Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Closure of Large Chronic Macular Hole by Scleral Imbrication and Retinal Expansion

Yodpong Chantarasorn, MD; Patrinee Thamsriswadi, MD

Abstract

BACKGROUND AND OBJECTIVE:

The purpose of this study is to describe a new technique for the treatment of large, chronic macular hole (MH) using scleral imbrication and retinal expansion and to report the outcomes of MH closure.

PATIENTS AND METHODS:

This retrospective study demonstrates a procedure for correcting the disproportion between an area of stiff neurosensory retina and the inner scleral wall. Baseline MH parameters were collected. MH closure rate, visual outcomes, and biometry were reported at 6-month follow-up.

RESULTS:

MH closure was achieved in six out of seven patients (85.7%). Mean minimal hole diameter, base hole diameter, and MH index were 712 μm ± 136.8 μm, 1,440 μm ± 444 μm, and 0.27 μm ± 0.08 μm, respectively. At 6-month follow-up, median logarithm of the minimum angle of resolution (logMAR) corrected distance visual acuity significantly improved from 1.2 (interquartile range [IQR] = 1.0 to 1.6) preoperatively to 0.7 (IQR = 0.58 to 0.8) postoperatively (P = .018; Wilcoxon signed-rank test).

CONCLUSION:

This technique provided both satisfactory hole closure rates and acceptable structural outcomes.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:e57–e64.]

Abstract

BACKGROUND AND OBJECTIVE:

The purpose of this study is to describe a new technique for the treatment of large, chronic macular hole (MH) using scleral imbrication and retinal expansion and to report the outcomes of MH closure.

PATIENTS AND METHODS:

This retrospective study demonstrates a procedure for correcting the disproportion between an area of stiff neurosensory retina and the inner scleral wall. Baseline MH parameters were collected. MH closure rate, visual outcomes, and biometry were reported at 6-month follow-up.

RESULTS:

MH closure was achieved in six out of seven patients (85.7%). Mean minimal hole diameter, base hole diameter, and MH index were 712 μm ± 136.8 μm, 1,440 μm ± 444 μm, and 0.27 μm ± 0.08 μm, respectively. At 6-month follow-up, median logarithm of the minimum angle of resolution (logMAR) corrected distance visual acuity significantly improved from 1.2 (interquartile range [IQR] = 1.0 to 1.6) preoperatively to 0.7 (IQR = 0.58 to 0.8) postoperatively (P = .018; Wilcoxon signed-rank test).

CONCLUSION:

This technique provided both satisfactory hole closure rates and acceptable structural outcomes.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:e57–e64.]

Introduction

Idiopathic full-thickness macular hole (MH) is a disorder characterized by a defect of neurosensory retina at the fovea. It has an annual incidence of 8.7 eyes per 100,000 population and is strongly associated with female sex and increasing age.1–2 Tangential and anterior-posterior forces play an important role in the pathogenesis; therefore, vitrectomy with internal limiting membrane (ILM) peeling is the typical procedure for MH repair.3 If left untreated, MH can progress to the chronic stage, which responds poorly to surgery. The predictive factors for poor closure rate in chronic MH include low MH index (MHI),4 wide base diameter (BD) and large minimal hole diameter (MD),5–6 and greater than 3.4 years' onset duration.7 Several techniques involving ILM manipulation have been proposed to repair large, chronic MH by relieving tangential contraction, promoting proliferation of glial cells and late photoreceptor migration.8–10 Patching MH with transplanted autologous intraocular tissues including ILM, lens capsule, and neurosensory retina has also been developed for such challenging conditions.11–13

Nevertheless, an ideal goal for achieving visual improvement requires restoration of the original foveal structure at the defect site. In order to accomplish such a goal, two strategies for reversing the mechanisms of pathogenesis of a large chronic MH, a disproportion between areas of stiff neurosensory retina and the inner scleral wall, need to be carried out. The first strategy, as demonstrated by recent studies, is an induction of macular detachment, which allows the centripetal extension of the hole edge by removing the adhesive force between the retinal pigment epithelium (RPE) and photoreceptor outer segments.14–18 However, horizontal elongation of the central retina has a certain limit of 27% after ILM removal.19 Therefore, a large chronic MH still has a chance of closure with thin fovea.8,17–18 The second strategy is a reduction of contact area beneath the detached retina. A scleral shortening procedure using temporal scleral imbrication seems to be a reasonable approach. This concept has also shown to be safe and promising in eyes with myopic traction maculopathy.20 This procedure creates a relatively excess neurosensory retina for hole apposition by flattening the posterior eye wall curvature.

