysts at 6 months postoperatively tended to be more frequent in the highly myopic group as compared to the other groups (p = 0.065). Discussion We investigated the clinical characteristics, OCT findings, and the visual outcomes of eyes with MPH, ERM-FS, and LMH according to the AL. The present findings provide insights into the prognostic factors and highlight the importance of specific OCT parameters in potential visual outcomes. Our literature reviews have not found any prior studies that have investigated the visual outcomes in MPH, ERM-FS, and LMH when specifically based on the AL. In the present study, significant postoperative improvement in BCVA was observed across all of the AL groups and disease types. Notably, in MPH, eyes in the highly myopic group exhibited significantly better postoperative BCVA as compared to that observed in the myopic group. These results may appear counterintuitive, as high myopia is often associated with poorer surgical outcomes due to retinal thinning or degenerative changes. However, other previous studies have shown mixed results regarding surgical outcomes in retinal diseases, with some reporting a poorer outcome, while others, including the present study, indicating that there were comparable or even better visual outcomes in highly myopic eyes [ 8 , 13 – 18 ]. In many of these studies, the longer AL was associated with worse outcomes in myopic macular hole [ 16 ] and in macular hole retinal detachment [ 15 ]. In contrast, there was no association or even better outcomes reported in ERM [ 13 , 17 ], retinal detachment [ 14 ], and diabetic retinopathy [ 9 , 18 ]. Minami et al. [ 13 ] reported that the postoperative BCVA was worse in patients with an AL that was 69 years as compared to those with an AL that was ≥ 23.6 mm and an age ≤ 69 years at both 1 and 3 months after surgery for ERM. These results suggested that eyes with a longer AL might have less traction and less damage, which could possibly be due to an earlier posterior vitreous detachment (PVD) in longer AL eyes. Similarly, Miura et al. [ 7 ] found that there was no significant difference in the postoperative BCVA between eyes with an AL ≥ 26 and an AL < 26 mm in ERM. Thylefors et al. [ 14 ] reported finding a better primary anatomical success when there was a longer AL in the eyes of patients with retinal detachment. MPH is characterized by fovea-sparing ERM, and PVD tends to occur more frequently in highly myopic eyes. In some cases, PVD may precede the formation of MPH, which results in minimal vitreoretinal traction at the macula. In contrast, eyes with a shorter AL may experience stronger and more persistent vitreous traction both before and during surgery, thereby potentially leading to greater morphological damage and poorer visual outcomes. Moreover, the ERM in MPH generally spares the fovea center, and thus, the tractional forces on the central fovea are relatively mild. This anatomical configuration allows the foveal photoreceptor structure to remain relatively preserved. Additionally, the central retinal layers in non-pathological highly myopic eyes may remain as thick as, or even thicker than that found in emmetropic eyes, indicating there is a structural preservation, particularly of the photoreceptor layers [ 19 ]. As a result, this may allow for better adaptation to the tangential traction without causing an abrupt deformation of the foveal contour. This retinal extensibility may contribute to the preservation of the foveal microstructure and, consequently, lead to better visual outcomes after the surgical intervention. To illustrate this, Fig. 3 shows representative preoperative and postoperative OCT images of eyes with MPH in the normal (A), myopic (B), and highly myopic (C) AL groups. Notably, the BCVA improved postoperatively in all three cases, which indicates favorable visual outcomes regardless of the AL. There were no significant differences in the frequency of the OCT findings among the AL groups in any of the diseases. However, outer retinal cysts tended to be more frequent at 6 months postoperatively in the highly myopic LMH group. While MPH and ERM-FS are primarily treated by releasing retinal traction through ERM and ILM peeling, the pathophysiology of LMH involves tissue loss at HFL and OPL, which cannot be reversed simply by releasing the retinal traction. Outer cysts in LMH may represent the preceding stage of tissue loss and could be associated with Müller cell dysfunction. Additionally, retinoschisis is more common in highly myopic eyes, which may explain the persistence of changes associated with these cysts. There were some limitations in the present study. First, the number of eyes studied was relatively small in each group, especially in the highly myopic eyes with LMH. Second, most patients underwent combined cataract surgery. Third, variations in the surgical technique, such as total ILM peeling versus the inverted ILM flap technique, may have influenced the outcomes. Finally, there was only a relatively short follow-up period. Thus, OCT findings, such as retinal cysts and EZ disruption, may require a longer time to resolve. In conclusion, we found that vitrectomy improved visual acuity across all AL groups in MPH, ERM-FS, and LMH. Thus, these results suggest that AL may not have a significant impact on the surgical outcomes in these conditions. Although, OCT findings did not differ significantly among AL groups, the outer cysts tended to persist longer in highly myopic eyes. Abbreviations AL axial