Supplementary Material for: Development of macular atrophy after macular hole surgery in an eye with retinitis pigmentosa

Introduction
Macular hole is a rare complication that occurs in patients with retinitis pigmentosa, significantly reducing visual acuity. Although vitreous surgery for macular hole yields favorable outcomes, macular atrophy after surgery has been reported. We report the second case of retinitis pigmentosa in a patient who developed a 13-year progressive macular atrophy after macular hole surgery.
Case Presentation
A 64-year-old Japanese woman, who had been diagnosed with retinitis pigmentosa at 52 years of age, presented to our hospital with blurred vision in the left eye. Phacovitrectomy of the left eye was performed after a full-thickness macular hole was revealed by optical coherence tomography. We stained the internal limiting membrane during surgery using 0.05% indocyanine green and peeled it around the macular hole. Nevertheless, slight atrophy of the retinal pigment epithelium appeared in the left macula 17 days after surgery. The macular hole closed 1 year after surgery, and the macular atrophy gradually became more apparent and enlarged. Thirteen years later, atrophy had expanded to 2.5-disc diameters, and the left decimal best-corrected visual acuity was 0.1; no macular degeneration appeared in the right eye. Genetic examination revealed compound heterozygous variants in the EYS gene.
Discussion　
Macular atrophy can develop after dye-assisted macular hole surgery for patients with retinitis pigmentosa. Potential risk factors for the development of postoperative macular atrophy include dye toxicity, light toxicity, surgical intervention in the macula, postoperative inflammation, and genotype. However, the exact cause of atrophy remains uncertain.

Introduction
黄斑裂孔（macular hole）是视网膜色素变性（retinitis pigmentosa）患者中罕见的并发症，可显著降低视力（visual acuity）。尽管黄斑裂孔的玻璃体手术（vitreous surgery）疗效良好，但术后黄斑萎缩（macular atrophy）已有报道。本文报告第二例视网膜色素变性患者在黄斑裂孔手术后发生13年进展性黄斑萎缩的病例。
Case Presentation
一名64岁日本女性，于52岁时确诊视网膜色素变性，因左眼视物模糊就诊于我院。光学相干断层扫描（optical coherence tomography）显示全层黄斑裂孔后，对其左眼行超声乳化联合玻璃体切除术（phacovitrectomy）。术中使用0.05%吲哚菁绿（indocyanine green）染色内界膜（internal limiting membrane）并在黄斑裂孔周围剥除。然而，术后17天左眼黄斑区出现轻度视网膜色素上皮（retinal pigment epithelium）萎缩。术后1年黄斑裂孔闭合，黄斑萎缩逐渐明显并扩大。13年后，萎缩范围扩展至2.5个视盘直径，左眼最佳矫正小数视力为0.1；右眼未出现黄斑变性。基因检测显示EYS基因存在复合杂合变异。
Discussion
视网膜色素变性患者接受染料辅助的黄斑裂孔手术（dye-assisted macular hole surgery）后可能发生黄斑萎缩。术后黄斑萎缩的潜在危险因素包括染料毒性（dye toxicity）、光毒性（light toxicity）、黄斑区手术干预（surgical intervention）、术后炎症（postoperative inflammation）及基因型（genotype）。然而，萎缩的确切原因仍不明确。