Chronic Macular Holes Research Articles

Parafoveal atrophy after human amniotic membrane graft for macular hole in patients with high myopia

PurposeTo report the surgical outcome and postoperative hypopigmented change around fovea among patients with high myopia who received human amniotic membrane (hAM) graft transplantation for macular hole (MH).MethodThis retrospective, interventional...

Literature Review of Surgical Treatment in Idiopathic Full-Thickness Macular Hole.

PurposeTo summarize current surgical techniques for treating primary macular holes (MHs).MethodsWe reviewed publications detailing surgical approaches to primary MHs, briefly described their protocols, and outlined their results.ResultsCurrently, the technique for primary MH repair is pars plana vitrectomy, removing the posterior cortical vitreous, stripping the epiretinal membranes, and ending with intraocular gas tamponade. The evident benefit of peeling off the internal limiting membrane (ILM) was clearly shown for MHs at stages 2 to 4 by achieving an anatomical closure rate of >90%, even in large MH up to 650 µm. Newer MH surgical techniques include modification of ILM flap techniques, placing an autologous scaffolding of tissue within the hole, and cell therapy has shown to increase the closure rate of large and chronic macular holes, resulting in modest functional improvement in complicated MHs.ConclusionSince the turn of the century, the success rate of modern macular surgery has increased, even for large and chronic MHs. There seems to be no limit to novel concepts in MH surgery, which range from anatomical closure to those proposing natural restoration of visual function via stem cell therapy.

Treatment of large, chronic and persistent macular hole with internal limiting membrane transposition and tuck technique

BackgroundLarge, chronic full thickness macular holes which failed previous treatments are difficult to manage and even left untreated due to poor prognosis. A retrospective review of consecutive cases with chronic (at least 1 year) full thickness macular holes and internal limiting membrane (ILM) free flap transposition with tuck technique, after previously failed vitrectomy.MethodsThis was a retrospective and interventional study conducted in a single centre by a single surgeon. Patients with full thickness macular hole for at least 1 year and at least one previously failed vitrectomy with ILM peeling were recruited. A 25G vitrectomy with ILM free flap transposition was done without assistance of PFCL, viscoelastic or autologous blood. The free flap was manually tucked into the macular hole free space and gas fluid exchange was performed with 20% SF6 as tamponade. The patients were postured prone for 2 weeks postoperatively. Best corrected visual acuity, macular hole duration, previous surgeries, optical coherence tomography (OCT) appearance, hole size and closure rate were recorded.Results8 consecutive patients were included from May 2016 to Feb 2018. Transposition surgery was performed an average of 1481 days (SD 1096) after diagnosis of macular hole and average of 1226 days (SD 1242) after first vitrectomy. Macular hole mean size was 821 μm (SD 361.3), preoperative VA was logMAR 1.038 (SD 0.19), postoperative VA was logMAR 0.69 (SD 0.19) at 3 months. There were 1.13 lines gained and a significant improvement of logMAR 0.33 (p = 0.0084) at 6 months. Hole closure was seen in 7 out of 8 eyes (87.5%). The OCT with failed closure showed ILM flap within a flat hole, however no overlying neurosensory layers was seen. The duration from diagnosis to surgery was 2349 days in this case.ConclusionFree flap ILM transposition tuck without the use of additional intraoperative tamponade is an effective technique in treating large chronic macular holes with previously failed primary macular hole surgeries.Trial registration (IRB of the Hong Kong University and Hospital Authority Hong Kong West Cluster, ref UW19-440), June 17, 2019.

An Analytical Study with a Novel Surgical Technique By “Traction Release ILM Peeling” for Large Diameter Chronic Macular Holes

An Analytical Study with a Novel Surgical Technique By “Traction Release ILM Peeling” for Large Diameter Chronic Macular Holes

Outcomes of Vitrectomy for Long-Duration Macular Hole.

