Standard surgeries for macular holes (MHs) were recently combined with inverted internal limiting membrane (ILM) flap technique in refractory MHs, highly myopic patients, and especially in MHs measuring greater than 400 μm,1–3 which would otherwise be left untreated or might have resulted in a poor anatomical closure.4–6 Other novel surgeries like temporal scleral imbrication, autologous blood with ILM, and autologous anterior or posterior lens capsule flap thus far have been reported as a case report or series of case reports7–9 and seem successful in the short term.10 Moreover, even in the inverted ILM flap technique, mechanisms of underlying visual acuity recovery are unclear.6 We present a case report of full closure and visual acuity improvement in a patient with macular hole of more than 700 μm by performing an autologous retinal free flap surgery, which was first successfully done by Grewal and Mahmoud for closure of refractory myopic MH.11
A 55-year-old patient presented with 20/200 best-corrected visual acuity (BCVA) of the left eye, previously symptomatic for 6 months. A large MH of 700 μm apex and 900 base measurement was confirmed by optical coherence tomography (OCT) (DRI OCT Triton; Topcon, Tokyo, Japan) (Figures 1a and 1b). Combined phacoemulsification and 23-gauge vitrectomy (Stellaris; Bausch + Lomb, Bridgewater, NJ) was performed since the surgery carried higher risk for cataract formation especially in that age group. ILM-blue (DORC, Zuidland, The Netherlands) was used for staining and ILM peeling was performed. The surgeon anticipated that ILM inverted flap technique may not be enough due to large defect and stiff retina around the MH. A neurosensory retina harvesting site of about disc diameter was selected superior to superotemporal arcade.11 Circular endodiathermy was used to mark the area and to diathermitize retinal vessels. Afterwards, laser was performed around retinal hole but not the transplant edges. During the flap harvesting the infusion pressure was increased from 30 mm Hg to 40 mm Hg. The flap was secured over the MH by perfluoro-n-octane heavy liquid (PFC) (Perfluoron; Alcon, Forth Worth, TX), gently tucked in below the edges of the MH utilizing soft tip needle and spatula. This bimanual maneuver was alleviated by chandelier light. Direct PFC-silicone oil (1,000 cs) exchange was performed aspirating PFC with the flute needle and gently securing the flap with the spatula until the oil covered the flap.11 The patient was positioned face-down for 3 days. At a weekly follow-up, MH was closed (Figure 2) and BCVA (+4.0 diopters [D]) was 20/80. At months 1 and 3, BCVA (+4.0 D) increased to 20/60 (Figures 3a and 4a). OCT first showed a hyperreflective area with no evident fovea (Figure 3b). Throughout follow-up, the graft incorporated and fovea formed (Figure 4b). Furthermore, OCTA showed normal circulation (Figure 5).
(a) Native fundus photo at the time of presentation. Macular hole (MH): the apex measurement of 700 μm and the base measurement of 900 μm; best-corrected visual acuity (BCVA): 20/200. (b) Optical coherence tomography scan at the time of presentation. MH: the apex measurement of 700 μm and the base measurement of 900 μm; BCVA 20/200.
Optical coherence tomography scan at 1-week follow-up with best-corrected visual acuity of 20/80. Silicone oil tamponade.
(Left) Native fundus photo with closed macular hole and harvested site; at 1-month follow-up with best-corrected visual acuity (BCVA) of 20/60. Silicone oil tamponade. (Right) Optical coherence tomography scan at 1-month follow-up with BCVA 20/60. Silicone oil tamponade.
(Left) Native fundus photo with closed macular hole and harvested site; at 3-month follow-up with best-corrected visual acuity (BCVA) of 20/60. Silicone oil tamponade. (Right) Optical coherence tomography scan at 3-month follow-up with BCVA of 20/60. Silicone oil tamponade.
Optical coherence tomography angiography at 3-month follow-up with normal retinal circulation. The top four boxes present en face sections: of the superficial retina, deep retina, superficial choriocapillaris, and deep choroid. Cross-sectional cut in the bottom was used to delineate en face cuts.
