Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

A Technique for Closing Challenging Macular Holes

Robert A. Sisk, MD, FACS

Abstract

BACKGROUND AND OBJECTIVE:

To describe a new technique for closing challenging macular holes (MHs).

PATIENTS AND METHODS:

The technique involves vitrectomy with internal limiting membrane (ILM) peeling, isolating the macula under perfluorocarbon liquid, alternating scraping of the retina toward the MH, aspirating fluid from the MH until closure is achieved intraoperatively, and sealing the MH with an inverted ILM flap or autologous ILM free flap. Gas or oil tamponade is used to prevent rehydration of the MH.

RESULTS:

Covering the MH with ILM scaffolding by the inverted flap technique or autologous ILM free flap promoted closure of large MHs by photoreceptor layer migration rather than gliosis. Iatrogenic macular trauma from manipulation produced funduscopic and optical coherence tomography changes but did not preclude significant vision improvement.

CONCLUSIONS:

ILM scaffolding over the surgically reduced MH enhanced surgical closure by photoreceptor migration. Although anatomic success resulted in improvement in visual acuity, further study is required regarding long-term outcomes.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:450–452.]

Abstract

BACKGROUND AND OBJECTIVE:

To describe a new technique for closing challenging macular holes (MHs).

PATIENTS AND METHODS:

The technique involves vitrectomy with internal limiting membrane (ILM) peeling, isolating the macula under perfluorocarbon liquid, alternating scraping of the retina toward the MH, aspirating fluid from the MH until closure is achieved intraoperatively, and sealing the MH with an inverted ILM flap or autologous ILM free flap. Gas or oil tamponade is used to prevent rehydration of the MH.

RESULTS:

Covering the MH with ILM scaffolding by the inverted flap technique or autologous ILM free flap promoted closure of large MHs by photoreceptor layer migration rather than gliosis. Iatrogenic macular trauma from manipulation produced funduscopic and optical coherence tomography changes but did not preclude significant vision improvement.

CONCLUSIONS:

ILM scaffolding over the surgically reduced MH enhanced surgical closure by photoreceptor migration. Although anatomic success resulted in improvement in visual acuity, further study is required regarding long-term outcomes.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:450–452.]

Introduction

Despite generally high surgical success rates, a minority of full-thickness macular holes (MHs) remain challenging to close. Recent analysis supports the covering or filling of larger MHs with internal limiting membrane (ILM) scaffolding to facilitate closure and improve visual and anatomic outcomes.1 In one recent series, drainage of fluid from the MH by subretinal cannula produced superior vision outcomes compared to the inverted flap technique.2 In this modified technique, we utilize the advantages of both techniques. This technique is not recommended as the primary procedure for small or medium-sized idiopathic macular holes.

Technique

After pars plana vitrectomy (PPV), the ILM is stained with indocyanine green (ICG) diluted in 20 mL 5% dextrose solution for 15 seconds to provide an intense green stain. The ILM is peeled with temporal sparing, and then perfluorocarbon liquid (PFCL) tamponade isolates the aqueous phase within the MH. A membrane scraper centripetally migrates subretinal fluid (SRF) and retinal tissue from the peripheral macula gradually toward the MH, taking advantage of retinal elasticity.3 Scraping is avoided over the papillomacular bundle. Fluid is drained from the MH under PFCL with a subretinal cannula (38-gauge outer diameter polyimide tip) to produce a progressively more elliptical and, ultimately, slit-like configuration of the MH. The maneuvers of scraping and aspirating are repeated until the MH is closed under the PFCL. The temporal ILM flap is peeled to the edge of the MH and placed over or tucked into the MH to seal it (Figure 1; see Supplemental Video 1 below).4 If the ILM has been peeled from a prior surgery, an autologous ILM flap is harvested from the margin of the prior staining, dragged under the PFCL to the MH and used to cover or plug it (Figure 2; see Supplemental Video 2 below). A fluid-air exchange is performed to remove all the aqueous down to the PFCL bubble. Three to 5 minutes are allowed for aqueous to reaccumulate posteriorly before removing it again to the PFCL bubble. This minimizes rehydration of the MH and maximizes tamponade. Finally, the PFCL bubble is slowly removed from the anterior margin centripetally. A drop of viscoelastic can be used to cover the ILM free flap if gas tamponade is planned.5 Alternatively, direct perfluorocarbon-silicone oil exchange can be performed. Patients are immediately placed in a prone (or nasal retina side down position if under general anesthesia) for 30 minutes after the procedure and remain face-down for 1 week or until MH closure is demonstrated by SD-OCT.

An 11-year-old male with large traumatic macula hole (MH) associated with choroidal rupture and subretinal hemorrhage (SRH) failed to have hole closure with 6 weeks of observation. It measured 941 μm at its smallest diameter and 4,403 μm at its largest diameter at the base, including subretinal fluid. Ultrawide-field color fundus photography before (A) and 1 month after (C) MH repair with modified Karabas technique with silicone oil tamponade and 1-week face-down positioning. Ultrawide-field fundus autofluorescence before (B) and 1 month after (D) MH repair showed reduction in macular hypoautofluorescence after drainage of SRH and closure of MH. Spectral-domain optical coherence tomography (SD-OCT) horizontal foveal raster scans before (E) surgery show large MH with SRH associated with choroidal rupture. SD-OCT scans 1 day (F) and 1 month (G) shows ILM flap (*) is replaced by photoreceptors with continued healing. Preoperative visual acuity improved from 20/400 to 20/100 at 4 months postoperatively. See Supplemental Video 1, available at www.healio.com/OSLIRetina.

