Original Article

Structural and Functional Outcomes of Surgery for
Lamellar Macular Holes with or without Epimacular

Proliferations
Ramesh Venkatesh, MS; Arpitha Pereira, DO, DNB; Kushagra Jain, MS; Naresh Kumar Yadav, DO, FMRF

Department of Retina-Vitreous, Narayana Nethralaya Eye Hospital, Rajaji Nagar, Benguluru, India

ORCID:
Ramesh Venkatesh: https://orcid.org/0000-0002-4479-9390

Abstract

Purpose: To compare the clinical, optical coherence tomography (OCT) features, and
surgical outcomes of lamellar macular hole (LMH) depending on the presence of
epimacular membrane proliferation (EMPF).
Methods: This retrospective chart review included 112 eyes with LMH. The patients were
divided into two groups depending on the presence of EMPF. Group 1 had LMH without
EMPF and Group 2 had LMH with EMPF. The best-corrected visual acuity was recorded
and OCT scans were obtained.
Results: Lamellar macular hole without and with EMPF was noted in 62 (55%) and 50
(45%) eyes, respectively. The presence of EMPF was associated with lower presenting
visual acuity (P = 0.049), wider LMH size at the largest diameter on the horizontal scan (P =
0.001), thinner residual retinal tissue (P =<0.0001), and larger IS-OS defects (P =<0.0001)
as compared to the non-EMPF group. Of the 112 eyes, 18 eyes underwent surgery for
LMH. Seven eyes had EMPF and the remaining eleven did not have EMPF. The average
follow-up time for patients post-surgery and under observation was 16.8 and 24.1 weeks,
respectively. A significant improvement in visual acuity was noted in the operated eyes
with no EMPF as compared to the eyes with EMPF (P = 0.008). Worsening visual acuity
(P = 0.021) was noted in eyes with LMH associated with EMPF which did not undergo
surgery. Eyes with LMH and no EMPF, which were not operated on showed a minimal
negative change in visual acuity.
Conclusion: LMH with EMPF showed a higher association with accompanying ellipsoid
zone disruption. Better anatomical and functional outcomes were achieved in those eyes
that underwent surgery for LMH with no presence of EMPF and ellipsoid zone defect.

Keywords: Epimacular Membrane Proliferation; Full-Thickness Macular Hole; Lamellar Hole
Epithelial Proliferation; Lamellar Macular Hole; Surgery

J Ophthalmic Vis Res 2022; 17 (1): 42–50

42 © 2022 Venkatesh R. THIS IS AN OPEN ACCESS ARTICLE DISTRIBUTED UNDER THE CREATIVE COMMONS ATTRIBUTION LICENSE | PUBLISHED BY KNOWLEDGE E

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Surgery for Lamellar MH; Venkatesh R

INTRODUCTION

Epimacular membrane proliferation (EMPF) was
previously described as a “thick” epiretinal
membrane (ERM) by Witkin et al in 2006, “dense
non-tractional membrane” by Parolini et al in
2011, and then more commonly as the lamellar
hole epithelial proliferation (LHEP) by Pang and
associates in 2014.[1–3] This different type of ERM
seen in cases of lamellar macular holes (LMH)
on high-resolution optical coherence tomography
(OCT) was identified as a homogenous mass
of medium reflectivity lying over the retinal
surface.[3] In 2015, Schumann et al renamed
this phenomenon as “atypical epiretinal tissue”,
because it occurred in conditions other than LMH,
such as in a full-thickness macular hole (FTMH)
condition.[4] The commonly accepted hypothesis
for the formation of LMH is that it arises from
the ERM contraction, which then results in a
tear in the inner retinal layers.[2, 5] During clinical
examination, EMPF is identified as a yellow elastic
jelly lying over the epiretinal surface and commonly
associated with a thick non-contractile ERM. Its
yellowish color is likely due to the xanthophyll
pigment identified in histological analysis.[2, 6]
Despite the absence of a clear mechanism for
EMPF formation, the most likely theory is that it
results from the migration of the retinal Muller
glial cell.[3] The association of the EMPF with
higher rates of ellipsoid disruption and positivity to
pan-keratin created another theory of the retinal
pigment epithelial origin of the disease.[4, 7–10] It
has been reported that patients with EMPF tend
to have lower baseline visual acuities, greater
external MH diameters, thinner residual retinal
tissue, and higher rates of inner segment-outer
segment (IS-OS) band disruption when compared
to non-EMPF eyes.[4, 7, 9] Visual acuity in eyes with
LMH varies from having baseline normal vision to

