*Disha Eye Hospitals Pvt Ltd, 88(63A) Ghosh Para Road, Barrackpore, West Bengal, India*

***Corresponding Author:**Dr Subhendu Kumar Boral, MBBS, MD (AIIMS), DNB “Keshab Residency”, 138 Keshab Chandra Sen Street, Block II, Flat 1E, Amherst Street Kolkata - 700009, West Bengal, India.

**Received:**December 28, 2018;

**Published:**March 19, 2019

**Aim**: To calculate AIP & to find correlation between hole closure pattern with AIP in idiopathic Full Thickness Macular Hole (FTMH) cases.

**Method**: In this prospective, non-randomised interventional single blind study, 105 eyes of symptomatic FTMH (< 6month duration) were operated. Minimal diameter of macular hole (MDMH) was calculated on OCT, divided into Group I (>400μ, n=75) & Group II (<400μ, n=30). 23G vitrectomy, ILM peeling, gas injection done in all & recorded. Final AIP calculated using Adobe photoshop CS2 (PSD format) in disc diameter (DD) from still frame. A minimum of 6 month follow up done after surgery in all and further follow up done at 6monthly interval upto a maximum of 5 years after surgery.

**Results**: FTMH closed in 92.38% eyes. In Group I, mean preoperative BCVA was 1.14 ± 0.39 logMAR and improved to 0.79 ± 0.26 logMAR postoperatively at 6 month. In Group II, mean preoperative BCVA was 0.95 ± 0.44 logMAR and improved to 0.60 ± 0.24 log MAR af-ter surgery. When AIP >3DD, Type I & Type II closure were 72.77% & 27.27% in Group I (p<0.01) and 84.21% & 15.79% in Group II (p<0.01).

**Conclusion**: AIP can be calculated using Adobe photoshop CS2. Type I closure was sig-nificantly high with AIP >3DD in both groups. Intra-operatively using video overlay, surgeon can increase the diameter of AIP, to get better closure pattern post-operatively.

**Keywords:**Full Thickness Macular Hole (FTMH); Area of ILM Peeled(AIP); Minimal diame-ter of macular hole (MDMH); Adobe photoshop CS2; Video overlay, Boral’s Ring*et al*. also showed that closure rate significantly improved from 81% in non-ILM peeling group to 92% with ILM peeling group. Recent dye, Brilliant Blue( BBG) has high affinity to ILM like ICG, but with minimal toxicity. [11,12]

*et al*. mentioned that the standard recommendation was to peel ILM of [13] around 2 disc diameter (DD) in size, centering macular hole in general. OCT plays an important role in predicting surgical outcomes in macular hole surgery. Pre-operative Macular Hole Index (MHI), considering mid-hole diameter and basal diameter, is an well established prognostic factor for visual outcome. Kusuhara S.,

*et al.*showed BCVA [14] was better in the MHI ≥ 0.5 group than that in the MHI < 0.5 group. Ip MS.,

*et al.*showed successful anatomical closure in 92% eyes with preoperative macular hole diameter < 400μ, [15] but only in 56% eyes with macular hole diameter > 400μ.

*et al.*TypeI closure [16] was 61.3% and TypeII closure was 38.7%. Macular hole is considered as open when there is persistent defect in foveal neurosensory retina with surrounding serous detachment at it’s base.

- All other types of macular holes with secondary origin, including traumatic cases, cases with epimacular membrane, cystoids macular oedema etc.
- Old macular holes with symptoms more than 6 months and
- Disc diameter <1.5mm & >1.9mm.