Figure 1.

An 11-year-old male with large traumatic macula hole (MH) associated with choroidal rupture and subretinal hemorrhage (SRH) failed to have hole closure with 6 weeks of observation. It measured 941 μm at its smallest diameter and 4,403 μm at its largest diameter at the base, including subretinal fluid. Ultrawide-field color fundus photography before (A) and 1 month after (C) MH repair with modified Karabas technique with silicone oil tamponade and 1-week face-down positioning. Ultrawide-field fundus autofluorescence before (B) and 1 month after (D) MH repair showed reduction in macular hypoautofluorescence after drainage of SRH and closure of MH. Spectral-domain optical coherence tomography (SD-OCT) horizontal foveal raster scans before (E) surgery show large MH with SRH associated with choroidal rupture. SD-OCT scans 1 day (F) and 1 month (G) shows ILM flap (*) is replaced by photoreceptors with continued healing. Preoperative visual acuity improved from 20/400 to 20/100 at 4 months postoperatively. See Supplemental Video 1, available at www.healio.com/OSLIRetina.

A 55-year-old female whose right eye (OD) underwent conventional macular hole (MH) surgery with vitrectomy, internal limiting membrane (ILM) peeling, and 20% sulfur hexafluoride tamponade failed to have hole closure despite good compliance to 1-week postoperative face-down positioning. Spectral-domain optical coherence tomography (SD-OCT) horizontal raster scans through the fovea (A) before and (B) 1 week after first surgery. Preoperatively, the MH measured 384 μm at its smallest dimension and 1,587 μm at the base. She underwent the repair with autologous ILM free flap and face-down positioning for 1 week. SD-OCT scans (C) 1 month and (D) 4 months (1 month after silicone oil removal) show hole closure and progressive reconstitution of the foveal photoreceptor layer. Fundus autofluorescence imaging (E) before the procedure and (F) 4 months postoperatively show conversion of foveal hyperautofluorescence to isoautofluorescence. Preoperative visual acuity of 20/200 improved to 20/60 at 4 months postoperatively. See Supplemental Video 2, available at www.healio.com/OSLIRetina.

Figure 2.

A 55-year-old female whose right eye (OD) underwent conventional macular hole (MH) surgery with vitrectomy, internal limiting membrane (ILM) peeling, and 20% sulfur hexafluoride tamponade failed to have hole closure despite good compliance to 1-week postoperative face-down positioning. Spectral-domain optical coherence tomography (SD-OCT) horizontal raster scans through the fovea (A) before and (B) 1 week after first surgery. Preoperatively, the MH measured 384 μm at its smallest dimension and 1,587 μm at the base. She underwent the repair with autologous ILM free flap and face-down positioning for 1 week. SD-OCT scans (C) 1 month and (D) 4 months (1 month after silicone oil removal) show hole closure and progressive reconstitution of the foveal photoreceptor layer. Fundus autofluorescence imaging (E) before the procedure and (F) 4 months postoperatively show conversion of foveal hyperautofluorescence to isoautofluorescence. Preoperative visual acuity of 20/200 improved to 20/60 at 4 months postoperatively. See Supplemental Video 2, available at www.healio.com/OSLIRetina.

Discussion

In practice, overly aggressive scraping (retinoplasty) can traumatize the retina or retinal pigment epithelium (RPE). The subretinal cannula can damage the RPE by direct blunt trauma or aspiration, resulting in depigmentation of the fovea. Visual acuity recovered if photoreceptors closed the base of the MH even if the RPE lost pigment funduscopically or as transmission defects on spectral-domain optical coherence tomography. Early postoperative appearance of the residual MH width is variable, from closed at day 1 to open with ILM coverage. As long as ILM covers the residual MH, the MH may ultimately close by 1 month postoperatively.

References

  1. Rossi T, Gelso A, Costagliola C, et al. Macular hole closure patterns associated with different internal limiting membrane flap techniques. Graefes Arch Clin Exp Ophthalmol. 2017;255(6):1073–1078. doi:10.1007/s00417-017-3598-9 [CrossRef]
  2. Iovino C, Caminiti G, MIccoli M, Nasini F, Casini G, Peiretti E. Comparison of intverted flap and subretinal aspiration technique in full-thickness macular hole surgery: A randomized controlled study. Eur J Ophthalmol. 2018;28(3):324–328. doi:10.5301/ejo.5001040 [CrossRef]
  3. Alpatov S, Shchuko A, Malyshev V. A new method of treating macular holes. Eur J Ophthalmol. 2007;17(2):246–252. doi:10.1177/112067210701700215 [CrossRef]
  4. Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology. 2010;117(10):2018–2025. doi:10.1016/j.ophtha.2010.02.011 [CrossRef]
  5. Morizane Y, Shiraga F, Kimura S, et al. Autologous transplantation of the internal limiting membrane for refractory macular holes. Am J Ophthalmol. 2014;157(4):861–869. doi:10.1016/j.ajo.2013.12.028 [CrossRef]

Authors

From the Cincinnati Eye Institute, Cincinnati; the Department of Ophthalmology, University of Cincinnati, Cincinnati; and the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, Cincinnati.

This technique was presented at the 6th Annual Vit-Buckle Society Meeting in Miami on March 23, 2018.

Dr. Sisk reports no relevant financial disclosures.

Address correspondence to Robert A. Sisk, MD, Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242; email: rsisk@cincinnatieye.com.

Received: August 06, 2018
Accepted: January 17, 2019

10.3928/23258160-20190703-07

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