In this study, we report postoperative outcomes at 6-month follow-up from a new surgical technique for large chronic MH.

Patients and Methods

Ethics committee approval was obtained, and the principles for this research were based on the Declaration of Helsinki, the Belmont Report, CIOMS guideline, and the International Conference on Harmonization Good Clinical Practice. Informed consent was obtained from patients after the potential risks and benefits of the surgery had been discussed. Medical charts were retrospectively reviewed starting from July 2015 to March 2017. We included patients with stage 3 to 4 large MH with duration of more than 1 year and vitrectomized eyes with persistent MH. All patients had one of the following predictive parameters of poor outcome: MHI less than 0.5, MD between edges greater than 600 μm, and BD greater than 1,200 μm.4,21 Exclusion criteria consisted of hyperopic eyes with axial length (AXL) of less than 22.0 mm, eyes with scleral thinning, patients who underwent prior placement of a scleral buckle, and patients with systemic disease who were not eligible for surgery.

Primary outcome was closed MH without foveal neurosensory retinal defect whereas secondary outcomes were improvement of corrected distance visual acuity (CDVA) and other refractive results. CDVA was measured by Early Treatment Diabetic Retinopathy Study (ETDRS) chart. The decimal visual acuity (VA) of counting fingers at 30 cm was converted to 0.014.22 Other data collected included prior diagnosis, onset duration, AXL change measured by immersion A-scan ultrasonography, diplopia tested by Worth 4-dot test, change of spherical equivalent, and digital fundus photography. All MH parameters were measured by spectral-domain optical coherence tomography (OCT) (Spectralis OCT2; Heidelberg Engineering, Heidelberg, Germany). Preoperative data included BD, MD, MHI, and Gass MH stage. Presence of MH closure and postoperative central foveal thickness were also obtained. Data for potential complications, such as induction of hyperopic astigmatism, ocular hypertension, reopening of MH, and endophthalmitis, were collected at every visit (preoperative visit and postoperative visits at 1, 3, and 6 months).

All patients were operated on under retrobulbar block by one surgeon (CY) at Vajira Hospital, Navamindradhiraj University. To summarize the technique, three rectus muscles (superior rectus, lateral rectus, and inferior rectus) were hooked. The globe was nasally displaced in order to expose the temporal sclera. Two mattress sutures of 5-0 polyester suture (Surgidac; Covidien, Dublin, Ireland) were preplaced in the superotemporal and inferotemporal quadrants. The anterior border of each suture was situated at the equator (8 mm to 10 mm from limbus) whereas each bite width was 6 mm as we aimed an axial length shortening at between 1.0 mm to 1.5 mm and approximately temporal displacement of foveal RPE at 500 μm.23,24

Phacoemulsification with intraocular lens implantation was done in patients with crystalline lens. Standard 23-gauge pars plana vitrectomy was performed by using high-speed vitrectomy system (Stellaris PC; Bausch + Lomb, Bridgewater, NJ). The remaining ILM was stained by brilliant blue G (Geuder, Heidelberg, Germany) and peeled up to the major vascular arcade. Consequently, an induction of the macular detachment was gently performed by subretinal injection of a balanced salt solution shortly after decreasing the infusion pressure to 22 mm Hg. The retinotomy was initiated at the temporal horizontal raphe in order to avoid nerve fiber layer damage. A 41/23-gauge subretinal needle with polyamide tip (Dutch Ophthalmic, MedOne, Zuidland, Netherlands) connected with the viscous fluid injection of the vitrectomy machine infused the balanced salt solution at the maximum injection pressure of 10 PSI. The anterior border of the induced retinal detachment was limited to the equator (Figure 1A, right) in order to avoid the postoperative macular fold caused by redundant retina. The subretinal needle was removed once the detached retina reached the MH edge (Figure 1A, left). A manual macular massage was not performed in this study in order to preserve the integrity of the photoreceptors.