*Area of ILM Peeled (AIP)- A novel technique*was introduced to calculate AIP. Per- opera-tive Area of ILM Peeled (AIP) had been calculated from the recorded video. Still frame of the final Area of ILM Peeled (AIP) had been taken using Adobe photoshop CS2 (in PSD format). Final AIP, centering macular hole had been calculated according to the longest disc diameter(DD) using three equidistant concentric rings with enlarging diameter( 1DD, 2DD and 3DD) and divided into two groups—more than 3DD & less than 3DD, depending on whether the margin of ILM peeled area is covering the 3DD circle in at least three quadrants or not. AIP had been measured in the following way : a) 3 equidistant concen-tric circles were made in Adobe photoshop CS2 in PSD format (Figure 1), b) smallest circle was fitted according to the longest disc diameter in the final still frame of the ILM peeling from the recorded video (Figure 2) and c) now these three circles were shifted to the ILM peeled area to note whether the margin of the ILM peeled area was crossing the outer-most circle in at least in three quadrants or not, depending on it would be >3DD or <3DD (Figure 3).*Pre-operative Minimal diameters of macular holes (MDMH)*- measured on Spectral Do-main OCT using callipers, divided into two groups–GroupI (with MDMH >400μ, n=75) & GroupII (with MDMH <400μ, n=30).*Post-operative macular hole closure pattern on SD-OCT*- performed in all either after 7days or 14 days (if closure pattern was certain on 7th day OCT) and to note Type I, Type II or open closure pattern.

Pre-Op | Combined Sx | Phac/PCIOL | ILM Peeled Area | Hole Closure | OPEN | BCVA | BCVA | BCVA | BCVA | BCVA | BCVA | BCVA | ||||||

Patient No. | BCVA | MDMH>400µ | <3DD | >3DD | Type I | Type II | 6 month | 12month | 18month | 24month | 36month | 42month | 60month | |||||