length BCVA best-corrected visual acuity EP epiretinal proliferation ERM epiretinal membrane ERM-FS epiretinal membrane foveoschisis EZ ellipsoid zone HFL Henle’s fiber layer INL inner nuclear layer ILM internal limiting membrane LMH lamellar macular hole MPH macular pseudohole OCT optical coherence tomography OPL outer plexiform layer PVD posterior vitreous detachment SD spectral-domain Declarations Ethics approval and consent to participate: Written informed consent was obtained from all enrolled participants. All procedures adhere d to the tenets of the Declaration of Helsinki and were approved by the Ethics Committee of Nippon Medical School (ID: M-2023-161) in accordance with the ethical review processes utilized at our institution. Consent for publication: Patients signed informed consent regarding publishing their data. Availability of data and materials: Data can be made available from the corresponding author at [email protected] on a reasonable request. Competing interests: Not applicable Funding: Not applicable Authors’ contributions: F.O. conceived and designed the study and supervised the project. N.K., R.S., Y.M., K.M., T.K., Y.N., and H.G. contributed to material preparation, data collection, and data analysis. N.K. wrote the first draft of the manuscript. All authors critically reviewed and commented on previous versions of the manuscript, and all approved the final version for submission. Acknowledgements: Not applicable References Hubschman JP, Govetto A, Spaide RF, Schumann R, Steel D, Figueroa MS, Sebag J, Gaudric A, Staurenghi G, Haritoglou C, Kadonosono K, Thompson JT, Chang S, Bottoni F, Tadayoni R. Optical coherence tomography-based consensus definition for lamellar macular hole. Br J Ophthalmol. 2020;104(12):1741–7. 10.1136/bjophthalmol-2019-315432 . Epub 2020 Feb 27. 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Cite Share Download PDF Status: Published Journal Publication published 17 Oct, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 09 Sep, 2025 Reviews received at journal 07 Sep, 2025 Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 20 Aug, 2025 Reviews received at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 03 Aug, 2025 Editor invited by journal 28 Jul, 2025 Editor assigned by journal 24 Jul, 2025 Submission checks completed at journal 24 Jul, 2025 First submitted to journal 22 Jul, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7183858","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495014785,"identity":"8ff52fa0-db35-4f17-a317-335bc1ccdb2c","order_by":0,"name":"Noriko Kubota","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACZgY2hgQgzcbDwPgAJmhArBZmuEr8WoCKIRQPA5sEUe7iZ2d/9uDhDpt8Pp7Dx6oLc+oY+NsPMBQX4NEi2cxjbpB4Js2yjbct7fbMbYcZJM4kMBjPwKPF4DAPm0Ri22EDNn4es9u82w4wMNxgYDDmwauF/RlcSzHvtjoGecJaGMwgWnh7zJh5tzEzGBDSAvQLSEuaARvPsWRp3m2HeQzPJDbg9Qs///Fnkj/bbAzke5IPfgY6TE7u+OFjxvhCDAMAncTYZkyKDjBgfkyyllEwCkbBKBjOAAD1eD5Rt5aemgAAAABJRU5ErkJggg==","orcid":"","institution":"Nippon Medical School","correspondingAuthor":true,"prefix":"","firstName":"Noriko","middleName":"","lastName":"Kubota","suffix":""},{"id":495014786,"identity":"47a2939e-3799-4b71-865e-ae0d02d1b013","order_by":1,"name":"Reo Sueno","email":"","orcid":"","institution":"Nippon Medical School Tama Nagayama","correspondingAuthor":false,"prefix":"","firstName":"Reo","middleName":"","lastName":"Sueno","suffix":""},{"id":495014787,"identity":"92d1e63a-8733-4040-b692-90a218c421ea","order_by":2,"name":"Yosai Mori","email":"","orcid":"","institution":"Miyata Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yosai","middleName":"","lastName":"Mori","suffix":""},{"id":495014788,"identity":"8c5fe0f5-cb09-432d-9252-3613e43b75e0","order_by":3,"name":"Kazunori Miyata","email":"","orcid":"","institution":"Miyata Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kazunori","middleName":"","lastName":"Miyata","suffix":""},{"id":495014789,"identity":"e959f6a8-86fe-4cfd-8bcc-da7d23d4dffb","order_by":4,"name":"Tomoyuki Kunishige","email":"","orcid":"","institution":"Nippon Medical School","correspondingAuthor":false,"prefix":"","firstName":"Tomoyuki","middleName":"","lastName":"Kunishige","suffix":""},{"id":495014790,"identity":"bf39fb53-5d50-4511-958c-403fe8984559","order_by":5,"name":"Yuji Nakano","email":"","orcid":"","institution":"Nippon Medical School","correspondingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Nakano","suffix":""},{"id":495014792,"identity":"e9f7fa20-9920-47d9-8383-5fce2e9d1fb8","order_by":6,"name":"Hitoshi Goto","email":"","orcid":"","institution":"Nippon Medical School Tama Nagayama","correspondingAuthor":false,"prefix":"","firstName":"Hitoshi","middleName":"","lastName":"Goto","suffix":""},{"id":495014794,"identity":"8162bb84-7475-4be6-a519-d150b4ebe0dc","order_by":7,"name":"Fumiki Okamoto","email":"","orcid":"","institution":"Nippon Medical School","correspondingAuthor":false,"prefix":"","firstName":"Fumiki","middleName":"","lastName":"Okamoto","suffix":""}],"badges":[],"createdAt":"2025-07-22 07:23:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7183858/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7183858/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-025-04424-x","type":"published","date":"2025-10-17T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88489801,"identity":"b11e1874-4609-43fc-88f3-92a950ccaa60","added_by":"auto","created_at":"2025-08-07 04:09:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":437657,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between preoperative and postoperative best-corrected visual acuity (BCVA) in the normal group in macular pseudohole (MPH) (A) and in the myopic group in lamellar macular hole (LMH).