Macular hole (MH) formation has been reported as a complication following pars plana vitrectomy (PPV). Although these are usually singular, development of multiple MHs is considered a very rare complication, with an incidence that ranges from 0.6% to 2.5%.1,5
Even though outer retinal degenerative changes are thought to be a predisposing factor,7 the main reported causes include mechanical surgical trauma, removal of the internal limiting membrane (ILM), contraction of residual ILM, or cystoid macular edema.1,3
Although most cases do not progress, others suffer progressive visual loss due to foveal involvement, and despite improvements in surgical techniques, such lens capsular graft as proposed by Cheng et al., their treatment remains challenging.2
We report the first case of multiple eccentric MH (MEMH) associated with retinal detachment following an uneventful PPV and epiretinal membrane (ERM) peel successfully managed by autologous capsular lens graft plugged into each one of the MHs.
A 58-year-old female previously diagnosed with retinitis pigmentosa complained of gradual deterioration of her right eye visual acuity (VA). Her mother and siblings also had retinitis pigmentosa. On presentation, her best-corrected VAs were 20/40 and 20/25 in her right (Spheric equivalent −1.50 diopters [D]) and left eyes (Spheric equivalent +0.50 D), respectively. Non-contact biometry showed right axial length of 22.21 mm in the right eye and 21.6 mm in the left eye. Anterior chamber depths were 2.39 mm and 2.20 mm in the right and left eyes, respectively.
Slit-lamp examination revealed mild cataract formation in both eyes, and dilated fundus examination confirmed the presence of paravascular bone-spicule pigmentary changes and tessellated fundus appearance without evidence of posterior staphyloma in both eyes, but foveoschisis and ERM formation in the right eye.
However, 4 months later the patient's right VA dropped to 20/400 due to progression of her foveoschisis (Figure 1A) and an uneventful PPV and MembraneBlue-Dual (DORC, Zuidland, The Netherlands) assisted ERM peel was performed with Tano 23-gauge microforceps (DORC, Zuidland, The Netherlands).
(A) At presentation, multicolor retinography in the right eye illustrates tessellated fundus with epiretinal membrane and in macular optical coherence tomography (OCT). (B) After uneventful pars plana vitrectomy, OCT shows four eccentric macular holes (red arrows) with retinal detachment.
(A) Two months after autologous anterior lens capsule transplantation, the holes are closed and retina reattached, the largest hole is closed with a residual fragment of the capsule. (B) The superior holes are closed without remnants of the lens capsule flap.
At the time of surgery, no evidence of retinal injury was observed; however, 6 weeks later, despite having improved her VA to 20/200, four eccentric MHs were seen by means of optical coherence tomography (OCT) (Figure 1B).
Having initially declined further treatment, 4 weeks later, the patient developed a macula-off retinal detachment and her vision deteriorated to counting fingers, and a combined PPV and cataract surgery was proposed. Conventional phacoemulsification was performed with trypan blue (DORC, Zuidland, The Netherlands) dye to stain the lens capsule for enhanced visibility during grafting. The stained anterior capsular flap was preserved under viscoelastic (Provisc; Alcon, Fort Worth, TX). During PPV, no residual internal limiting membrane (ILM) was visualized using the MembraneBlue-Dual dye, so we decided to use the capsular fragments as grafts. The capsule was cut into five pieces with the 25-gauge curved microscissors (Alcon / Grieshaber, Switzerland). Fluid-air exchange and a gentle aspiration of subretinal fluid through the largest MH were performed. Under complete fluid-air exchange, one graft was plugged into each hole with the Tano 25-gauge microforceps. Finally, 12% C3F8 gas tamponade was used. The patient was asked to maintain a head-down position for 3 weeks.
Eight months after surgery, the retina remained reattached with resolution of the foveal retinoschisis and her VA improved to 20/200. In addition to this, OCT scanning confirmed full closure of all four holes, with complete capsular graft reabsorption in two holes (Figures 1C and 1D).
ILM and lenticular capsule are both considered basement membranes, and their use has demonstrated to improve the anatomical and visual outcomes of patients who undergo MH surgery.2,4
Two groups have shown that lens capsular grafting facilitates anatomical closure. Chen and Yang reported in a series of 20 cases a closure rate of 75%.2 Similarly, Peng et al. described a 90% closure rate when combined with autologous blood. Due to initial concerns regarding possible lens epithelial proliferation Peng et al. suggested to soak the flaps in sterilized distilled water for 10 minutes.4 Other possible adverse side effects may include intraocular inflammation and graft rejection; however, none of these complications have been reported.
After 8 months of follow-up, no complications related to the procedure were observed in our patient.
The natural history of eccentric MHs is often variable and are usually not treated, but in these cases with visual impairment due to foveal involvement or retinal detachment, as in our case, a surgical approach is recommended and remains challenging.1,5
To our knowledge, this is the first reported case of multiple MHs with or without retinal detachment successfully treated with this technique.
We conclude that PPV combined with autologous lens capsular graft and gas tamponade is a safe and effective option in improving visual and anatomical outcomes in multiple MHs.
- Brouzas D, Dettoraki M, Lavaris A, Kourvetaris D, Nomikarios N, Moschos MM. Postoperative eccentric macular holes after vitrectomy and internal limiting membrane peeling. Int Ophthalmol. 2017;37(3):643–648. doi:10.1007/s10792-016-0320-6 [CrossRef]
- Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies. Retina. 2016;36(1):163–170. doi:10.1097/IAE.0000000000000674 [CrossRef]
- Kiilgaard JF, Wiencke AK, Scherfig E, Prause JU, la Cour M. Transplantation of allogenic anterior lens capsule to the subretinalspace in pigs. Acta Ophthalmol Scand. 2002;80(1):76–81. doi:10.1034/j.1600-0420.2002.800115.x [CrossRef]
- Peng J, Chen C, Jin H, Zhang H, Zhao P. Autologous lens capsular flap transplantation combined with autologous blood application in the management of refractory macular hole. Retina. 2017Oct17. doi:10.1097/IAE.0000000000001830 [CrossRef]. [Epub ahead of print]
- Sandali O, El Sanharawi M, Basli E, et al. Paracentral retinal holes occurring after macular surgery: Incidence, clinical features, and evolution. Graefes Arch Clin Exp Ophthalmol. 2012;250(8):1137–1142. doi:10.1007/s00417-012-1935-6 [CrossRef]