1 | 1 | PCIOL | 523 | Y | Y | 1 | ||||||||||||

2 | 1 | PHAC | 798 | Y | Y | 0.78 | 0.5 | 0.2 | ||||||||||

3 | 0.78 | PCIOL | 548 | Y | Y | 0.78 | 0.78 | 0.78 | 0.78 | 0.6 | ||||||||

4 | 1.1 | Y | 885 | Y | Y | 1 | 1 | 1 | 1 | 1 | ||||||||

5 | 2 | PCIOL | 498 | Y | Y | 2 | ||||||||||||

6 | 1.4 | Y | 736 | Y | Y | 1 | ||||||||||||

7 | 2 | PCIOL | 536 | Y | Y | 1 | ||||||||||||

8 | 1 | PHAC | 616 | Y | Y | 0.78 | ||||||||||||

9 | 2 | PHAC | 735 | Y | Y | 0.78 | 0.78 | 0.6 | 0.6 | 0.6 | ||||||||

10 | 2 | PCIOL | 633 | Y | Y | 0.6 | 0.6 | 0.6 | ||||||||||

11 | 1.2 | PHAC | 582 | Y | Y | 1 | ||||||||||||

12 | 1 | Y | 517 | Y | Y | 1 | 1 | 1 | 1 | 1 | 1 | |||||||

13 | 2 | Y | 836 | Y | Y | 0.6 | ||||||||||||

14 | 1 | PHAC | 460 | Y | Y | 0.6 | ||||||||||||

15 | 1 | PHAC | 465 | Y | Y | 1 | ||||||||||||

16 | 1.3 | PCIOL | 567 | Y | Y | 1 | ||||||||||||

17 | 1 | PCIOL | 753 | Y | Y | 0.5 | ||||||||||||

18 | 1.3 | PCIOL | 717 | Y | Y | 0.78 | 0.3 | |||||||||||

19 | 1 | PCIOL | 555 | Y | Y | 0.5 | ||||||||||||

20 | 1 | PCIOL | 533 | Y | Y | 0.6 | ||||||||||||

21 | 1 | PCIOL | 869 | Y | Y | 0.78 | 0.78 | 0.78 | ||||||||||

22 | 0.6 | PCIOL | 778 | Y | Y | 0.78 | 0.78 | 0.78 | 0.6 | |||||||||

23 | 1 | PCIOL | 717 | Y | Y | |||||||||||||

24 | 1 | Y | 709 | Y | Y | 0.78 | ||||||||||||

25 | 0.6 | Y | 464 | Y | Y | 1 | 0.78 | 0.6 | ||||||||||

26 | 2 | PCIOL | 743 | Y | Y | 1 | ||||||||||||

27 | 1 | PCIOL | 954 | Y | Y | 1 | ||||||||||||

28 | 0.78 | PCIOL | 465 | Y | Y | 0.5 | ||||||||||||

29 | 1 | PCIOL | 623 | Y | Y | 1 | 1 | 1 | 1 | 1 | 1 | 1 | ||||||

30 | 0.78 | PCIOL | 511 | Y | Y | 0.5 | 0.3 | 0.3 | 0.3 | 0.3 | 0.3 | 0.3 | ||||||

31 | 1.1 | PCIOL | 473 | Y | Y | 0.6 | ||||||||||||

32 | 1 | PHAC | 717 | Y | Y | 0.78 | ||||||||||||

33 | 1 | PHAC | 514 | Y | Y | 0.6 | ||||||||||||

34 | 1 | PHAC | 449 | Y | Y | 1 | ||||||||||||

35 | 1.3 | PHAC | 561 | Y | Y | 0.78 | 0.3 | |||||||||||

36 | 0.78 | PCIOL | 616 | Y | Y | 1 | ||||||||||||

37 | 1 | Y | 1005 | Y | Y | 0.5 | 0.5 | 0.5 | 0.4 | 0.4 | 0.4 | 0.3 | ||||||

38 | 1 | PCIOL | 549 | Y | Y | 0.5 | ||||||||||||

39 | 1 | PHAC | 659 | Y | Y | 0.78 | ||||||||||||

40 | 1.3 | Y | 532 | Y | Y | 0.78 | ||||||||||||