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative and postoperative BCVA was significantly correlated in the normal group in MPH (p\u0026lt;0.01) and in the myopic group in LMH (p\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7183858/v1/80efeba6958c7725ca95a784.png"},{"id":88489806,"identity":"2033370b-120e-43dd-83b5-fe0b31f05ee6","added_by":"auto","created_at":"2025-08-07 04:09:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":871805,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentages of preoperative and postoperative optical coherence tomography findings in macular pseudohole (MPH) (A), epiretinal membrane foveoschisis (ERM-FS) (B), and lamellar macular hole (LMH) (C).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo significant differences were observed among the groups across all of the diseases, while eyes with LMH in the highly myopic group tended to present an outer cyst.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-7183858/v1/4c09459a60bfbc137f469a0f.png"},{"id":88491851,"identity":"2eaffaf8-2606-48ad-bcfa-ced5600da902","added_by":"auto","created_at":"2025-08-07 04:25:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8496737,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRepresentative preoperative and postoperative OCT images of eyes with macular pseudohole (MPH) in the normal (A), myopic (B), highly myopic (C) axial length (AL) group.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach panel shows OCT images that were obtained preoperatively (upper row) and postoperatively (lower row) in patients with MPH. (A) shows a case in the normal AL group (AL=22.71 mm) in which the preoperative and 4-month postoperative BCVA were 0.301 and 0.097, respectively. (B) shows a case in the myopic AL group (AL=24.41 mm) in which the preoperative and 6-month postoperative BCVA were 0.523 and 0.155, respectively. (C) shows a case in the highly myopic AL group (AL=30.07 mm) in which the preoperative and 4-month postoperative BCVA were 0.155 and -0.079, respectively. In all three of these AL groups, the BCVA improved postoperatively, which indicated that favorable visual outcomes were achieved regardless of the AL.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-7183858/v1/ae1247b6f5373c25e3167a15.png"},{"id":93956140,"identity":"f8819a70-437c-4dc8-9b68-7f657896e3cb","added_by":"auto","created_at":"2025-10-20 16:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":12051682,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7183858/v1/9d28fe2e-6a9c-4e5f-ab1a-c34b21b9028c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Axial Length-Based Comparison of Clinical Characteristics and Visual Outcomes in Macular Pseudohole, Epiretinal Membrane Foveoschisis, and Lamellar Macular Hole","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMacular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) are distinct macular pathologies that can lead to visual impairment. Advances in optical coherence tomography (OCT) have enabled detailed characterization of these conditions and facilitated more accurate diagnoses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Several studies have undertaken comparisons of the clinical features, prognostic factors and surgical outcomes of these diseases [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAxial length (AL) is an important anatomical parameter that influences retinal structure and vitreoretinal interface. In highly myopic eyes, elongation of the AL may lead to mechanical stresses and structural alterations, which may affect the development and progression of macular diseases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Previous studies have reported differences in macular morphology and surgical outcomes between myopic and non-myopic eyes with regard to some macular diseases, including macular hole and diabetic retinopathy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe previously reported that the AL in eyes with MPH, ERM-FS, and LMH was significantly longer than in eyes with idiopathic epiretinal membrane (ERM) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, Miura et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] reported favorable surgical outcomes following vitrectomy in highly myopic eyes with ERM, suggesting that myopia does not necessarily preclude visual improvement. However, comprehensive comparisons of clinical characteristics and visual outcomes among MPH, ERM-FS, and LMH across different AL groups remain limited. A better understanding of the influence of AL on these macular diseases may help refine surgical indicators and improve visual prognosis. Therefore, the purpose of this study was to compare the clinical characteristics, OCT findings, and visual outcomes in patients with MPH, ERM-FS, and LMH stratified by AL.