A description of surgical procedures. (A) Intraoperative view demonstrates an induction of the macular detachment at the temporal horizontal raphe (left). Cross-sectional schematic image shows both a detached retina and the preplaced suture (right). (B) Intraoperative view reveals scleral tucking line (black arrows) after suture tightening (left). Cross-sectional schematic image presents a shortening of temporal sclera after suture tightening in relation to the previous outline (dotted line). Note that the macular hole becomes smaller compared with the preoperative condition (1A, right).

Figure 1.

A description of surgical procedures. (A) Intraoperative view demonstrates an induction of the macular detachment at the temporal horizontal raphe (left). Cross-sectional schematic image shows both a detached retina and the preplaced suture (right). (B) Intraoperative view reveals scleral tucking line (black arrows) after suture tightening (left). Cross-sectional schematic image presents a shortening of temporal sclera after suture tightening in relation to the previous outline (dotted line). Note that the macular hole becomes smaller compared with the preoperative condition (1A, right).

Ocular hypotony was induced to facilitate inward scleral tucking. The scleral area between the two needle passes was pressed by the iris spatula shortly before suture tightening (Figure 1B). A fluid-air exchange was completed slowly and repeated three times for retinal massage. Air was exchanged for 16% C3F8 before closure of the sclerotomies and conjunctiva. We instructed all patients to maintain prone position for 1 week postoperatively. (A video of the detailed surgical procedures is available below.)


Despite having a small sample size in this study, a statistical analysis of visual outcomes was analyzed using Stata, version 13 (StataCorp, College Station, TX). Moreover, qualitative data are described in the tables.

Results

This retrospective case series comprised one eye each of seven patients. Baseline characteristics of participants and results are shown in Tables 1 and 2, respectively. At 6-month follow-up, MH closure was found in six patients (85.7%) (Figure 2). Mean CDVA improved from 20/320 (range 20/200 and 20/1,280) preoperatively to 20/100 (range 20/63 and 20/200) postoperatively. Wilcoxon signed rank test indicated that postoperative CDVA (median logarithm of the minimum angle of resolution [logMAR]) ranks, median = 0.7 (interquartile range [IQR]= 0.58 to 0.8) were statistically better than preoperative CDVA (logMAR) ranks, median = 1.2 (IQR = 1.0 to 1.6), (Z = −2.36, P = .018). The median operative time was 77 minutes (range 72 to 85 minutes). A fine subretinal gliosis starting from the puncture site was found in case 2 (Figure 3A, right). A common postoperative complication was retinal hemorrhage at the puncture site, which generally recovered within 6 weeks (Figure 3B, right). Only case 5 had postoperative flat open configuration with smaller MH diameter of 308 μm (Figure 2E). In this case, we were unable to separate the hole's edge from the underlying RPE due to the firm attachment of a preoperative marginal scar (Figure 3C). None of the patients had experienced diplopia, scleral perforation, retinal fold, or endophthalmitis by the time of their 6-month follow-up.

Baseline Characteristics Obtained From Participants

Table 1:

Baseline Characteristics Obtained From Participants

Postoperative Results Obtained From Data on Both Groups at 6-Month Follow-Up

Table 2:

Postoperative Results Obtained From Data on Both Groups at 6-Month Follow-Up

A demonstration of both preoperative optical coherence tomography (OCT) images with macular hole parameters on left column and postoperative OCT images at 6-month follow-up on right column. Case numbers were indicated by using consecutive letters on the left upper corner of each photo.

Figure 2.

A demonstration of both preoperative optical coherence tomography (OCT) images with macular hole parameters on left column and postoperative OCT images at 6-month follow-up on right column. Case numbers were indicated by using consecutive letters on the left upper corner of each photo.

