A post-traumatic macular hole (PTMH) is a complication of ocular trauma first described by Herman Knapp in 18691 and represents about 10% of all full-thickness macular holes (FTMHs). They are produced by a sudden increase in tangential traction vector forces in the vitreous cortex and exerted on the macula.2 Numerous reports in literature show cases of spontaneous closure of the PTMH in a period of 2 weeks to 4 months after the trauma, with a percentage between 44% and 67%.3–7
When PTMH does not close spontaneously, pars plana vitrectomy (PPV) with fluid-gas exchange and internal limiting membrane (ILM) peeling remains the gold standard of treatment, with a percentage of success of 94% to 96%,8,9 and a mean final best-corrected visual acuity (BCVA) reported of 20/40.
In cases of large chronic macular hole (MH), various adjuvant therapies include transforming growth factor-beta-2,10 autologous platelets concentrate,11 biological tissue as autologous retinal graft,12 or ILM as inverted flap13 or autologous transplantation.14
We report the first use of the human amniotic membrane (AM) plug to close a large, chronic PTMH.
Patients and Methods
A 50-year-old male was referred to our clinic for a 25-year history of a PTMH in the right eye after sustaining blunt trauma from a work-related injury. BCVA was 20/400 in the affected eye and 20/20 in the fellow eye. The patient was phakic in both eyes with mild cataract opacification. Fundus examination revealed a FTMH with posterior vitreous detachment. Optical coherence tomography (OCT) (AngioVue; Optovue, Fremont, CA) scan confirmed a 971-μm chronic MH with flat atrophic margins.
We performed a 23-gauge PPV (Alcon Laboratories, Fort Worth, TX) combined with cataract extraction and intraocular lens implantation. A chandelier endo-illuminator was used to achieve bimanual maneuvers. The 23-gauge size was chosen to facilitate the insertion of the AM through the valved trocar.
We performed a complete vitrectomy with extensive vitreous base shaving. The ILM was stained with a mixture of vital dyes (Dual Blue; DORC International, Zuidland, Netherlands) and peeled away. We used a cutaneous punch (Disposable Biopsy Punch; Kai Medical, Solingen, Germany) of 1 mm diameter to cut an AM plug. The plug was nestled within the MH with the chorion layer facing toward the retinal pigmented epithelium. Fluid-gas exchange with 20% sulfur hexafluoride (SF6) (Fluoron GmbH, Ulm, Germany) was performed at the end of the procedure. The patient was asked to maintain face-down positioning for the first 5 days after surgery (Video below).
On postoperative day 10, OCT imaging confirmed complete MH closure, and BCVA improved to 20/200. MH remained closed at 3 months after surgery, with BCVA improving to 20/100. Visual acuity remained stable during the entire follow-up. No adverse events were registered during the 6-month follow-up (Figure 1).
Optical coherence tomography (OCT) shows chronic post-traumatic macular hole (MH) with flat margin and an epiretinal membrane. The caliper indicates the internal dimension of the MH (A). Three-month OCT showing amniotic membrane plug (red arrow) well positioned under the retina and complete closure of the MH (B).
A PTMH is not a rare complication of blunt ocular trauma and represents 10% of all MHs. Spontaneous closure of PTMH is commonly reported between 44% and 67%, with a final BCVA recovery to 20/40 or better in more than 50% of cases.
When spontaneous closure does not occur, PPV with ILM peeling and gas tamponade remains the gold standard of choice, with a percentage of success more than 90% and final BCVA of 20/40 in most of the cases described. Large, chronic PTMH is a rare complication with poor likelihood of closure.15
The use of various adjuvant or biological tissue in MH surgery has been reported by various authors in order to improved hole closure rates and reaches better final BCVA recovery.
ILM inverted flap or autologous transplant have been used with great anatomical results. Recent reports have shown that ILM implantation within the MH can induce gliosis of the retinal layers and result in poor final BCVA recovery.16
Recent studies with autologous neurosensory retinal free flap (ANRFF) graft introduced by Akshay et al.17 in 2017 to close recurrent MHs, with subsequent applications in a chronic PTMH, have shown promising results.
More recently, Rizzo et al. proposed the use of an AM plug instead of ILM or ANRFF to promote recurrent MH closure, with encouraging results reported.18
Herein, we have described the application of the AM plug to close a chronic large PTMH with excellent anatomical and functional results. It is important to consider the easier maneuvers used in our technique, instead of harvesting a ANRFF to implant in the MH area. The AM plug should be cut with a disposable cutaneous punch depending on the dimensions of the MH measured with OCT to ensure a perfect fitting of the plug inside the hole. All maneuvers necessary to manage and implant the AM plug are very simple, and the timing for surgery results is short. No permanent endotamponade, such as as silicone oil or perfluorocarbon, is necessary to ensure the right adhesion and integration of the AM plug in the retina, but a short-term gas, such as 20% SF6, produces adequate results, and no other surgeries are required.
AM plug provides postoperative support for MH closure and retinal regenerations in few postoperative days, comparable in timing with idiopathic MH surgery, leading to an excellent final BCVA recovery.
Postoperative OCT shows progressive improvements of the outer retinal layers as external limiting membrane starting from the edge of the AM plug proportional with the BCVA recovery reported.
In conclusion, the effectiveness of the AM plug to promote recurrent MH closure has already been demonstrated. We have investigated as this new technique can be adapted to large PTMH with encouraging anatomical and functional results. Future and extended casuistry are necessary to attest the efficacy of this new technique.
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