The present study investigated the functional and anatomical outcomes of idiopathic chronic macular hole (MH) surgery with different surgical approaches related to the chronicity and diameter of the MH. A comparative retrospective study between three groups of patients who underwent vitrectomy for long-duration MH (mean: 13.5 months) was conducted. In the first group of patients (G1 or IP), the internal limiting membrane (ILM) was systematically peeled; in the second group (G2 or IPEP), the ILM and epiretinal membrane (ERM) were peeled; and in the third group (G3 or IF), patients underwent inverted ILM flap technique surgery. Pre- and post-operative best corrected visual acuities (pre- and post-op BCVA) were studied. Macular optical coherence tomography (OCT) scans were performed to measure the MH minimum and maximum diameter pre-operatively, as well as to confirm its post-op closure and evaluate the integrity of the ellipsoid zone (EZ). Fifty eyes of 48 patients (33 female and 15 male) were retrospectively evaluated. MH closure rate was 100% in IP group, 66.7% in IPEP, and 95.2% in IF group. All three groups had a statistically significant improvement of BCVA. EZ post-op was restored in 88.2% of the cases from G1, 41.6% from G2, and 23.8% from G3. No statistically significant relationship between the smaller or larger MH diameter and the visual acuity improvement was found. Patients with chronic MH and ERM have worse functional and anatomical outcomes after surgery. Treatment of chronic MHs without ERM results in a better closure rate with either an inverted ILM flap approach or systematic ILM peel.

NO FACE-DOWN POSITIONING SURGERY FOR THE REPAIR OF CHRONIC IDIOPATHIC MACULAR HOLES.

To report visual and anatomical outcomes after the repair of chronic idiopathic macular holes (MHs) with no face-down positioning. We conducted a retrospective review of chronic MH cases of greater than 1-year duration that were repaired through pars plana vitrectomy with broad internal limiting membrane peeling and no face-down positioning between March 2009 and December 2017. There were 18 eyes of 18 patients that met inclusion criteria. Patients with MH duration of less than 1 year and without at least 1 month of follow-up were excluded. Macular hole staging and measurements were performed with spectral domain optical coherence tomography. Mean MH duration was 5.0 ± 6.9 years. Two-thirds of MHs had a basal diameter of more than 1,000 μm. Mean preoperative Snellen visual acuity was 20/302 and improved to a mean postoperative visual acuity of 20/112 (P ≤ 0.0001). Visual acuity improved in all patients who achieved successful anatomical closure, 94.4% (17/18) of eyes. Patients in this series with chronic MH who underwent no-face-down MH repair demonstrated a high single-surgery anatomical closure rate with a significant improvement in visual acuity.

Autologous retinal graft for closure of large chronic macular hole with old retinal detachment : A report of two cases

Purpose: To report 2 cases of the use of autologous retinal graft for the surgical treatment of traumatic atrophic large macular holes with old retinal detachment.
 Case report: The patients had pars plana vitrectomy with membrane peeling and flattening of the retina under perfluorocarbon liquid, and autologous retinal graft to close the large atrophic macular holes. Postoperativereviews show closure of the macular holes, attachment of the retina and some improvement of visual acuity.
 Conclusion: Autologous retinal free patch transplantation may offer a new solution for treatment of large chronic traumatic macular holes with old retinal detachment.

Autologous retinal graft for closure of large chronic macular hole with old retinal detachment : A report of two cases

Purpose: To report 2 cases of the use of autologous retinal graft for the surgical treatment of traumatic atrophic large macular holes with old retinal detachment.
 Case report: The patients had pars plana vitrectomy with membrane peeling and flattening of the retina under perfluorocarbon liquid, and autologous retinal graft to close the large atrophic macular holes. Postoperativereviews show closure of the macular holes, attachment of the retina and some improvement of visual acuity.
 Conclusion: Autologous retinal free patch transplantation may offer a new solution for treatment of large chronic traumatic macular holes with old retinal detachment.

AUTOLOGOUS RETINAL TRANSPLANTATION AS A PRIMARY TREATMENT FOR LARGE CHRONIC MACULAR HOLES.