In our patient, retinal flap procedure appeared to be safe, yielded good anatomical closure and improved BCVA, which has also been described.11 We cannot exclude there was some eccentricity involved in BCVA both preoperatively and postoperatively. We carefully examined preop BCVA, which was as good as 20/200. Postoperatively, BCVA improved to 20/80 and 20/60 which regardless of possible element of eccentricity could not be achieved preoperatively. To our knowledge this technique was only described by Grewal and Mahmoud on a refractive myopic MH.11 Although the ILM inverted flap is a leading novel technique nowadays in complicated, refractive, and large MHs, there are circumstances when it may have unfavorable factors, such as a hard-to-obtain ILM due to its fragility or adherence, very large and old holes with stiff attached borders, myopic MH with stafilomas, etc. In such cases, a neurosensory flap could be used as an alternative. Since there are limited number of cases and follow-up, we cannot know long-term results. With ILM inverted flap techniques, there are many more studies published so far. It has been shown that ILM potentially acts not only as a scaffold by bridging the deficit of retinal tissue, but also ILM peeling induces retinal gliosis and glial cells placed on the hole may produce intermediate filaments, thus provoking tissue remodeling within MH.4,12 Accordingly, we may presume that along with serving like a possible better scaffold, a full-thickness retinal flap could have additional benefits such as the possibility to facilitate photoreceptor rearrangement, and even the incorporation of the flap's own photoreceptors. Therefore, there was a particular reason for choosing the harvesting place since we presumed that the temporal retina closer to arcades had a higher density of photoreceptors than the nasal retina. As far as the superior position, we believed there was a smaller risk of proliferative vitreoretinopathy due to better tamponade of upper quadrants. If we went more posteriorly, we could have created more central scotoma, and in more anteriorly situated case, the concern was lower density of photoreceptors. Electroretinogram and other tests may show whether the flap's photoreceptors continue functioning within the flap itself or may be even further stimulated in new microenvironment. OCTA clearly demonstrated the viability of the flap and the underlying retinal pigment epithelium. Along with the flap, we have also transplanted ILM on the flap itself and probably maintained all its healing properties previously described.12 Nowadays, most patients undergo the surgery earlier and are successfully treated. Furthermore, even those who do not have primarily closed MHs are then operated by the ILM inverted flap technique, which has already proven to be safe and effective.1,4 Additionally, possible complications such as iatrogenic tears of peripheral retina or even retinal detachment due to harvesting of retinal flap makes ILM inverted flap surgery much more appealing. However, we believe the retinal flap technique may present an alternative in cases with stiff-edged, large MHs and, if done by an experienced surgeon and planned ahead, it could have a low complications rate. Viability of graft itself is significant for further investigations, even if the vision may not improve in other possible cases. Nevertheless, before recommending it to be routinely utilized in clinical practice, we strongly caution on careful patient selection. Although it is possible to use gas for the tamponade, we used silicone oil, as this was our first case and the oil enabled follow-up of the vision recovery and closure by OCT in early follow-up intervals. We removed silicon oil 6 months postoperatively with BCVA of +1.0 D stable at 20/60.
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- 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. doi:10.1016/j.ajo.2013.12.028 [CrossRef]
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- Fujikawa M, Kawamura H, Kakinoki M, et al. Scleral imbrication combined with vitrectomy and gas tamponade for refractory macular hole retinal detachment associated with high myopia. Retina. 2014;34:2451–2457. doi:10.1097/IAE.0000000000000246 [CrossRef]
- Lai CC, Chen YP, Wang NK, et al. Vitrectomy with internal limiting membrane repositioning and autologous blood for macular hole retinal detachment in highly myopic eyes. Ophthalmology. 2015;122(9):1889–1898. doi:10.1016/j.ophtha.2015.05.040 [CrossRef]
- Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies. Retina. 2016;36:163–70. doi:10.1097/IAE.0000000000000674 [CrossRef]
- Yepez JB, Murati FA, De Yepez J, et al. . Anterior lens capsule in the management of chronic full-thickness macular hole. Retin Cases Brief Rep. 2016 ; doi:. [Epub ahead of print] doi:10.1097/ICB.0000000000000513 [CrossRef]
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- Kase S, Saito W, Mori S, et al. Clinical and histological evaluation of large macular hole surgery using the inverted internal limiting membrane flap technique. Clin Ophthalmol. 2016;16:9–14. doi:10.2147/OPTH.S119762 [CrossRef]