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective study was reviewed and approved by the Ethics Committee of Nippon Medical School (ID: M-2023-161) in accordance with the ethical review processes utilized at our institution [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Patients provided written consent for their information to be stored in the hospital\u0026rsquo;s database and to be used for research purposes. This study was performed according to the tenets of the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient Data and OCT Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study retrospectively reviewed the medical records of consecutive patients with MPH, ERM-FS, and LMH who underwent vitrectomy between April 2020 and December 2023 and who were followed-up for at least 6 months postoperatively. Exclusion criteria included patients with a previous history of vitreoretinal surgery, ophthalmic disorders, except for mild cataract, retinal vascular disease, uveitis, and trauma. Clinical details collected from the medical records included patients\u0026rsquo; age, gender, and best-corrected visual acuity (BCVA). Patients were diagnosed with each disease based on the spectral-domain (SD) OCT findings (Spectralis version 1.8.6.0, Heidelberg Engineering GmbH, Heidelberg, Germany) and the updated criteria that were established by an international panel of vitreoretinal experts in 2020.\u003csup\u003e1\u003c/sup\u003e After the diagnosis of each disease, eyes were classified into three groups based on the AL; normal group (AL\u0026thinsp;\u0026lt;\u0026thinsp;24 mm), myopic group (AL\u0026thinsp;\u0026ge;\u0026thinsp;24 to \u0026lt;\u0026thinsp;26 mm), and highly myopic group (AL\u0026thinsp;\u0026ge;\u0026thinsp;26 mm) in all three groups (MPH, ERM-FS and LMH). The anatomical features examined included the presence of retinal cysts, disruption of the ellipsoid zone (EZ), and epiretinal proliferation (EP). The inner and outer retinal cysts were identified as the hyporeflective spaces in the inner nuclear layer (INL) and in Henle\u0026rsquo;s fiber layer (HFL) and/or the outer plexiform layer (OPL), respectively. The disruption of the EZ was identified as an irregularity of the EZ line within a 1 mm diameter at the fovea. These OCT parameters were evaluated preoperatively and at 3 and 6 months postoperatively. BCVA was measured before and after surgery using a standard Japanese decimal visual acuity chart at a distance of 5 meters. For statistical analyses, the decimal values were converted to the logarithm of the minimal angle of resolution (logMAR) units. The AL was measured by ultrasonography (AL-4000, Tomey Corporation, Nagoya, Japan).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical Procedures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients under local anesthesia underwent 25-gauge pars plana vitrectomy performed by two vitreoretinal surgeons (F.O., Y.M.). After complete posterior vitreous detachment and vitrectomy, 0.1\u0026ndash;0.2 mL of 0.025% brilliant blue G solution was gently injected over the macula and then washed out using irrigation solution. After the ERM was peeled, 0.1 mL of the brilliant blue G solution was applied to the macular area. Subsequently, we then completely peeled the remaining internal limiting membrane (ILM) within an area approximately equal to the vertical extent of the optic disc. In cases with EP, ILM was peeled toward the fovea following ERM removal, and then inverted on the fovea. The EP was embedded into the fovea defect with ILM. After removing the lens by phacoemulsification, an intraocular lens was then implanted when required, followed by vitrectomy.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe mean scores and standard deviations were calculated for age, AL, and the preoperative and postoperative BCVA. The difference between the preoperative and postoperative BCVA was analyzed by Wilcoxon\u0026rsquo;s signed-rank test. Spearman\u0026rsquo;s rank correlation test was used to examine the correlation between the preoperative and postoperative BCVA. A Kruskal-Wallis test was used to compare the difference among the AL groups. The analyses of the categorical data in the cross tables, such as distribution of the AL groups and the presence of inner and outer retinal cysts, EP, and EZ disruption were analyzed using Fisher\u0026rsquo;s exact test. All tests of association were considered statistically significant if p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The analyses were carried out using SPSS Statistics (version 29.0, IBM).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 170 patients (79 males and 91 females) with a mean age of 71.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) were included. Among these, 74 eyes met the criteria for MPH, 59 eyes for ERM-FS, and 38 eyes for LMH. Based on the AL, eyes were classified into three groups: normal, myopic, and highly myopic eyes.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the number of eyes, age, preoperative and postoperative BCVA, and preoperative OCT parameters in all eyes. The distribution of eyes in each group was as follows: In the MPH group, 33 eyes (44.6%) were classified as normal, 23 eyes (31.1%) as myopic, and 18 eyes (24.3%) as highly myopic. In the ERM-FS group, 25 eyes (42.3%) were classified as normal, 22 eyes (37.3%) as myopic, and 12 eyes (20.3%) as highly myopic. In the LMH group, 15 eyes (39.5%) were classified as normal, 14 eyes (36.8%) as myopic, and 9 eyes (23.7%) as highly myopic. There were no significant differences in the distribution of the AL groups among the three disease types. Regarding preoperative OCT parameters, EZ disruption was observed significantly more frequently in eyes with LMH versus in those with MPH and ERM-FS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Postoperatively, EZ disruption was more frequently observed in LMH at both 3 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005) and at 6 