Correspondence to:

Ramesh Venkatesh, MS. Vitreo Retina consultant,
Narayana Nethralaya Eye Hospital, 121/C, Chord Road,
1st ’R’ Block, Rajaji Nagar, Benguluru 560010, India.
Email: vramesh80@yahoo.com
Received 05-12-2019; Accepted 22-11-2021

Access this article online

Website: https://knepublishing.com/index.php/JOVR

DOI: 10.18502/jovr.v17i1.10169

having lower visual acuities depending upon the
integrity of the ellipsoid zone. A wide variety of
anatomic and visual outcomes has been reported
after the performance of vitrectomy for macular
holes with and without EMPF presence. Marques
et al reported no differences in visual performance
or closure rates between the EMPF group and
non-EMPF group after surgery or in the subset of
patients who did not undergo treatment.[11] One
paper reported a significantly poor visual outcome
for patients with LMH and EMPF after surgery,[6]
while another study showed an increase in area of
EMPF and a decline in the visual function in eyes
who were managed conservatively.[12] The majority
of retinal specialists in the Indian subcontinent tend
to manage the cases of LMH conservatively either
because of underlying ellipsoid layer integrity,
better presenting visual acuity, or associated poor
visual prognosis. Given the variable characteristics
in the physical and structural properties of EMPF,
there are no clear guidelines currently available
regarding patient selection and timing of surgery
in such eyes with LMHs. In addition, to the
best of our knowledge, there is no reported
literature from the Indian subcontinent describing
this clinical entity in these eyes or discussing
the treatment outcomes either from surgery or
through conservative management. In this report,
we intend to analyze the morphological changes
and visual outcomes of the LMH cases that
presented with EMPF, and describe the surgical
outcomes. By comparing the clinical and surgical
data from the LMH cases with and without
EMPF, we intend to appreciate and understand
better the significance of this unique epimacular
proliferation. The objective of this study is also to
make the readers aware of this clinical entity in
clinical/OCT examinations and to encourage them
to understand the relevance and impact it can have
on the final outcome of the disease.

METHODS
This study was approved by Narayana Nethralaya
institutional review board and ethics committee
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work non-commercially, as
long as appropriate credit is given and the new creations are licensed under the
identical terms.

How to cite this article: Venkatesh R, Pereira A, Jain K, Yadav NK. Structural
and Functional Outcomes of Surgery for Lamellar Macular Holes with or
without Epimacular Proliferations. J Ophthalmic Vis Res 2022;17:42–50.

JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2022 43

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Surgery for Lamellar MH; Venkatesh R

(C-2019/01/003). This retrospective study was
conducted at the retina clinic of a tertiary eye
hospital in Southern India. In this study, a single
observer (RV) reviewed the SD-OCT images
acquired by the Spectralis, Heidelberg machine,
which were saved in the folders labelled as
lamellar macular hole and epiretinal membrane
between the January 2011 and December
2018. The diagnosis of LMH was based on
the updated criteria proposed by the International
Vitreomacular Traction Study Group.[13] According
to the group, LMH is a non-full-thickness
retinal defect seen at the macula. This defect
is characterized by the presence of the following
features on the SD-OCT: (1) an irregular foveal
contour; (2) inner foveal defect; (3) intraretinal
splitting, typically between the outer plexiform
and outer nuclear layers; and (4) presence of a
photoreceptor layer at the base of the hole. The
OCT images were viewed to identify the presence
or absence of EMPF in these eyes. EMPF was
identified on the OCT imaging as a homogenous
material of medium reflectivity arising from the
outer retinal layers, crawling along the walls of the
macular hole and lying on the epiretinal surface.
The eyes were categorized into two groups for
further analysis: (1) LMH with no EMPF and (2) LMH
with EMPF. Demographic data records included
age, gender, laterality, and Snellen visual acuity
(VA) at presentation. Features on OCT which
were recorded included presence of LMH, EMPF,
IS-OS defect, and ERM. The macular hole size
in LMH was measured as the widest horizontal
diameter at the level of the middle retinal layers at
the foveal center. The length of the IS-OS defect
and thickness of residual retinal tissue in LMH
were manually measured at the fovea using the
calipers provided with the software. The LMHs
observed on the OCT were further divided into
tractional or degenerative types based on the
classification proposed by Govetto et al.[14] The
tractional type was characterized by the schitic
separation of neurosensory retina between outer
plexiform and outer nuclear layers with an intact
ellipsoid layer and was associated with tractional
epiretinal membranes and/or vitreomacular
traction at the fovea. The degenerative type
was characterized by the presence of intraretinal
cavitation, non-tractional epiretinal proliferation,
a retinal ”bump” and with an early ellipsoidal
zone defect. In addition, other documented data