41 | 1 | PHAC | 720 | Y | Y | 0.5 | 0.5 | |||||||||||

42 | 1 | PHAC | 515 | Y | Y | 0.78 | 0.6 | 0.6 | 0.6 | 0.6 | 0.5 | 0.5 | ||||||

43 | 2 | PCIOL | 519 | Y | Y | 0.6 | ||||||||||||

44 | 1.1 | Y | 886 | Y | Y | 0.78 | ||||||||||||

45 | 1.4 | PHAC | 608 | Y | Y | 0.6 | 0.6 | 0.6 | 0.6 | 0.5 | 0.5 | |||||||

46 | 1.3 | Y | 422 | Y | Y | 0.78 | ||||||||||||

47 | 1 | PCIOL | 616 | Y | Y | 1 | ||||||||||||

48 | 1.3 | PHAC | 456 | Y | Y | 1 | 0.6 | |||||||||||

49 | 1 | PCIOL | 476 | Y | Y | 1 | 0.78 | 0.78 | 0.78 | 0.78 | 0.78 | 0.78 | ||||||

50 | 1 | PCIOL | 656 | Y | Y | 0.78 | ||||||||||||

51 | 1 | PHAC | 474 | Y | Y | 0.48 | 0.3 | |||||||||||

52 | 0.78 | PHAC | 735 | Y | Y | 0.3 | 0.3 | 0.3 | 0.3 | |||||||||

53 | 0.78 | PHAC | 456 | Y | Y | 0.6 | 0.6 | 0.6 | ||||||||||

54 | 2 | Y | 720 | Y | Y | 1.4 | ||||||||||||

55 | 1.4 | Y | 473 | Y | Y | 1 | ||||||||||||

56 | 2 | Y | 726 | Y | Y | 1 | ||||||||||||

57 | 0.78 | PHAC | 405 | Y | Y | 0.78 | ||||||||||||

58 | 1 | PHAC | 449 | Y | Y | 0.6 | ||||||||||||

59 | 1 | PHAC | 461 | Y | Y | 0.5 | ||||||||||||

60 | 0.78 | Y | 473 | Y | Y | 0.6 | ||||||||||||

61 | 1 | PHAC | 745 | Y | Y | 0.6 | 0.6 | 0.6 | ||||||||||

62 | 1.1 | PHAC | 717 | Y | Y | 0.78 | 0.78 | 0.78 | ||||||||||

63 | 1.1 | Y | 549 | Y | Y | 1 | ||||||||||||

64 | 1 | PCIOL | 709 | Y | Y | 0.78 | ||||||||||||

65 | 1 | PHAC | 591 | Y | Y | 0.6 | ||||||||||||

66 | 1 | Y | 532 | Y | Y | 1 | 0.3 | 0.3 | ||||||||||

67 | 0.6 | PCIOL | 447 | Y | Y | 0.5 | 0.5 | 0.3 | 0.2 | 0.2 | 0.2 | |||||||

68 | 0.6 | PHAC | 422 | Y | Y | 0.5 | ||||||||||||

69 | 0.6 | PCIOL | 551 | Y | Y | 0.3 | ||||||||||||

70 | 1 | PCIOL | 928 | Y | Y | 0.78 | 0.78 | |||||||||||

71 | 2 | PCIOL | 768 | Y | Y | 1 | 0.78 | |||||||||||

72 | 1.3 | Y | 658 | Y | Y | 1 | ||||||||||||

73 | 1 | Y | 684 | Y | Y | 0.78 | 0.6 | 0.6 | 0.5 | 0.5 | ||||||||

74 | 1 | Y | 717 | Y | Y | 0.78 | ||||||||||||

75 | 1.3 | Y | 719 | Y | Y | 1 |

**Table 1:**Pre-Op | Combined Sx | Phac/PCIOL | ILM Peeled Area | Hole Closure | OPEN | BCVA | BCVA | BCVA | BCVA | BCVA | BCVA | BCVA | ||||

Patient No. | BCVA | MDMH<400µ | <3DD | >3DD | Type I | Type II | 6 month | 12month | 18month | 24month | 36month | 42month | 60month | |||