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, outer cysts were more frequently observed in ERM-FS at 3 months postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and tended to be more frequent in ERM-FS at 6 months (p\u0026thinsp;=\u0026thinsp;0.069). Across all disease groups, patients in the highly myopic group were significantly younger than those in the normal group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 in MPH, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 in ERM-FS, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 in LMH). Preoperative BCVA did not significantly differ among the AL groups in any of the three diseases, while that of the eyes in the highly myopic group tended to be worse in the ERM-FS group (p\u0026thinsp;=\u0026thinsp;0.07). In the MPH group, postoperative BCVA was significantly better in the highly myopic group as compared with the myopic group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical characteristics and preoperative optical coherence tomography (OCT) parameters of patients with macular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) classified by axial length\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAxial Length (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003enormal\u003c/p\u003e\u003cp\u003e\u0026lt;\u0026thinsp;24\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emyopic\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;24 to \u0026lt;\u0026thinsp;26\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ehighly myopic\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;26\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMPH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNumber of eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (44.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (31.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (24.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u0026Dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative BCVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.277\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.361\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.242\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePostoperative BCVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.058\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.112\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.010\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative OCT parameters\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (21.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (21.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOuter cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (27.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.264\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInner cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (15.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (21.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.924\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEZ disruption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (21.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (17.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eERM-FS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNumber of eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (42.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (37.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (20.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative BCVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.216\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.331\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.420\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePostoperative BCVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.028\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.041\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.177\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative OCT parameters\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (16.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (27.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOuter cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInner cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (31.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEZ disruption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (28.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (22.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.927\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLMH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNumber of eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (39.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (36.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (23.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative BCVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.284\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.383\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.421\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePostoperative BCVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.120\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.136\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.120\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative OCT parameters\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (71.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (44.