The illustrations of preoperative fundus photographs (left column) and postoperative complications (right column). (A) At 3-month follow-up, a strand of subretinal gliosis (black arrow) was detected on the inferotemporal side of the macula in case 2. (B) At 1-month follow-up, faint retinal hemorrhage and pigmentary change (black arrow) were observed at the puncture site in case 3. (C) Preoperative photograph of case 5 demonstrates chronic macular hole with marginal scar. Early postoperative image shows flat open configuration with smaller macular hole and parafoveal hemorrhage, resulted from the process of internal limiting membrane removal

Figure 3.

The illustrations of preoperative fundus photographs (left column) and postoperative complications (right column). (A) At 3-month follow-up, a strand of subretinal gliosis (black arrow) was detected on the inferotemporal side of the macula in case 2. (B) At 1-month follow-up, faint retinal hemorrhage and pigmentary change (black arrow) were observed at the puncture site in case 3. (C) Preoperative photograph of case 5 demonstrates chronic macular hole with marginal scar. Early postoperative image shows flat open configuration with smaller macular hole and parafoveal hemorrhage, resulted from the process of internal limiting membrane removal

Discussion

In recent years, several techniques have been developed aiming at closure of chronic MH. ILM removal alone does not appear to generate enough retinal elasticity for chronic MH closure because the closure rate is only 46.7% using enlargement of the ILM rhexis.25 Apart from the standard procedure including vitrectomy and ILM removal,26–27 covering the MH with intraocular basement membrane seems to reinforce the closure rate of a larger hole by promoting glial cell proliferation.8,11,28 Nonetheless, neither the actual histology of postoperative foveal tissue nor a predictive factor for late photoreceptor migration has ever been confirmed. Some postoperative images from previous studies also showed closed MH with thin fovea and disorganized ellipsoidal layer.8,11,28 Patching a highly myopic MH by autologous neurosensory retina has been reported in one case; however, improvement of postoperative VA is a matter of concern because of the lower density of the graft's cone cells compared with original foveal tissue.12 After all, any of these transplanted tissues could potentially dislocate after surgery.

The macular undermining technique, first described by Oliver and Wojcik,16 has been further developed by several authors in order to extend the retina over the flat opening hole. Even though there is no anatomic bridge between the RPE microvilli and the outer segment of photoreceptors, these two structures are held together by the electrostatic forces and an intercellular matrix.14,15 Consequently, a mechanical separation of RPE and photoreceptors should allow a better expansion of the retina. A previous study using macular detachment technique alone for patients with mean hole diameter of 653 μm reported MH closure with retained foveal tissue at the rate of 50% and mean improvement of 16 ETDRS letters.18

Although our study included patients with a large mean baseline MD and BD of 712 μm ± 136.8 μm and 1,440 μm ± 444 μm, respectively, and low MHI of 0.27 ± 0.08, all cases with closed MH had some layers of neurosensory retina on fovea with a mean central foveal thickness of 186.8 μm ± 26.4 μm. Theoretically, the MH should be postoperatively covered by the original foveal tissue because we did not perform ILM transplantation in any participants. Despite a concern about retinal cell damage from this procedure, the theory of photoreceptor recovery is supported by improvement of VA after repairing the macula-off retinal detachment.29–31 In case 5, we hypothesize that failure to the detach MH edge intraoperatively may relate to a flat open configuration.

Scleral imbrication, earlier described as a primary treatment for retinal detachment32 and a combined procedure for limited macular translocation,33 was later modified as tucking of the middle portion of the temporal sclera. Recent studies reported the effectiveness of this procedure in treating myopic MH-retinal detachment and myopic traction maculopathy by reducing the posterior scleral area. The posterior scleral apex was also temporally shifted for approximately 600 μm per 6-mm imbrication.24 An effect of mean axial length shortening on emmetropic eyes was approximately 1.5 mm, which was greater than the effect of myopic eyes.23 This effect is slightly higher than the mean result of our paper (0.75 mm) because three cases of ours (42%) had high axial myopia. Although this method is theoretically appealing, it has some unavoidable disadvantages, including induction of refractive errors and loss of peripheral photoreceptor cells inside the folded sclera.34