To report the outcomes of autologous neurosensory retinal transplant as a primary treatment for patients with large chronic macular holes and evaluate the safety and feasibility of the procedure. Retrospective study, consecutive case series. We reviewed seven patients with a primary chronic large macular hole, who underwent autologous neurosensory retinal transplant. Mean preoperative minimum and maximum hole diameters were 643 µm and 1214 µm, respectively. Changes in visual acuity were measured postsurgery, and optical coherence tomography, fluorescein angiography, and microperimetry-3 were analyzed after the procedure. Closure of the macular hole was achieved in all seven eyes in the study. At 1 year post-surgery, there was significant improvement in mean visual acuity (LogMAR 1.10 vs. 0.68, P = 0.001). Optical coherence tomography showed that all grafts had formed attachments to the retinal epithelial cells of the recipient retina. Mean preoperative ellipsoid zone defect was 1,089 ± 403.8 µm (range, 918-1,329 µm) which further decreased to 921 ± 129.1 µm (range, 670-1,201 µm) at final follow up (P = 0.09). Microperimetry-3 testing indicated retinal sensitivity in the graft in five eyes. Autologous retinal transplantation may help rebuild the macular structure resulting in functional improvement for eyes with primary chronic large macular hole.

Folding the internal limiting membrane flap under perfluorocarbon liquid in large, chronic and myopic macular holes.

The purpose of the present paper is to describe a surgical technique aimed at creating multiple layers of Internal Limiting Membrane (ILM) using Perfluorocarbon Liquid (PFCL) in order to favour the closure of large, chronic and myopic Macular Holes (MH). Thirty patients belonging to 3 subgroups: large (> 500μm), chronic (> 12months) and myopic (> - 9 diopters), MHs, underwent surgery and completed 6months follow-up. The ILM was engaged and peeled 360° around the MH, hinged to the rim and folded over the hole. A PFCL bubble spanning the vascular arcades was then injected and the ILM is grasped repeatedly to fold the distal edge towards the MH centre, creating multiple ILM layers over the MH. MH closed in 26/30 cases (86.6%) with no significant difference among subgroups. Vision improved 2.57 ± 1.56 Snellen lines from LogMAR 1.50 ± 1.19 to 1.19 ± 1.32 (p< 0.01). Ellipsoid Zone (EZ) interruption width reduced from 1129 ± 439μm to 258 ± 507μm (p< 0.001) and correlated to pattern of MH closure, post-BCVA and line improvement (p< 0.001 in all cases). The use PFCL allows multiple ILM layers and resulted in a high closure rate. Pattern of MH closure differs from those previously described leaving a plug of ILM tissue that interrupts retinal architecture often only in the inner layers. PFCL gravity and hydrophobicity displace aqueous while the intensely polar opposite faces of the ILM attract each other. The folded ILM plugs MH and bridges the gap and may help glial cell proliferation and migration.

Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery.

To assess the efficacy of dynamic intraoperative spectral-domain optical coherence tomography (iSD-OCT) imaging for inverted internal limiting membrane (ILM) flap technique (IILMFT) in large macular hole (MH) surgery. Prospective, non-randomized, observational study was conducted on 8 eyes of 7 patients with large, chronic and recurrent MHs, which were treated by pars plana vitrectomy (PPV) with IILMFT. All patients underwent standard pre- and postoperative examination. The iSD-OCT imaging was performed using microscope integrated systems before, during, and after ILM peeling. The iSD-OCT data were post-processed using graphic software and reviewed for tissue behavior and instruments position. The real-time iSD-OCT-assisted IILMFT allowed for real-time imaging of the entire surgery with visualization of the MH, vitreoretinal instruments, and all steps of inverted ILM flap formation. In spite of shadowing created by the steel instruments, it was possible to follow and control the distance between the instrument tips and retinal layers. Dynamic imaging of the surgical maneuvers including ILM peeling and mechanical apposition of MH edges revealed the iatrogenic impact on the retina (depression and appearance of hyporeflective zones). iSD-OCT imaging could confirm the proper position of the inverted ILM flap at the very end of the surgery after fluid-air exchange. iSD-OCT imaging is an effective tool for learning and performing a well-controlled and safe inverted ILM flap technique in patients with large MH. Clinical significance of the structural iSD-OCT findings has to be further studied.

