Surgery of large and persistent macular holes

Abstract

Modern macular hole surgery results in high closure rates of over 90% and good functional results especially in macular holes up to 400 µm in diameter. The standard of care in most of these cases consists of transconjunctival sutureless pars plana vitrectomy, peeling of the inner limiting membrane (ILM) around the hole, followed by gas tamponade and positioning of the patient. As closure rates and functional results decrease with larger macular hole diameters over approximately 400 µm, alternative surgical techniques have been introduced to improve anatomical and functional results in these cases. These techniques include the positioning of tissue within the macular hole to improve hole closure. This can be performed using an ILM flap or free flap technique and the transplantation of autologous retinal tissue, lens capsule or homologous amniotic tissue in or under the defect. An alternative promising approach is the attenuation of the rim of the hole by induction of alocalized retinal detachment at the posterior pole which is achieved by subretinal injection of balanced salt solution (BSS) using a41 gauge needle. The operation is completed by an endotamponade using gas or silicone oil.