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOuter cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (46.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (64.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (55.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInner cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (21.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEZ disruption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (35.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.412\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eMPH\u0026thinsp;=\u0026thinsp;macular pseudohole, ERM-FS\u0026thinsp;=\u0026thinsp;epiretinal membrane, LMH\u0026thinsp;=\u0026thinsp;lamellar macular hole, BCVA\u0026thinsp;=\u0026thinsp;best-corrected visual acuity, OCT\u0026thinsp;=\u0026thinsp;optical coherence tomography, EP\u0026thinsp;=\u0026thinsp;epiretinal proliferation, EZ\u0026thinsp;=\u0026thinsp;ellipsoid zone\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eValues are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003eSignificantly different from the other groups (*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u0026dagger;p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u0026Dagger;p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Kruskal-Wallis test)\u003c/p\u003e\u003cp\u003eA significant correlation between the preoperative and postoperative BCVA was observed in the normal group of the MPH (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, r\u0026thinsp;=\u0026thinsp;0.47), whereas no significant correlations were found in the myopic or highly myopic groups. No significant correlations between the preoperative and postoperative BCVA were observed in any of the AL groups within the ERM-FS. In the LMH, a significant correlation between the preoperative and postoperative BCVA was observed in the myopic group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, r\u0026thinsp;=\u0026thinsp;0.59).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the percentages of the preoperative and postoperative (at 3 and 6 months) OCT findings in each of the AL groups for MPH (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA), ERM-FS (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB), and LMH (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Across all diseases, there were no significant differences in the frequency of the OCT findings among the AL groups. However, in LMH, the presence of outer retinal cysts at 6 months postoperatively tended to be more frequent in the highly myopic group as compared to the other groups (p\u0026thinsp;=\u0026thinsp;0.065).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe investigated the clinical characteristics, OCT findings, and the visual outcomes of eyes with MPH, ERM-FS, and LMH according to the AL. The present findings provide insights into the prognostic factors and highlight the importance of specific OCT parameters in potential visual outcomes. Our literature reviews have not found any prior studies that have investigated the visual outcomes in MPH, ERM-FS, and LMH when specifically based on the AL.\u003c/p\u003e\u003cp\u003eIn the present study, significant postoperative improvement in BCVA was observed across all of the AL groups and disease types. Notably, in MPH, eyes in the highly myopic group exhibited significantly better postoperative BCVA as compared to that observed in the myopic group. These results may appear counterintuitive, as high myopia is often associated with poorer surgical outcomes due to retinal thinning or degenerative changes. However, other previous studies have shown mixed results regarding surgical outcomes in retinal diseases, with some reporting a poorer outcome, while others, including the present study, indicating that there were comparable or even better visual outcomes in highly myopic eyes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In many of these studies, the longer AL was associated with worse outcomes in myopic macular hole [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and in macular hole retinal detachment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In contrast, there was no association or even better outcomes reported in ERM [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], retinal detachment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and diabetic retinopathy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Minami et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported that the postoperative BCVA was worse in patients with an AL that was \u0026lt;\u0026thinsp;23.6 mm and an age\u0026thinsp;\u0026gt;\u0026thinsp;69 years as compared to those with an AL that was \u0026ge;\u0026thinsp;23.6 mm and an age\u0026thinsp;\u0026le;\u0026thinsp;69 years at both 1 and 3 months after surgery for ERM. These results suggested that eyes with a longer AL might have less traction and less damage, which could possibly be due to an earlier posterior vitreous detachment (PVD) in longer AL eyes. Similarly, Miura et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] found that there was no significant difference in the postoperative BCVA between eyes with an AL\u0026thinsp;\u0026ge;\u0026thinsp;26 and an AL\u0026thinsp;\u0026lt;\u0026thinsp;26 mm in ERM. Thylefors et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported finding a better primary anatomical success when there was a longer AL in the eyes of patients with retinal detachment.