included treatment and outcome of surgery for
the LMH, postoperative VA, and anatomic status
of the macular hole. The indications to operate in
the LMH group were visual acuity < 6/12, patient
who complained of metamorphopsia and had a
presence of an epiretinal membrane. In the present
study, we looked at patients with a minimum follow-
up of eight weeks following surgery to analyze the
outcomes. Successful macular hole closure was
defined as the collapse of the excavation between
the outer nuclear and outer plexiform layers while
achieving a normal foveal contour.

Surgical Technique

All the surgeries were performed by a single
surgeon (NKY). A three-port 23- or 25-gauge
pars plana vitrectomy was performed. After core
vitrectomy, intravitreal triamcinolone acetonide
was injected to stain the posterior cortical vitreous
and the posterior vitreous detachment was then
induced. In cases where epimacular membrane
was present, removal was performed. Care was
taken to not forcibly peel the ERM from the edge of
the LMH. A vitrectomy cutter was used to trim and
leave the adherent epiretinal tissue at the margin of
the hole. An attempt was made to remove the EMPF
that was lying over the internal limiting membrane
(ILM). A 0.1–0.2 cc of Brilliant Blue Green (BBG) dye
was injected to stain the ILM to facilitate its removal
from the macular area. If the ERM was difficult
to identify, BBG-assisted ILM peeling was done
from outside the ERM-covered area that was not
stained. The ERM was then removed along with the
ILM. Again, care was taken to not forcibly peel the
ERM/ILM from the edge of the hole. Finally, air–fluid
exchange was done and 15 % perfluoropropane
(C3F8) or 20% Sulphur hexafluoride (SF6) gas
was used for an endotamponade procedure. A
minimum of seven days of prone positioning was
recommended.

Statistical Analysis

Normal distribution of quantitative variables was
checked using the Kolmogorov–Smirnov test.
Snellen’s vision data were converted to logarithm
of minimum angle of resolution (logMAR) vision
for statistical analysis. Categorical variables were
labelled as numerical for easy analysis as in
identification of the IS-OS defects, the ERM, and

44 JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2022



Surgery for Lamellar MH; Venkatesh R

the hole closures. Value 1 indicated presence and
value 0 absence of these findings. Categorical
variables between the two groups were compared
using the Chi-square test. The Mann–Whitney
U-test was used to compare quantitative data
between the two groups. Correlations between
the presence of EMPF and other variables were
determined using the Spearman correlation test.
A correlation (r) value of 0 means no correlation
between the two variables while values closer to
–1 indicate strong negative correlation and values
closer to +1 indicate strong positive correlation. For
the analysis of surgical outcomes, the eyes were
divided into two groups: (1) eyes with EMPF and (2)
eyes without EMPF. Wilcoxon signed-rank test was
applied for the comparison of VA changes in the
two groups. All data were analyzed with GraphPad
Prism software (version 8.1.1). P-values < 0.05 were
considered statistically significant.

RESULTS

During the study period, a total of 112 eyes with
LMHs were included. The number of eyes included
in each group were: (1) Group 1 – Eyes with LMH
and no EMPF (62, 55%); (2) Group 2 – Eyes with
LMH and EMPF (50, 45%).

The comparison of clinical and OCT findings
of patients with lamellar macular hole presenting
with and without EMPF is described in Table 1 and
depicted in Figure 1.

