Vitrectomy was first introduced by Kelly and Wendel in 1991 to close macular holes (MHs).1 This technique is used to remove the anteroposterior vitreoretinal traction, which has been described as the primary mechanism responsible for MH formation.2,3 Many other additional surgical maneuvers have been developed to increase MH closure rate. Internal limiting membrane (ILM) peeling has been used in conjunction with vitrectomy to remove residual vitreous cortex and possible contraction of rigid ILM and to induce glial cell proliferation.4 The introduction of ILM peeling increased closure rates from 58% to 90% or more.5,6
However, closure rates depended strongly on base diameter, inner opening size, and chronicity.7,8 Surgical treatment is less likely to be successful in MHs larger than 400 μm and holes that have persisted for longer than 1 year.8 Furthermore, the closure rates of persistent MHs have been reported to be lower than those of primary MHs.9 The inverted ILM flap technique was introduced to close large and chronic MHs, and success rates increased dramatically.10 However, in persistent MHs, there is no perihole ILM to use. Wong described a technique that utilizes the elastic properties of detached retina around the MH and obtained a 100% success rate.11
Herein, we describe a modified technique of Wong's and evaluate the anatomical and functional success of this technique.
Patients and Methods
We reviewed the records of 14 patients with persistent MHs between January 2015 and January 2016. Four patients were not operated on due to uncontrolled systemic problems (eg, diabetes, hypertension). We accordingly included 10 consecutive patients who underwent surgical intervention during this period. All patients had undergone previous MH surgery (vitrectomy, large area of ILM peeling, 12% C3F8 gas endotamponade, and face-down positioning). The study was approved by the ethics committee of Gazi University Faculty of Medicine and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients prior to the surgical interventions.
All patients underwent a comprehensive ophthalmological examination including best spectacle-corrected visual acuity (BSCVA), slit-lamp microscopy, fundus examination, and spectral-domain optical coherence tomography (SD-OCT) measurements before and after the surgical intervention. All patients were examined on postoperative day 1, week 1, and months 1, 3, and 6. The primary outcome was closure of MH. The secondary outcome was an improvement in BSCVA. Preoperative and postoperative OCT measurements were performed using the Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany).
After entrance of the three-port transconjunctival 23-gauge sutureless vitrectomy instruments, complete removal of ILM at the prior surgery was checked using brilliant blue staining. A 39-gauge /41-gauge cannula was used to inject a small amount of balanced salt solution under the superior, inferior, and temporal perihole retina (nasal bundle fibers were spared) at a distance of about 1 disc diameter (Figure 1) to create shallow retinal detachment (RD). The balanced salt solution was injected until the injected fluid ran out of the hole. A shallow RD was formed to obtain an elastic, movable retina around the MH. Retinal massage to facilitate the closure of the edges was not performed to avoid further retinal or retinal pigment epithelium (RPE) damage. The edges of the hole were brought closer using small passive aspirations with a silicone-tipped cannula (Figure 2). After fluid-air exchange, the tip of a 39-gauge/41-gauge cannula was placed over the hole (without touching the RPE), and the subretinal fluid was actively aspirated until the base of the hole was dry (Figure 3). In most cases, the hole appeared to be closed during this step. Then, the air was changed with 20% sulfur hexafluoride gas endotamponade. All ports were checked and sutured, if necessary. The patients were given face-down positioning for 1 week.
This patient was 19 years old, and macular hole (MH) was developed following retinal detachment surgery. The MH did not close after a standard MH surgery with internal limiting membrane (ILM) peeling. There was an epiretinal membrane (ERM) between the borders of inferior retinotomy and the ILM removal area. This ERM may have been responsible for the failure of primary MH surgery. The MH was persistent and enlarged over time. A 39-gauge subretinal cannula was used to create shallow retinal detachments at the temporal, inferior, and superior sides of the MH.
The edges of the macular hole were brought closer with passive aspirations by a silicone-tipped cannula.
During the fluid-air exchange, 39-gauge cannula was placed just over the macular hole to drain submacular fluid.
There were three men and seven women in the study. The mean follow-up time was 7.2 months (range: 6 months to 9 months). The mean age of the patients was 58.5 years ± 14.6 years (range: 19 years to 73 years). MHs developed after RD surgery in two eyes and after blunt trauma in one eye. The remainder of the MHs were idiopathic. The mean interval between the decrease in vision and primary MH repair could not be identified due to a lack of information. The mean interval between our surgical interventions and prior surgical interventions was 9.7 months ± 3.1 months (range: 5 months to 14 months). The preoperative MH OCT measurements are listed in Table 1. MHs were closed in all eyes (holes were closed after fluid aspiration step just over the hole in seven out of 10 eyes) and remained closed in all patients during the follow-up period (100%). The preoperative and postoperative 6-month BSCVAs are listed in Table 2. In OCT sections, ellipsoid zone (EZ) degeneration was noted in all patients. There were no intraoperative or postoperative complications.