Choroidal thickness in macular holes.

To determine the association between choroidal thickness (CT) and anatomic success in closed and open macular holes (MHs) following surgery. One hundred and thirty-six eyes of 136 patients who underwent surgery due to primary MH were included in this study. Choroidal thickness was measured from various points (subfoveal, temporal, nasal, superior and inferior 1500µm from the center of the fovea) in both eyes with MH and fellow eyes. We determined associations among the duration of symptoms, MH dimensions and CTs from various points with anatomic success and correlations between CT and MH dimensions and duration of symptoms. Choroidal thickness was significantly lower in eyes with MH than fellow eyes in both open and closed MHs. Base diameter [p = 0.025, odds ratio (OR) = 0.428], minimum hole diameter (p = 0.030, OR = 0.211) and duration of symptoms [p = 0.034, OR = 0.443] were significantly associated with anatomic success. However, CTs from various points were not associated with anatomic success despite a significant preoperative subfoveal CT difference between open and closed MHs (198 ± 21µm in open MHs and 230 ± 30µm in closed MHs; p < 0.001). Preoperative subfoveal CT was moderately correlated with base diameter (r = - 0.505, p < 0.001), minimum hole diameter (r = - 0.518, p < 0.001) and duration of symptoms (r = - 0.510, p < 0.001). Failed MHs were associated with larger hole dimensions (base diameter and minimum hole diameter) and longer duration of symptoms. Preoperative subfoveal CT was thinner in open MHs, but there was no association with anatomic success. Choroidal thinning may be linked to larger and chronic MHs.

MACULAR HOLE HYDRODISSECTION: Surgical Technique for the Treatment of Persistent, Chronic, and Large Macular Holes.

To present a new technique, macular hole hydrodissection, that increases the likelihood of closure for challenging macular holes (MHs) with multiple risk factors. A retrospective review of all consecutive eyes with idiopathic Stage 3 and 4 MHs that were either persistent (failed previous vitrectomy surgery), chronic (symptoms of central vision loss of ≥2 years or a clinical diagnosis for ≥1 year), and/or large (aperture diameter of ≥400 μm), having undergone the macular hole hydrodissection surgical technique between January 1, 2014, and May 1, 2017, from an institutional practice setting was conducted. This technique lyses retina-retinal pigment epithelium adhesions by injecting fluid into the MH and allows for successful closure as the mobile edges are then brought closer together. Thirty-nine eyes of 39 patients with mean MH aperture and base diameters of 549.1 ± 159.47 μm and 941.97 ± 344.14 were included. Complete anatomical closure was achieved in 87.2% (34/39) of MHs. Vision improvement was observed in 94.9% (37/39) and gain of ≥2 lines was achieved in 79.5% (31/39). Of the MHs that achieved anatomical success, 100% (34/34) had a Type 1 closure. The mean postoperative follow-up was 320.33 ± 269.04 days. The macular hole hydrodissection surgical technique improves anatomical and functional outcomes of persistent, chronic, and/or large MHs.

Closure of Large Chronic Macular Hole by Scleral Imbrication and Retinal Expansion.