Tractional types of LMH were identified in 25
(22%) eyes, the degenerative types of LMH in 81
(72%) eyes, and mixed variety in 6 (6%) eyes. EMPF
was most commonly seen with the degenerative
type of LMH (45/50, 90%) followed by the mixed
type (5/50, 10%). ERM was absent in eight eyes
with EPMF and LMH. Analysis of presence of EMPF
with different OCT features showed strong positive
correlations with the presence (r = 0.742) and size
(r = 0.743) of IS-OS defects while strong negative
correlation was noted with thickness of the residual
retinal tissue (r = –0.641) present within the MH
[Table 2].

Moreover, 18 of the 112 (16%) cases with LMH
were treated surgically using the pars plana
vitrectomy procedure. The remainder of the cases
were managed conservatively. Of the 18 eyes
which underwent surgery, 7 eyes had EMPF. Table
3 compares the clinical and OCT features of eyes
with and without EMPF that were operated on.

The width of the LMH (p = 0.027), size of the
IS-OS defect (p = 0.002), and residual retinal
tissue thickness (p = 0.000) showed statistically
significant correlation between the two groups. The
average follow-up period for patients post-surgery
was 16.8 weeks. Single surgery hole closure was
achieved in 4 (57%) eyes and 11 (100%) eyes in
cases with and without EMPF, respectively. Of the
remaining three eyes where surgical success was
not achieved due to the development of a full-
thickness macular hole, repeat surgery introducing
a fluid-air exchange and silicone oil/intraocular gas
tamponade was performed in all the eyes. In two
eyes the hole closed while in one eye the hole
remained open despite the second surgery. In the
observation group, 43 of the 94 (46%) eyes, which
were managed by observation, showed EMPF on
the SD-OCT scans. However, by the end of the
final follow-up visit, an additional 16 eyes showed
development of EMPF, thus increasing the number
to 59 (63%) eyes for those who were managed
conservatively. The average follow-up period for
patients under observation was 24.1 weeks.

The mean preoperative visual acuity in eyes with
EMPF and without EMPF was 0.5 (20/63) and 0.592
(20/78) (p = 0.052), respectively. The eyes in the
EMPF group showed a mean decrease of –0.312
logMAR units (p = 0.797) in visual acuity following
surgery while eyes in the non-EMPF group showed
a mean of 0.272 logMAR units’ improvement (p
= 0.008) following surgery. By the end of the
final follow-up visit, a significant decrease in visual
acuity was noted in eyes with LMH and EMPF
who were managed conservatively (p = 0.021).
Eyes with LMH and no EMPF who were managed
conservatively showed a minimal worsening in
visual acuity.

Changes in the visual acuity in the two groups
before and after surgery is described in Table 4.

DISCUSSION

The use of spectral domain OCT has allowed us
to visualize the presence of substantive material
on the epiretinal surface in the LMH and the FTMH
which we describe as EMPF or LHEP as described
by Pang et al.[3] In this article, we studied the clinical
and OCT features and surgical outcomes of LMHs
with and without EMPF.

The findings in this study suggest that in
LMHs, EMPF formation was accompanied by

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Surgery for Lamellar MH; Venkatesh R

ellipsoid layer loss, a wider than normal macular
hole diameter, deep retinal defects, and the
presence of IS-OS defects in large-sized MHs.
The ERM was not present in all the cases of
EMPF. The EMPF was yellowish in color and
connected to the retinal tissue within the hole.
Taken together, these findings suggested that
EMPF could be a secondary event following LMH
formation and is usually accompanied with deep
outer retina involvement. Also, histological studies

have shown absence of the inner retinal tissue
within the epiretinal tissue.[2] Many theories were
proposed for the development of EMPF in LMH;
however, none are conclusive.[3, 4, 10] The findings
of this study reinforce an alternate theory for
the EMPF formation. According to this theory,
EMPF originates secondary to the defects in
the ellipsoid zone which then allows the retinal
pigment epithelial cells to migrate along the walls
of the MH and then onto the retinal surface and
finally leading to EMPF and ERM formation.

