Pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling is the treatment of choice for a macular hole (MH).1 If the hole remains open after primary surgery, closure by autologous ILM transplantation can be attempted.2 However, detaching the ILM may be difficult in cases with extensive ILM peeling during previous surgeries. Moreover, if the free ILM flap is not large enough to fill the MH, the postoperative success rate of hole closure is low.3 Current treatment strategies for such cases include lens capsular flap transplantation or an autologous neurosensory retinal free flap.4,5 However, anterior lens capsules cannot be used after cataract surgery, and often, appropriately sized posterior capsule fragments cannot be obtained. Harvesting a retinal free flap is also associated with risk of bleeding and retinal detachment. Further complications caused by implanted neurosensory retinal tissues should be considered. To overcome these limitations, we suggest a new treatment technique involving the use of a contralateral autologous ILM free flap for closure of refractory MHs.
A 72-year-old woman presented with a 1-month history of sudden loss of vision in her right eye. Corrected visual acuity (VA) was 20/125 in the right eye (OD) and 20/400 in the left eye (OS). Funduscopy revealed central retinal vein occlusion and macular edema OD and a full-thickness 550-μm MH OS (Figure A). Corrected VA OD improved to 20/50 after two intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) injections. Total vitrectomy, wide ILM peeling, and intravitreal gas injection had not reduced the size of the retinal tissue defect OS at 4 months postoperatively (Figure). Therefore, partial vitrectomy and ILM autotransplantation were planned. However, additional ILM for the autologous flap could not be harvested because of previous extensive ILM peeling, and lens capsule transplantation could not be performed because almost no posterior capsule tissue remained. Consequently, a few small ILM fragments were obtained and implanted into the hole. The size of the MH decreased postoperatively, but the hole remained unclosed (Figure C). To address her recurrent macular edema OD, we performed an intravitreal triamcinolone injection, after which the edema decreased, and VA improved. After 4 months, the macular edema recurred and intravitreal triamcinolone injection was repeated, but this was unsuccessful because of the development of an epiretinal membrane (ERM). Therefore, we planned vitrectomy and membrane peeling OD and simultaneous surgery to treat the unclosed MH OS. Because we suspected that no transplantable flaps remained OS, we planned to transplant ILM tissue from the right eye to the patient's left eye. The surgical procedure was approved by the Institutional Review Board at our institution and written informed consent was obtained.
(A) Preoperative photograph of the left eye obtained by optical coherence tomography. (B) Four months after the first surgery, the full-thickness retinal tissue defect persisted. (C) Two months after the second surgery, the macular hole was smaller but had not closed. (D) Four months after the third surgery, the hole was closed.
On the day of surgery, after pars plana vitrectomy and removal of the ERM OD, we stained the ILM near the posterior pole using indocyanine green. The ILM was grasped with microforceps (Alcon, Fort Worth, TX) and peeled off in a circular fashion for approximately 2 disc diameters. Circular flaps around a half disc in diameter were obtained from the ILM of the residual posterior pole and stored in a sterile container containing balanced salt solution. Surgery on the right eye was completed after fluid-air exchange. For the left eye, after insertion of a three-port trocar, the ILM flap from the right was gently grasped with microforceps, moved to the posterior pole, and carefully implanted into the MH. The hole was then completely covered with the flap so that the retinal pigment epithelium in the hole would not be exposed to the vitreous cavity. After performing fluid-air exchange, the surgery on the left eye was completed by injecting 13% C3F8 (See Supplemental Video below). The patient was instructed to remain prone for 1 week. Four months postoperatively, the MH had disappeared and corrected VA was 20/50 OD and 20/125 OS (Figure D).
The present case revealed the usefulness of obtaining ILM through surgery of the contralateral eye when a proper free flap cannot be obtained from the operated eye. The mechanism of intractable MH closure through transplantation of an ILM from the contralateral eye is likely identical to those underlying inverted ILM flap and autologous ILM transplantations. Limitations of the described technique include inadequate follow-up time and unknown potential long-term complications. Furthermore, this technique can be used only in special cases where the contralateral eye can be operated. Despite these limitations, this study showed that, when obtaining a free ILM flap or a lens capsule fragment is difficult or impossible, successful closure of refractory MH is conceivable through contralateral autologous ILM transplantation. This is a useful method that can present another solution to surgeons who are trying to overcome such difficult situations. Future development of this technique may be directed for obtaining transplantable free flaps from the lens capsule of the contralateral eye or from other tissues, individuals, animals, or even artificial tissues.
- Spiteri Cornish K, Lois N, Scott NW, et al. Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole. Ophthalmology. 2014;121:649–655. doi:10.1016/j.ophtha.2013.10.020 [CrossRef]
- Morizane Y, Shiraga F, Kimura S, et al. Autologous transplantation of the internal limiting membrane for refractory macular holes. Am J Ophthalmol. 2014;157:861–869.e1. doi:10.1016/j.ajo.2013.12.028 [CrossRef]
- Chung CY, Wong DS, Li KK. Is it necessary to cover the macular hole with the inverted internal limiting membrane flap in macular hole surgery? A case report. BMC Ophthalmol.2015;15:115. doi:10.1186/s12886-015-0104-1 [CrossRef]
- Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies. Retina. 2016;36:163–170. doi:10.1097/IAE.0000000000000674 [CrossRef]
- Grewal DS, Mahmoud TH. Autologous neurosensory retinal free flap for closure of refractory myopic macular holes. JAMA Ophthalmol. 2016;134:229–230. doi:10.1001/jamaophthalmol.2015.5237 [CrossRef]