1 | 2 | Y | 312 | Y | Y | 0.6 | 0.6 | |||||||||

2 | 0.78 | Y | 186 | Y | Y | 0.5 | 0.5 | |||||||||

3 | 0.6 | PHAC | 338 | Y | Y | 0.5 | 0.3 | 0.2 | 0.2 | 0.2 | 0.2 | 0.2 | ||||

4 | 0.6 | PHAC | 287 | Y | Y | 0.6 | 0.5 | |||||||||

5 | 0.6 | PHAC | 382 | Y | Y | 0.6 | ||||||||||

6 | 0.5 | PHAC | 304 | Y | Y | 0.3 | 0.3 | |||||||||

7 | 0.5 | PCIOL | 135 | Y | Y | 0.3 | ||||||||||

8 | 1.4 | PCIOL | 287 | Y | Y | 0.78 | 0.78 | 0.6 | 0.5 | |||||||

9 | 0.6 | PCIOL | 321 | Y | Y | 0.5 | 0.3 | 0.3 | 0.3 | |||||||

10 | 1.1 | PCIOL | 354 | Y | Y | 0.6 | 0.5 | 0.5 | 0.3 | 0.3 | 0.3 | 0.3 | ||||

11 | 1 | Y | 321 | Y | Y | 1 | ||||||||||

12 | 0.5 | Y | 346 | Y | Y | 0.3 | 0.3 | 0.2 | 0.2 | 0.2 | ||||||

13 | 0.5 | PHAC | 253 | Y | Y | 0.3 | ||||||||||

14 | 1 | PCIOL | 276 | Y | Y | 0.5 | ||||||||||

15 | 0.78 | PCIOL | 144 | Y | Y | 0.48 | 0.3 | 0.3 | 0.2 | |||||||

16 | 1 | PHAC | 336 | Y | Y | 0.78 | ||||||||||

17 | 0.5 | PCIOL | 236 | Y | Y | 0.2 | 0.2 | 0.2 | ||||||||

18 | 0.6 | PCIOL | 312 | Y | Y | 0.3 | ||||||||||

19 | 0.78 | PCIOL | 241 | Y | Y | 0.5 | ||||||||||

20 | 0.78 | PCIOL | 262 | Y | Y | 0.5 | 0.3 | 0.3 | 0.2 | |||||||

21 | 0.78 | PHAC | 245 | Y | Y | 0.78 | 0.78 | |||||||||

22 | 2 | PHAC | 361 | Y | Y | 1 | 0.78 | 0.6 | 0.6 | 0.5 | 0.5 | |||||

23 | 1 | PCIOL | 236 | Y | Y | 0.5 | 0.3 | 0.3 | 0.3 | 0.3 | ||||||

24 | 1.4 | PCIOL | 234 | 1 | 0.78 | 0.5 | 0.5 | |||||||||

25 | 0.78 | PCIOL | 219 | Y | Y | 0.6 | ||||||||||

26 | 2 | PCIOL | 194 | Y | Y | 1 | ||||||||||

27 | 1.3 | Y | 361 | Y | Y | 0.78 | 0.6 | 0.5 | 0.5 | 0.4 | 0.3 | 0.3 | ||||

28 | 1.1 | PCIOL | 263 | Y | Y | 1 | 0.78 | |||||||||

29 | 1 | PCIOL | 199 | Y | Y | 0.6 | 0.6 | 0.5 | ||||||||

30 | 1 | PHAC | 261 | Y | Y | 0.5 | 0.5 | 0.5 |

**Table 2:**GROUP | Pre-op mean BCVA (Log MAR) |
Post-op mean BCVA (Log MAR) |

In all | 1.09±0.41 | 0.73±0.26 |

I | 1.14±0.39 | 0.79±0.26 |

II | 0.95±0.44 | 0.60±0.24 |

**Table 3:**Shows pre and post operative best corrected visual acuity (BCVA) in both groups.GROUP | MDMH | AIP | Type I closure |
Type II closure |
Open hole |

I | >400μ | >3DD | 32 | 12 | 4 |

I | >400μ | <3DD | 8 | 15 | 4 |

II | <400μ | >3DD | 16 | 3 | 0 |

II | <400μ | <3DD | 8 | 3 | 0 |

**Table 4:**Shows relationship between Area of ILM Peeled (AIP) and Macular hole closure pattern, considering pre-operative Minimal Diameter of Macular Hole (MDMH).*can be regarded as a pilot study*, as till of now, no other study highlighted the logi-cal reproducible method to calculate area of ILM peeled and related the association between intra-operative ILM peeled area and post-operative pattern of macular hole closure.

*Boral’s*

*Ring*”. An online switcher is required for chroma keying and mixing using two analog inputs,one from camera microscope as live video and another from computer as video overlay (“Bo-ral’s Ring”). The final analog signal input will go to the video recorder (Figures 10) so that the sur-geon can use this video overlay intra-operatively to calculate ILM peeled area in respect to the disc diameter. Intra-operatively, surgeon can enlarge the area of ILM peeled by peeling more ILM (Figures 11-16), according to the preoperative MDMH to ensure better closure pattern.

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**Subhendu Kumar Boral, Arnab Das, Tushar Kanti Sinha and Bimal Roy. (2019). A Novel Standardised Reproducible Method to Calculate the Area of Internal Limiting Mem-brane Peeled (AIP) intra-operatively in Macular Hole Surgery by Using a Video Overlay (“Bo-ral’s Ring”) - A Long-term study in cases of Idiopathic Macular Holes.**

*Citation:**Journal of Ophthalmology and Vision Research*1(1).

**Copyright:**© 2019 Subhendu Kumar Boral. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.