The purpose of this study is to describe a new technique for the treatment of large, chronic macular hole (MH) using scleral imbrication and retinal expansion and to report the outcomes of MH closure. This retrospective study demonstrates a procedure for correcting the disproportion between an area of stiff neurosensory retina and the inner scleral wall. Baseline MH parameters were collected. MH closure rate, visual outcomes, and biometry were reported at 6-month follow-up. MH closure was achieved in six out of seven patients (85.7%). Mean minimal hole diameter, base hole diameter, and MH index were 712 μm ± 136.8 μm, 1,440 μm ± 444 μm, and 0.27 μm ± 0.08 μm, respectively. At 6-month follow-up, median logarithm of the minimum angle of resolution (logMAR) corrected distance visual acuity significantly improved from 1.2 (interquartile range [IQR] = 1.0 to 1.6) preoperatively to 0.7 (IQR = 0.58 to 0.8) postoperatively (P = .018; Wilcoxon signed-rank test). This technique provided both satisfactory hole closure rates and acceptable structural outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e57-e64.].

Spare some internal limiting membrane for later: free ILM patch and neurosensory retina graft

Editorial to De Giacinto et al case report on free autologous neurosensory retina patch. Literature review and experts' opinion RESULTS: In the present issue, De Giacinto et al describe a free autologous neurosensory retina patch to close a chronic macular hole. This new technique was made necessary by an extended internal limiting membrane peeling during the first surgery, that prevented grafting a patch of internal limiting membrane when the hole did not close. We hereby review pros and cons of patching a chronic macular hole with an internal limiting membrane patch, as well as the importance of not over-enlarging a peeling. Internal limiting membrane patch can be considered in chronic macular holes. It may not be an option in cases of over-enlargement of a previous peel; free autologous neurosensory retina patch may be a valid alternative in such cases.

Inverted Internal Limiting Membrane Flap Technique for Extra Large Macular Holes

Aim: To investigate the outcome of the inverted Internal Limiting Membrane (ILM) flap technique for extra large idiopathic macular holes (MHs).Methods: A retrospective non-comparative surgical case series of seven eyes of 7 patients with MHs (base diameter of at least 1000 ?m) was conducted. All the MHs were treated using pars plana vitrectomy and brilliant blue G (BBG)-assisted inverted ILM flap technique. Spectral Domain- Optical Coherence Tomography (SD-OCT) images were used to assess the anatomical outcomes of surgery including the macular microstructure, while Best Corrected Snellen Visual Acuity (BCSVA) was used to evaluate the functional outcomes.Results: The average MH size was 1241microns and average symptom duration was nineteen months. All eyes achieved successful anatomical closure and there was no occurrence of a flat open type closure. SD-OCT microstructural study revealed a reconstruction of the Ellispod Zone (EZ) and External Limiting Membrane (ELM), in only 3 eyes. There was an improvement in visual acuity in 5 eyes, while 2 eyes maintained the same as pre operative vision. The largest increase in post operative visual acuity gain was a 4-line improvement in Best Corrected Snellen Visual Acuity (BCSVA) noted in one of the 3 eyes with reconstructed EZ and ELM. The 3 months symptom duration in this patient was the shortest in this series.Conclusion: Inverted ILM flap technique is a safe and effective approach for the management of extra large chronic idiopathic MHs with demonstrably good anatomical and limited functional results in a majority of cases. Postoperative reconstruction of the microstructure is however seen only in a minority of eyes. Despite an absence of the outer retina (EZ and ELM), some eyes still experience an improvement in vision. The symptom duration may play a vital role in functional outcome in this subset of extra large chronic MHs.

INTERNAL ASPIRATION UNDER PERFLUOROCARBON LIQUID FOR THE MANAGEMENT OF LARGE MACULAR HOLES.

