Iatrogenic macular detachment for large macular holes: How to improve this technique

Abstract

AbstractIatrogenic macular detachment (IMD) with subretinal injection of balance salt solution (BSS) was proposed as an alternative treatment of the large, persistent and chronique macular holes (MH). Subretinal administration of BSS is aimed to detach the edges of the MH decreasing the stiffness and increasing the elasticity of the retina. Hence, the closure of the MH could be improved. Nevertheless, there are still cases that remain refractory to this approach. Preliminary observational studies of the surgery flow with the use of intraoperative optical coherent tomography revealed that in majority of cases after BSS was injected into subretinal space there was strong remaining almost circumferential adhesion between retinal pigment epithelium and photoreceptor outer segments at the edge of MH base. These data differ from the visually percepted MD and showed that in studied cases approximately just 5% to 20% of MH edge circumference were elevated predominantly in temporal area. Subretinal BSS blebs appeared to merge with each other within the macula but outside the MH edges. Additionally, there were no correlation between the size or height of the bleb with the extension of the MD at MH edges. It was noticed that nasally to the MH the adhesion between RPE and OPS was stronger. The causes of this adhesion remain unclear. This hypothesizes that separation of the adhesion could improve the closure rate of the refractory MH using IMD technique. Development of the new surgical approaches together with novel instruments to address the separation of the strong adhesion at the MH edge shall be considered in order to improve the results of iatrogenic macular detachment (IMD) technique in treatment of large, persistent and chronique MH.