The prevalence of EMPF in LMH has ranged from
20.5% to 44% in previous studies.[3, 7, 8, 16] In our
study, EMPF was noted in 44% of eyes with LMH.
This is comparable to that observed with other
studies. EMPF was seen more commonly with the
degenerative variety of LMH (90%) as compared
to the mixed or tractional variety. The presence
of EMPF was associated with lower presenting
visual acuity, larger MH size, thinner residual retinal
tissue, and larger IS-OS defects before operation.
As a result, the visual and anatomical outcomes
following surgery in these eyes were significantly
different from those with no EMPF. Eyes with LMH
with EMPF showed no visual acuity gain following
surgery. Also, successful anatomic closure of the
MH was achieved in only four of the seven (57%)
eyes following surgery compared to that of the
non-EMPF group where the MH closed in all cases
(100%). Similar observations were also noted by
Choi et al and Ko et al where the visual outcomes
in LHEP group was poorer as compared to the eyes
with no LHEP.[7, 16] However, Lai et al reported no
difference in the visual and anatomic outcomes
between the LHEP group and non-LHEP group
following surgery.[8] In their study, the largest mean
diameter on the horizontal scan of the LMH in eyes
with LHEP (98.4 µ) was less than the eyes with no
LHEP (146.9 µ). While in our study, eyes with LMH
with EMPF (1282 µ) had wider large mean diameters
on the horizontal scan as compared to eyes with no
EMPF (715 µ). Also, the IS-OS defects were much
larger in eyes with EMPF (808 µ) than in eyes with
no EMPF (54.4 µ). This would explain the poor
visual and anatomic outcomes following surgery in
our study.

The recommendations for the surgical repair
of eyes with LMH remain controversial.[15, 16] While
there have been reports with good surgical
outcomes,[17, 18] there have also been reports that
have advised caution with performing vitrectomy
in these cases.[1, 2] In our series, only 18 of the

112 (16%) eyes with LMH underwent surgery. The
rest of the eyes were managed conservatively
through observation. In the observation group, 43
of the 94 (46%) eyes, which were managed by
observation, showed EMPF on the SD-OCT scans,
this category further increased to 63% by the
end of the final follow-up visit. Thus, suggesting
that solely observing such cases may lead to
progression of the outer retinal defects and EMPF
formation, ultimately leading to decrease in vision.
Consequently, we recommend surgery for eyes
with LMH when visual acuity is 6/18 or less, there
is the presence of epiretinal membrane causing
retinal traction, presence of an intact ellipsoid zone,
progression in the size of LMH on follow-up visits
or progression to full-thickness within the macular
hole.

During surgery in cases that possess LMH
with EMPF, it is recommended to peel the
proliferative tissue while peeling the ERM. The
cellular composition of the EMPF may lead to the
recurrence of the ERM formation if not removed
completely. However, aggressive peeling of the
EMPF may lead to the conversion of the LMH to
FTMH as seen in three cases in this study. Care
should be taken to not forcibly pull the ERM from
the edge of the hole. Applying the least amount
of traction as possible may theoretically reduce the
possibility of retinal tissue damage or the formation
of FTMH. In fact, a few studies have reported a
high incidence of FTMH formation after the LHEP
was peeled in surgeries for LMH.[2, 3] Shiraga et al
recommended inversion of the pigment containing
proliferative tissue into the LMH to facilitate
normalization of the foveal contour;[21] however, we
did not practice this technique in any of our cases.
We did a conventional ILM peeling extending from
arcade to arcade in all our cases with the intention
of removing the cellular proliferative tissue where
possible without much damage to the retina. In
some cases, it is sometimes easier to start peeling

46 JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2022



Surgery for Lamellar MH; Venkatesh R

Figure 1. Lamellar macular hole (LMH) with EMPF. (a) Optical coherence tomography (OCT) image of a patient with LMH in right
eye showing the presence of epiretinal proliferative tissue at the margin of the hole (white arrow) with presence of ellipsoid zone
defect (red star). (b) Another OCT scan passing through a different section acquired on the same day demonstrating the extension
of the proliferative tissue (yellow arrow) from the ellipsoid zone defect (red star) and then crawling along the walls of the macular
hole to lie over the retinal surface.