To report the outcomes of pars plana vitrectomy with internal aspiration under perfluorocarbon liquid for large macular holes (MH). Retrospective consecutive case series of patients with large (>400 µm) MH. All treated were with pars plana vitrectomy, internal limiting membrane peeling, internal fluid aspiration under perfluorocarbon liquid, and gas/oil tamponade. Outcomes included closure rate and visual acuity at 6 months. Twenty eyes of 20 patients were included. Mean age of patients was 67.6 ± 7.3 years. Mean MH size was 609.4 ± 154.7 μm. Mean symptoms duration was 9.05 ± 7.3 months. Unfavorable prognostic factors included chronic MHs (≥4 months) in 15 eyes (75%), refractory MH in 6 eyes (30%), and poor initial visual acuity (≤20/200 logarithm of minimal angle of resolution) in 18 eyes (90%). Gas tamponade was used in 18 eyes (90%). Nineteen MHs (95%) had closed after a single operation. Two (10.5%) had Type-II closure. Mean visual acuity improved significantly from 20/330 to 20/140 Snellen acuity (1.22 ± 0.31-0.85 ± 0.35 logarithm of minimal angle of resolution; P < 0.001). Fifteen eyes (75%) had visual acuity improvement of more than 0.2 logarithm of minimal angle of resolution. Thirteen eyes (65%) achieved visual acuity better than 20/200. Pars plana vitrectomy combined with internal fluid aspiration under perfluorocarbon liquid is an effective and safe surgical technique for the management of large MH. This innovative technique offers improved closure rates and visual acuity results.

Large semicircular inverted internal limiting membrane flap in the treatment of macular hole in high myopia.

To describe the technique and surgical outcomes of a modified large semicircular inverted internal limiting membrane (ILM) flap in the management of macular holes (MHs) in patients with high myopia. We performed this retrospective study on consecutive patients with MH and high myopia (axial length≥28mm),who received vitrectomy, a large semicircular ILM flap 4 discs in diameter to cover the MH, incomplete air-fluid exchange, and SF6 gas tamponade. All of the patients maintained an upright position for 2h postoperatively, followed by either a face-down or upright position for 1week. Post-operative visual acuity was measured, and MH status was assessed using spectral-domain optical coherence tomography. Seventeen highly myopic eyes in 16 patients with a mean axial length of 30.49±0.98mm and mean age of 62.25±9.40years were included in this study, including five eyes with foveoschisis and four eyes with chronic MH, two with myopic choroidal neovascularization, and four with MH-associated retinal detachment. The MHs of all patients were successfully closed after a single operation. All of the patients were followed for at least 6months. The average visual acuity in logarithm of minimal angle of resolution improved from 1.26±0.52 preoperatively to 0.69±0.45 6months postoperatively (p=0.01, paired t-test). A large semicircular inverted ILM flap can close a myopic MH efficiently without the need for a long-term face-down position.

Intraoperative OCT for inverted ILM flap technique

PurposeTo evaluate the use of intraoperative spectral‐domain optical coherence tomography (iSD‐OCT) for large macular hole (MH) surgery using inverted internal limiting membrane (ILM) flap technique.MethodsWe analyzed 7 consecutive cases of iSD‐OCT assisted pars plana vitrectomy (PPV) with inverted ILM flap technique for large and chronic MHs. iSD‐OCT was performed using Rescan 700 (Zeiss, Oberkochen, Germany). iSD‐OCT data were post‐processed and analyzed postoperatively (study of tissue behavior).ResultsIn all cases iSD‐OCT imaging allowed the surgeon to carry on the procedure without significant time consumption. The iSD‐OCT imaging assisted: 1) to find the safe place on the retina while starting ILM peeling; 2) to control the formation of the inverted ILM flap; 3) to conduct the inversion of the ILM flap over MH. iSD‐OCT allowed to keep safe positioning of the vitreoretinal instruments.ConclusionsiSD‐OCT is a strong supporting tool during PPV, that gives prompt information about tissue behavior and surgical maneuvers. Inverted ILM flap technique for large MH can be performed in more controlled and save way without interruption of the surgical workflow.

Surgical techniques for failed/difficult macular holes

SummaryFree ILM flap technique for difficult macular hole cases: Failed macular holes, macular holes associated with pathologic myopia and retinal detachment and chronic atrophic macular holes are usually difficult to handle with standard techniques. Here we describe the PFCL‐assisted free ILM flap technique as a good surgical option for failed MH closures. The technique is very promising in retaining the flap during the crucial FAE, which results in favorable outcomes, both morphological and functional.