\u003c/p\u003e\u003cp\u003eMPH is characterized by fovea-sparing ERM, and PVD tends to occur more frequently in highly myopic eyes. In some cases, PVD may precede the formation of MPH, which results in minimal vitreoretinal traction at the macula. In contrast, eyes with a shorter AL may experience stronger and more persistent vitreous traction both before and during surgery, thereby potentially leading to greater morphological damage and poorer visual outcomes. Moreover, the ERM in MPH generally spares the fovea center, and thus, the tractional forces on the central fovea are relatively mild. This anatomical configuration allows the foveal photoreceptor structure to remain relatively preserved. Additionally, the central retinal layers in non-pathological highly myopic eyes may remain as thick as, or even thicker than that found in emmetropic eyes, indicating there is a structural preservation, particularly of the photoreceptor layers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As a result, this may allow for better adaptation to the tangential traction without causing an abrupt deformation of the foveal contour. This retinal extensibility may contribute to the preservation of the foveal microstructure and, consequently, lead to better visual outcomes after the surgical intervention. To illustrate this, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows representative preoperative and postoperative OCT images of eyes with MPH in the normal (A), myopic (B), and highly myopic (C) AL groups. Notably, the BCVA improved postoperatively in all three cases, which indicates favorable visual outcomes regardless of the AL.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThere were no significant differences in the frequency of the OCT findings among the AL groups in any of the diseases. However, outer retinal cysts tended to be more frequent at 6 months postoperatively in the highly myopic LMH group. While MPH and ERM-FS are primarily treated by releasing retinal traction through ERM and ILM peeling, the pathophysiology of LMH involves tissue loss at HFL and OPL, which cannot be reversed simply by releasing the retinal traction. Outer cysts in LMH may represent the preceding stage of tissue loss and could be associated with M\u0026uuml;ller cell dysfunction. Additionally, retinoschisis is more common in highly myopic eyes, which may explain the persistence of changes associated with these cysts.\u003c/p\u003e\u003cp\u003eThere were some limitations in the present study. First, the number of eyes studied was relatively small in each group, especially in the highly myopic eyes with LMH. Second, most patients underwent combined cataract surgery. Third, variations in the surgical technique, such as total ILM peeling versus the inverted ILM flap technique, may have influenced the outcomes. Finally, there was only a relatively short follow-up period. Thus, OCT findings, such as retinal cysts and EZ disruption, may require a longer time to resolve.\u003c/p\u003e\u003cp\u003eIn conclusion, we found that vitrectomy improved visual acuity across all AL groups in MPH, ERM-FS, and LMH. Thus, these results suggest that AL may not have a significant impact on the surgical outcomes in these conditions. Although, OCT findings did not differ significantly among AL groups, the outer cysts tended to persist longer in highly myopic eyes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eaxial length\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBCVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebest-corrected visual acuity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eepiretinal proliferation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eERM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eepiretinal membrane\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eERM-FS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eepiretinal membrane foveoschisis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEZ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eellipsoid zone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHFL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHenle\u0026rsquo;s fiber layer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eINL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003einner nuclear layer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eILM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003einternal limiting membrane\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003elamellar macular hole\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMPH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emacular pseudohole\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eoptical coherence tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOPL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eouter plexiform layer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePVD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eposterior vitreous detachment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003espectral-domain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Written informed consent was obtained from all enrolled participants. All procedures adhere d to the tenets of the Declaration of Helsinki and were approved by the Ethics Committee of Nippon Medical School (ID: M-2023-161) in accordance with the ethical review processes utilized at our institution.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Patients signed informed consent regarding publishing their data.