Table 1. Clinical and optical coherence tomography findings of patients with and without EMPF in eyes with LMH

Variable LMH without EMPF (n =
62)

LMH with EMPF (n = 50) P-value

Mean age (yr) 72.6 ± 8.25 69.9 ± 13.0 0.316#
Sex (M:F) 26:36 33:17 0.667#

Laterality (RE:LE) 35:27 31:19 0.667∗

Mean presenting logMAR VA
(Snellen equivalent)

0.396 (20/50) 0.518 (20/66) 0.05#

Size of LMH (µm) 715 ± 305 986 ± 471 0.001#
Residual retinal thickness (µm) 144 ± 28.1 102 ± 33.7 <0.001#
Presence of IS-OS defect (n, %) 8 (13) 42 (84) >0.999∗
Size of IS-OS defect (µm) 32.8 ± 101 401 ± 389 <0.001#
Presence of ERM (n, %) 52 (84) 42 (84) 0.667∗

Eyes undergoing surgery (n, %) 11 (18) 7 (14) 0.667∗

LMH, lamellar macular hole; EMPF, epimacular proliferative tissue; VA, visual acuity; ETDRS, Early Treatment Diabetic
Retinopathy Study; IS–OS, inner segment–outer segment; ERM, epiretinal membrane #P-value calculated using the
Mann–Whitney U-test; ∗P-value calculated using the Chi-square test

JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2022 47



Surgery for Lamellar MH; Venkatesh R

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48 JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2022



Surgery for Lamellar MH; Venkatesh R

Table 3. Surgical outcomes in eyes with and without EMPF

Variable Surgery in EMPF cases (n
= 7)

Surgery without EMPF
cases (n = 11)

P-value

Pre-op mean logMAR VA
(Snellen equivalent)

0.5 (20/63) 0.592 (20/78) 0.052#

MH width (µm) 1232 ± 528 795 ± 252 0.027#

Residual retinal thickness (µm) 82.1 ± 16.3 143 ± 30 0.0004#

Presence of IS–OS defect (n, %) 6(86) 2(18) 0.013∗

Size of IS–OS defect (µm) 808 ± 757 54.4 ± 128 0.002#

Presence of ERM (n, %) 6(86) 10(91) >0.999∗

Hole closure achieved (n, %) 4(57) 11(100) 0.043∗

Post op mean logMAR VA
(Snellen equivalent)

0.518 (20/130) 0.32 (20/42) 0.001#

VA, visual acuity; EMPF, epimacular proliferative tissue; MH, macular hole; IS–OS, inner segment–outer segment; ERM, epiretinal
membrane #P-value calculated using the Mann–Whitney U-test; ∗P-value calculated using the Chi-square test

Table 4. Visual acuity changes before and after surgery in eyes with and without EMPF

Mean Pre-op logMAR VA
(Snellen equivalent)

Mean Post-op logMAR VA
(Snellen equivalent)

P-value#

Surgery in EMPF 0.5 (20/63) 0.812 (20/130) 0.797

Surgery in no EMPF 0.592 (20/78) 0.32 (20/42) 0.008

EMPF, epimacular proliferative tissue; VA, visual acuity; ETDRS, Early Treatment Diabetic Retinopathy Study; MH, macular hole
#P-value calculated using the Wilcoxon signed rank test

by first engaging the ILM not occupied by the ERM,
and then removing the ILM along with the ERM.

Our study has several clinical implications. Our
study suggests that surgery in eyes with LMH
with EMPF have both poor anatomic and visual
prognosis. Intervention in eyes with LMH without
EMPF/LHEP and without ellipsoid zone disruption
can have better visual and surgical prognosis.

Our study has the advantage of having an
adequate number of eyes both with and without
EMPF in LMHs for evaluation. The descriptive
features of eyes with EMPF on OCT confirms
the outer retinal damage theory of EMPF origin.
The study also describes the surgical outcomes
of patients operated for LMH with EMPF. The
most significant limitation of our study is its
retrospective design in accessing pertinent
data for evaluation. Our study was further
limited as there was only a single observer
evaluating the OCT scans, in addition, only
a small number of eyes underwent surgery
for management of LMH . Extensive clinical
and pathological studies may be required to

complement our observations and to provide
answers to the questions of the cellular origin of
EMPF and the reason for its recurrence following
surgery.

From this study, we can conclude that EMPF
in LMH has a poor visual prognosis when
accompanied with ellipsoid zone disruption.
Better functional and anatomical outcomes can
be achieved following surgery when LMH are
not associated with EMPF and/or ellipsoid zone
disruption.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

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