Surgery for macular hole with retinal detachment: An enigma.

Abstract

Dear Editor, Macular hole with retinal detachment (MHRD) typically occurs in high myopes. The most accepted theory for its pathogenesis is that the vitreous cortex adherent to the retinal surface around the macula causes tangential traction on it causing retinal detachment along with a macular hole (MH) in staphylomatous eyes.[1–3] Electron microscopy of the surgical specimens shows the presence of myofibroblasts on internal limiting membrane (ILM), the contraction of which probably causes retinal detachment. Thus, the removal of ILM plays a pivotal role in MHRD surgery.[4] Macular buckling is a historical reversible technique used for treating MHRD, which was developed by Schepens. It acts by counteracting the pulling force caused by staphyloma. It can give both anatomical and functional outcomes. However, the placement of buckle at the correct place is difficult to achieve. Still, there has been renewed interest in the surgery recently. A newly developed suprachoroidal buckling technique uses stabilized, cross-linked, long-acting hyaluronic acid which is filled in the supra choroidal space in the area of the staphyloma so as to achieve a choroidal indenting effect.[5] Gonvers and Machemer were the first to perform pars plana vitrectomy (PPV), partial air-fluid exchange, and face-down positioning for the treatment of MHRD.[6] This technique did not give lasting results; however, advancements in the procedure made it the primary surgery for MHRD. Further studies proved that epiretinal membrane (ERM) removal alone does not relieve all the tangential traction. Seike et al.[3] achieved 50% reattachments rates with ERM removal due to recurrent membrane formation. The most popular surgery for MHRD presently is PPV with ILM peeling with intraocular tamponade. ILM peeling apparently removes all the residual vitreous cortex, ERMs, and cellular constituents but ILM peeling is difficult in such cases because the retina is mobile. Atrophic retina also makes visibility of macular hole difficult. The use of perfluorocarbon liquid facilitates ILM peeling. Modification of the surgery includes inverted ILM flap or lens capsule flap for closure of macular hole which may be assisted by an autologous blood clot, which showed better anatomical results than ILM peeling.[7,8] Endolaser to macular hole rim has also been performed but did not show significant results.[9] Gas tamponade has been found to have better retinal reattachment rates than silicone oil.[10] Ando et al.[11] used the technique of scleral imbrication in which they placed 4–5 mattress sutures in the superotemporal and inferotemporal quadrants which were then tightened, and vitrectomy with ILM was performed. This works by reducing the degree of curvature of the posterior staphyloma. Retina was attached in all patients, and 44% patients had closed macular hole. The most recent surgery for MHRD is autologous neurosensory retinal free flap closure of macular hole, first used by Grewal and Mahmoud.[12] This technique involves harvesting an autologous neurosensory retinal free flap and positioning it over the refractory MH to provide a scaffold and plug for hole closure. Several studies have been published for the same, and the reattachment rate is 88% as shown on optical coherence tomography. However, the data is small. The anatomical and visual outcomes of the above surgeries have not been promising. A study on long-term outcomes of PPV with ILM peeling or ILM flap technique, by Kim et al.,[13] showed that vision after surgery was not maintained and the closure effects were not observed at a 3-year follow-up. In another study comparing macular buckling and vitrectomy by Zhao et al.,[14] the results showed that both surgeries improved post-operative vision, but retinal reattachments rates were better by macular buckling. The pursuit for long-lasting favorable results continues. Surgery for MHRD still remains a challenge.