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Data can be made available from the corresponding author at [email protected] on a reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: Not applicable\u003c/p\u003e\n\u003cp\u003eFunding: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions: F.O. conceived and designed the study and supervised the project. N.K., R.S., Y.M., K.M., T.K., Y.N., and H.G. contributed to material preparation, data collection, and data analysis. N.K. wrote the first draft of the manuscript. All authors critically reviewed and commented on previous versions of the manuscript, and all approved the final version for submission.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHubschman JP, Govetto A, Spaide RF, Schumann R, Steel D, Figueroa MS, Sebag J, Gaudric A, Staurenghi G, Haritoglou C, Kadonosono K, Thompson JT, Chang S, Bottoni F, Tadayoni R. Optical coherence tomography-based consensus definition for lamellar macular hole. Br J Ophthalmol. 2020;104(12):1741\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bjophthalmol-2019-315432\u003c/span\u003e\u003cspan address=\"10.1136/bjophthalmol-2019-315432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 Feb 27. PMID: 32107208.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohammed TK, Thompson JT. 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PMID: 31570740; PMCID: PMC6769047.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"axial length, epiretinal membrane foveoschisis, lamellar macular hole, macular pseudohole, visual outcome","lastPublishedDoi":"10.21203/rs.3.rs-7183858/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7183858/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo evaluate clinical and optical coherence tomography (OCT) findings and visual outcomes in patients with macular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) based on axial length (AL).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively reviewed consecutive patients diagnosed with MPH, ERM-FS, and LMH who underwent vitrectomy and were followed for at least 6 months postoperatively. In each disease group, eyes were categorized into three groups based on AL; normal (\u0026lt;\u0026thinsp;24 mm), myopic (\u0026ge;\u0026thinsp;24 to \u0026lt;\u0026thinsp;26 mm), and highly myopic (\u0026ge;\u0026thinsp;26 mm). Analyzed factors included age, AL, preoperative and postoperative best-corrected visual acuity (BCVA), and OCT parameters such as the presence of inner and outer retinal cysts, epiretinal proliferation, and ellipsoid zone disruption.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 171 eyes from 170 patients (79 males and 91 females) were included: 74 eyes with MPH, 59 eyes with ERM-FS, and 38 eyes with LMH. Postoperative BCVA significantly improved in all AL groups across all disease types. In the MPH group, postoperative BCVA was significantly better in the highly myopic group than in the myopic group (p\u0026thinsp;=\u0026thinsp;0.04). There were no significant differences in the frequency of the OCT findings among the AL groups in any of the diseases. However, the presence of outer cysts at 6 months postoperatively tended to be more frequent in the highly myopic group (p\u0026thinsp;=\u0026thinsp;0.065).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eVitrectomy improved visual acuity in all AL groups across MPH, ERM-FS, and LMH. AL did not significantly affect the frequency of abnormal findings for the preoperative and postoperative OCT.\u003c/p\u003e","manuscriptTitle":"Axial Length-Based Comparison of Clinical Characteristics and Visual Outcomes in Macular Pseudohole, Epiretinal Membrane Foveoschisis, and Lamellar Macular Hole","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-07 04:09:20","doi":"10.21203/rs.3.rs-7183858/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T05:13:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T09:31:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T03:48:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73532480273890012816558927568971239216","date":"2025-08-21T00:30:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-15T01:21:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323561067064332890746657760309293331679","date":"2025-08-14T15:13:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225441817783629116447331593591672981563","date":"2025-08-14T08:59:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-03T23:15:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-28T06:06:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-24T11:26:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T11:26:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-07-22T07:17:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8721262d-7b89-4f25-9634-83b1ae103979","owner":[],"postedDate":"August 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:06:40+00:00","versionOfRecord":{"articleIdentity":"rs-7183858","link":"https://doi.org/10.1186/s12886-025-04424-x","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-10-17 15:57:55","publishedOnDateReadable":"October 17th, 2025"},"versionCreatedAt":"2025-08-07 04:09:20","video":"","vorDoi":"10.1186/s12886-025-04424-x","vorDoiUrl":"https://doi.org/10.1186/s12886-025-04424-x","workflowStages":[]},"version":"v1","identity":"rs-7183858","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7183858","identity":"rs-7183858","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}