Preoperative OCT Measurements of Macular Holes
Pre- and Postoperative (6-Month) Best Spectacle-Corrected Visual Acuities
In most MH cases, anatomic closure is obtained in more than 90% patients with vitrectomy, ILM peeling, and gas endotamponade.5,6 ILM peeling prominently increased the rate of MH closure. However, the closure rates are closely related with the base diameter of the hole and chronicity.7,8 Consequently, nearly half of large and chronic MHs remain opened despite ILM peeling.10 Therefore, a new technique called inverted ILM flap was introduced, and success rates increased to 98%, even in large and chronic MHs.10 The exact mechanism of this technique's success has not been clearly understood, but two possible theories have been proposed: 1) the ILM behaves as a barrier against fluid accumulation from vitreous into the MH, and 2) the ILM enhances glial proliferation by acting as a scaffold for Müller cells.10 However, in cases of persistent MHs, there remains no ILM to promote healing; the majority of these cases were previously believed to be inoperable and left without treatment. Some techniques have been described in a small number of cases, including retinal massage, laser photocoagulation of the RPE surrounding the MH, autologous ILM or neurosensory retinal free-flap transpositioning, making arcuate or radial retinotomies around the hole, the use of heavy silicone oil, and closing holes with a macular plug.12–22 All of these techniques have been reported to close persistent MHs successfully. Autologous ILM transplantation or closing holes with a macular plug have been recently used techniques for closing large MHs with high success rates.14–16,22 However, these techniques have some drawbacks, such as requiring surgical skill for obtaining retinal or ILM free flaps and the possibility of flap loss. Furthermore, a secondary surgery is required to remove the intraocular tamponade with heavy silicone oil use. Therefore, there is no definitive surgical treatment of persistent MHs. Wong described a technique that used the elastic properties of retina and had a 100% closure rate.11 In our study, we modified this technique. First, after forming a shallow RD by injecting subretinal balanced salt solution from three points, we performed small aspirations around the edges of the hole instead of the retinal massage to avoid further retinal damage. This maneuver allowed us to approximate the edges of the hole more easily using a mechanism that has been described by Rishi et al.23 These authors noted that a persistent MH with a cuff-off subretinal fluid was closed using repeating gas insufflation. They concluded that a subretinal cuff-off fluid appeared to break down the adhesions between the hole edges and the RPE and facilitate the centripetal contraction of the edges of the hole. However, unlike Rishi et al., we performed a second step by aspirating the subretinal fluid with a 39-gauge /41-gauge cannula to attach the fovea (because the fovea was detached) and to increase the likelihood of apposition of the edges of the hole. Indeed, in 70% of eyes, the MHs were observed as being closed during the surgical intervention. In the postoperative OCT sections, all of the holes — even the very large ones that have base diameter greater than 2,000 μm — were closed postoperatively and remained closed during the follow-up period. For example, Figure 4A shows the preoperative OCT section of a 19-year-old patient with a very large and persistent MH. The patient developed MH following RD surgery. The epiretinal membrane at the borders of the area of ILM removal may have been responsible for the failure of primary surgery (Figures 1, 2, and 3). Our modified surgical technique succeeded in closing even this very large persistent MH (Figure 4B). These findings demonstrated the efficacy of our modified surgical technique (Figures 5A and 5B). Although we achieved a 100% success rate with this technique, additional studies with larger cohorts of patients, that are comparable to other techniques such as the inverted ILM flap technique or the others noted above are required to determine the efficacy of our technique.
(A) Preoperative optical coherence tomography sections of the 19-year-old patient. Preoperative hole base diameter was 2,200 μm. (B) At postoperative month 6, the hole remained closed. Preoperative best spectacle-corrected visual acuity (BSCVA) was less than 20/200. BSCVA at 6 months postoperatively was 20/200.
(A, B) The preoperative and postoperative optical coherence tomography sections of a 73-year-old patient with persistent macular hole. Preoperative base diameter was 1,066 μm.
The increase in visual acuity was limited despite successful closure of the holes. Limitation was related to the degeneration of the EZ in all patients, as reported by previous studies.23,24 Although, we were unable to evaluate the mean interval between visual loss (MH formation) and our surgical interventions, one possible cause of EZ loss in all patients might potentially have been the late surgical intervention. The cause of late surgical intervention may be that this new surgical modification was performed on a pool of persistent MH cases those were evaluated to be inoperable prior to this technique. Our study consisted of large MHs (range: 1,066 μm to 2,200 μm), which meant that most of the central cones were already lost another potentially limiting factor in terms of visual acuity gain.
In conclusion, we have described a modified technique that focuses on narrowing hole diameter by creating perihole RD from three points. This technique yielded a 100% hole closure rate in a set of 10 eyes with large, persistent MHs following initial vitrectomy and ILM peeling. Persistent or large MHs can be closed successfully with this technique. A good visual outcome may be obtained by applying this modified technique to primary large MHs, which may potentially remain opened following standard surgical interventions.
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Preoperative OCT Measurements of Macular Holes
|Minimum Hole Diameter (μm)||691 ± 98||500||812|
|Hole Base Diameter (μm)||1,604 ± 321||1,066||2,200|
Pre- and Postoperative (6-Month) Best Spectacle-Corrected Visual Acuities
|< 20/200 (n)||20/200 (n)||> 20/200 (n)|