Given the results of this study, concurrent retinal expansion and scleral shortening procedure provided favorable postoperative structural outcomes after repairing chronic MH. MH closure rate (85.7%) and mean improvement of 50 ETDRS letters were comparable to previous studies.17,18 It is noteworthy that this VA improvement did not solely result from MH closure because the addition of cataract surgery was performed in cases 3 and 5. Interestingly, early postoperative continuities of external limiting membrane were detected in cases 1 and 3. This may explain the better visual outcomes of more than 20/80 because this finding was previously reported as an indicator for a good visual prognosis.35 After all, MH closure may not be directly associated with visual improvement, which was limited in our study. This may be due to other factors such as the disease chronicity and incapability of ellipsoidal layer restoration as seen in a prior study involving ILM flap technique.36

Drawbacks of this technique consisted of induction of hyperopic astigmatism and a long-term possibility of MH reopening from loose stitches. In addition, our procedure times are longer than standard MH surgery. This study's results cannot be generalized to traumatic MH because of the differences in the etiology of disease. Furthermore, the exact area of induced retinal detachment and the sutures' bite width are difficult to determine due to variations in MH parameters and AXL. However, despite some disadvantages, this technique should hypothetically bring the hole edge closer and can be augmented with other techniques, such as ILM inversion.

Finally, the fact that none of the study eyes had ILM inverting flap or ILM transplantation should reflect the true efficacy of this strategy. Adding these techniques to ours may improve postoperative clinical outcomes. Further study should be conducted prospectively by including a larger sample size.

References

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Baseline Characteristics Obtained From Participants

Case Sex/Age (Years) CDVA (logMAR) AXL (mm) Preoperative Clinical Setting MH Stage MD (µm) BD (µm) MHI
1 M/80 1.2 26.14 Post-vitrectomy + ILM removal N/A 549 1232 0.42
2 M/68 1.0 22.81 ERM 4 664 1,363 0.35
3 F/83 1.02 22.49 ERM 3 764 2,317 0.2
4 M/72 1.6 22.61 Post-vitrectomy + ILM removal N/A 665 1379 0.27
5 M/80 1.0 23.98 Scar at the MH's edge 4 676 1064 0.24
6 M/79 1.3 26.05 High myopia 4 908 1,206 0.21
7 F/76 1.85 24.22 High myopia 4 954 1,289 0.23
Median, IQR 79, 72–80 1.2, 1.0–1.6 23.98, 22.6–26.0 676, 664–908 1,289, 1,206–1,379 0.24, 0.21–0.35

Postoperative Results Obtained From Data on Both Groups at 6-Month Follow-Up

Case Closed MH/CFT (µm) CDVA (logMAR) Reduced AXL (mm) SE Change (D) Induced ATR (D) Complications
1 Yes/190 0.58 0.45 1.25 −0.25
2 Yes /238 0.7 0.69 1.5 −0.50 Subretinal gliosis
3 Yes /181 0.46 0.7 1.625 −2.75 Hemorrhage at puncture site
4 Yes /170 0.8 1.02 2.75 0
5 No 0.96 1.36 1.25 −0.75 Transient OHT
6 Yes /166 0.78 0.56 0.5 0 Hemorrhage at puncture site
7 Yes /176 0.7 0.53 1.25 −1.0
Median, IQR 178.5, 170–1901 0.7, 0.58–0.8, P = .0182 0.69, 0.53–1.02 1.25, 1.25–1.625 −0.5, −1.0–0
Authors

From the Department of Ophthalmology, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.

The authors report no relevant financial disclosures.

The authors would like to express their gratitude to Associate Professor Dean Eliott, who made a revision of this manuscript. They would also like to extend their appreciation to Mr. Jason D. Cullen, BSc, BA, for narrating the surgical video. Additionally, the completion of this study could not have been possible without the help of Dr. Chavanant Sumanasrethakul, who is the authors' consultant of methodology.

Address correspondence to Yodpong Chantarasorn, MD, Department of Ophthalmology, Vajira Hospital, Navamindradhiraj University, 681 Samsen St., Bangkok, Thailand, 10300; email: yodpong@nmu.ac.th.

Received: October 23, 2017
Accepted: February 27, 2018

10.3928/23258160-20180907-08

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