Macular hole surgery has evolved greatly from the initial studies of Wendel. Anatomical closure of 90% or greater is not uncommon. However, one of the controversies that has plagued retina specialists over the past few years is how to achieve macular hole closure in larger macular holes. Large holes were defined by Gass as greater than 400 µm in size, and with the advent of OCT, specialists have migrated to measuring the diameter between the retinal tissues.
In this prospective clinical study, Manasa and colleagues randomized patients to receiving traditional macular hole surgery with ILM peels vs. ILM flap surgery for holes greater than 600 µm in size. Their results are one of the first studies to finally look at this on a head-to-head fashion and found significant benefit in ILM flap for these larger holes over traditional surgery and the ability to achieve the desired anatomic outcome by OCT.
The study is limited in that holes with a greatest linear diameter of 600 µm were entered. While it is arguably a large hole, there still lacks clinical classification at to what constitutes a large hole. Also, ILM flap as described here and in other studies is technically difficult to perform. Lastly, the authors followed these patients for only 3 months, and there is a chance that the traditional ILM removal patients within the trial would have improved over time.
In summary, this is a very important article demonstrating the early benefit of ILM flap surgery in patients with large macular holes.
Rishi P. Singh, MD
Associate Editor, Ophthalmic Surgery Lasers & Imaging Retina
Disclosures: Singh reports no relevant financial disclosures.