What is the best way to treat refractory macular hole?

Abstract

AbstractBackground: Despite the abundance of surgical approaches proposed for persistent full thickness macular hole (PFTMH) treatment the choice of the optimal technique remains debatable.Purpose: to analyse the anatomical and functional outcome of surgery for persistent macular holes and to determine significant risk factors for failure of primary 25‐g vitrectomy with ILM peeling and gas tamponade for treatment of FTMH.Patients and Methods: Thirty‐eight eyes of thirty‐seven patients with FTMH that underwent primary 25‐gauge PPV, ILM peeling and gas tamponade (GT) were recruited to this retrospective, consecutive, interventional study. Four eyes with persistent holes underwent a re‐operation and outcome‐related factors were discussed.Results: The primary closure rate was 89.5% (34/38). In all failed to close (FTC) cases in this study we used the novel technique recently described by us previously. This manoeuvre included the combination of a subretinal‐fluid application technique with centripetal displacement of the macula and ILM flap technique (inverted pedicle ILM flap technique was used in 3 cases and free ILM flap in 1 case). Four eyes that underwent the repeated surgery obtained final closure. A hole size of >500 μm has a statistically significant effect on the primary macular hole closure (F = 0.048; φ = 0.38; p ˂ 0.05). In the Group 2 with primary unclosed holes, 75% of the eyes (3/4) had an axial length (AL) > 26 mm, while in Group 1 with primary closed holes such eyes were 12.5 times less (2/34) 5.9% (F = 0.004; φ = 0.63; р ˂ 0.01).Conclusion: The combination of a SR‐fluid application technique with centripetal displacement of the macula and ILM flap technique for refractory FTMH provide satisfactory morphologic and functional outcomes. Elongated AL, large diameter of MH and long duration of symptoms are the risk factors for initial closure. Proper second surgery can obtain satisfactory outcomes for persistent holes.