Macular holes (MH) are full-thickness retinal defects affecting central vision. While vitrectomy with inner limiting membrane (ILM) peel is the conventional MH treatment, non-surgical alternatives are gaining interest to mitigate surgical risks. This study conducted a comprehensive literature review and analysis of non-surgical MH management. A systematic literature search was conducted on PubMed, Embase, Scopus, and the Cochrane Library from January 1, 1973, to September 13, 2023. Treatments included laser therapy, carbonic anhydrase inhibitors (CAIs), non-steroidal anti-inflammatories (NSAIDs), steroids (topical, subtenons, peribulbar, intravitreal), intravitreal gas, anti-vascular endothelial growth factors (VEGF) and ocriplasmin injections. Data extraction covered study details, patient characteristics, MH features, treatment outcomes, and recurrence rates. The initial search yielded 3,352 articles, refined to 83 articles which met inclusion criteria following screening. Overall reported anatomical closure rates were 36% with laser photocoagulation, 37% with intravitreal ocriplasmin, 55% with intravitreal gas. Closures were more frequently observed with topical NSAIDs (79%), steroids (84%) and CAIs (73%). Closures were more often observed in patients with smaller MH and in the presence of cystic macular oedema. Although non-surgical MH management approaches show potential for conservative therapy, evidence is limited to support routine use. Stage 1 and traumatic MH may benefit from a short period of observation but the gold standard approach for full-thickness MH remains to be vitrectomy with ILM peel. 

Scoping review of non-surgical treatment options for macular holes.

Intraorbital arteriovenous fistulas (IOAVFs) are rare vascular pathologies that may be effectively treated with direct puncture (DP) of the venous supply and may offer a definitive and safe cure when done under ultrasound or stereotactic guidance. Here we present three new cases of DP treatment of IOAVFs, indications for safe use, and their potential complications in comparison to the existing literature on DP and other modalities.Three patients with IOAVFs were treated with DP with ultrasound guidance, stereotactic guidance, and fluoroscopy. Final digital subtraction angiography (DSA) revealed complete cure of IOAVFs. A literature review via PubMed was performed on treatments of IOAVFs since 1978.All three cases of DP resulted in successful cures with 2/3 cases resulting in complications from orbital hematoma formation. 49 total treatments including the cases herein have been documented. DP treatment constituted 5/49, conservative management 17/49, transarterial 8/49, transvenous 18/49, and surgical 3/49. Some cases received more than one mode of treatment. Transarterial and surgical managements were found to have higher complication rates than transvenous and DP.DP is a safe and effective treatment of IOAVFs that can be performed via multiple image guided methods and guarantees a definitive cure. Orbital hematomas are a potential complication of which operators should be aware.

Treatment of intraorbital arteriovenous fistulas with direct puncture: a case series and review of treatments since 1978.

Spontaneous arteriovenous fistula is a rare orbital lesion that may cause proptosis, ptosis, chemosis, and visual disturbances. The widely practiced treatment is a transvenous embolization approach accessed from the femoral or petrosal sinus. In this case report, we present a surgical approach via transconjunctival orbitotomy for direct access to achieve complete fistula embolization. The postoperative course revealed progressive, near-complete symptomatic improvement.

Surgical treatment of a spontaneous intraorbital arteriovenous fistula with direct embolization via transconjunctival orbitotomy

Periorbital vascular malformations and tumours are a heterogeneous group of conditions with a complex nomenclature and classification. This chapter aims to clarify the current classification, as well as the clinical presentation, diagnosis, and management of the principal conditions within this group. Infantile haemangioma is the most common benign orbital vascular lesion in the paediatric population. It tends to regress in most cases. Oral propranolol is considered the treatment of choice in persisting cases. Solitary encapsulated venous-lymphatic malformation (SEVLM), traditionally known as cavernous haemangioma, is the most common orbital lesion in adult patients. It is usually diagnosed incidentally, and treatment can be postponed until significant proptosis or visual symptoms appear; in those cases, the surgical excision is the treatment of choice. The group of vascular malformations includes a broad spectrum of lesions that very in terms of histology, size and location, blood flow, and management. Included within this group are venous malformations, SEVLM, lymphangioma, orbital varices, arterio-venous malformations. Arterio-venous fistulae or shunts are characterised by an abnormal communication of the arterial into the venous systems without the normal capillary bed, which leads to an increase in the venous pressure and congestive signs and symptoms. Other rare conditions described in this chapter, are sinus pericranii, a vascular anomaly that results when there is communication between intracranial and extracranial venous systems, and orbital vascular occlusion, which may occur in the context of underlying vascular anomaly, injury, or infection. 

Orbital Vascular Anomalies and Vascular Tumours

Conservative management of spontaneous intraorbital arteriovenous fistulas

Purpose: This work aims to discuss the case of a 32-year-old man with diabetic macular edema (DME) who underwent successful treatment of a full-thickness macular hole (FTMH) with a single dose of aflibercept. Methods: A case report is presented. Results: A 32-year-old man with reduced vision and DME in the right eye was found to have a FTMH. The patient was scheduled for pars plana vitrectomy; however, following a single dose of intravitreal aflibercept, the FTMH closed and the patient avoided surgical intervention. Conclusions: FTMH formation in DME is a rare complication that typically requires surgical intervention. We present a case of FTMH closure after a single dose of intravitreal aflibercept, which to our knowledge is the first of its kind. This report highlights the importance of considering conservative treatment initially to avoid surgery.

Full-Thickness Macular Hole Closure Following a Single Intravitreal Injection of Aflibercept in an Eye With Diabetic Macular Edema

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Conservative management of spontaneous intraorbital arteriovenous fistulas

Full-Thickness Macular Hole Closure Following a Single Intravitreal Injection of Aflibercept in an Eye With Diabetic Macular Edema