Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study

Inverted internal limiting membrane flap combined with subretinal viscoelastic injection for large or chronic macular holes

Purpose

To report two cases with a large or chronic macular hole (MH) that was closed by combining the inverted internal limiting membrane (ILM) flap technique with the injection of ophthalmic viscoelastic device (OVD) into the subretinal space through the MH.

Observations

A 76-year-old woman was referred to our clinic for surgery of a MH with a maximum diameter of 1089 μm as determined by optical coherence tomography (OCT). Her visual acuity was 20/50 in the left eye after vitrectomy was performed at a local clinic to remove vitreous opacities. For our surgery, the ILM was peeled and the ILM flap was inverted and placed over the MH. Then, cohesive OVD was injected into the subretinal space through the MH to create a retinal detachment around the MH. The MH was closed by a gas tamponade, and the vision improved to 20/40. The second patient was a 62-year-old man whose vision had been decreasing for 3 years, and he was referred to our clinic. His vision was 20/40 in the left eye and OCT detected a MH with a maximum diameter of 853 μm. After core vitrectomy, the ILM was peeled, inverted, and placed over the MH. Then, dispersive and cohesive OVD was injected through the MH. During this procedure, the MH appeared to enlarge and elevate. Then a yellowish arch-shaped lesion appeared at the temporal edge of the macular detachment. The intraoperative OCT showed that the curled-up retinal pigment epithelium (RPE) within the temporal arch-shaped lesion was adherent to the outer retinal layer. Following gas tamponade, the MH was closed but the patient noticed a paracentric scotoma on the nasal side. The fundus autofluorescence (FAF) images showed a hypo-autofluorescent lesion corresponding to the RPE defect. At postoperative 4 months, his visual acuity had improved to 20/22 and the OCT image showed that the MH was closed with a recovery of the ellipsoid zone of the photoreceptors. The subjective paracentric scotoma disappeared, however the hypo-autofluorescent lesion persisted.

Conclusions and importance

A combination of the inverted ILM flap and the subretinal injection of OVD can close a large or chronic MH. An RPE detachment caused by injecting OVD into the subretinal space should be avoided.

Advances in management strategies for large and persistent macular hole: An update

The standard of care to treat small- and medium-sized macular holes (<400 µm diameter) consists of a conventional transconjunctival sutureless pars plana vitrectomy followed by ILM peeling and endotamponade, mainly with gas or in some cases with silicone oil, resulting in closure rates of over 90% and good functional results. Large (>400 µm diameter), chronic and persistent macular holes remain a surgical challenge since closure rates and functional results decrease with larger macular hole diameters. Various modifications of the conventional surgical technique were introduced to improve anatomic and functional success in refractory cases not suitable for conventional macular hole surgery. These techniques comprise the positioning of tissue at the top of the hole to improve closure as performed by an inner limiting membrane flap and free flap preparation or the transplantation of autologous retinal tissue, lens capsule or amniotic membrane. For the treatment of very large and persistent macular holes, the induction of a localized retinal detachment at the posterior pole by subretinal injection of balanced salt solution and a subsequent attenuation of the rim of the hole during fluid-air exchange has been suggested as a promising surgical technique. In particular, accurate patient education about the expected surgical outcome in this specific group of patients appears important.

[Macular hole: Differential diagnosis, treatment options and new guideline recommendations]

Full-thickness macular holes (FTMH) usually result in a pronounced reduction of visual acuity and represent one of the most frequent indications for retinal surgery. If diagnosed and treatment is initiated at an early stage, surgery has a high success rate with respect to both hole closure and improvement of visual acuity. Optical coherence tomography (OCT)-based staging and sizing enables an estimation of the surgical outcome. The differential diagnostic distinction from clinically similar disorders, such as lamellar macular holes, macular pseudoholes, and foveoschisis is clinically relevant as the pathogenesis, prognosis and treatment are significantly different. While vitrectomy with peeling of the inner limiting membrane (ILM) and gas tamponade is established as the standard treatment for FTMH, some aspects of treatment are handled differently between surgeons, such as the timing of surgery, the choice of endotamponade and the type and duration of postoperative positioning. For FTMH associated with vitreomacular traction, alternative treatment options in addition to vitrectomy include intravitreal ocriplasmin injection and pneumatic vitreolysis. The current clinical guidelines of the German ophthalmological societies summarize the evidence-based recommendations for diagnosis and treatment of FTMH.

A Case of Closure of Recurrent Full-Thickness Macular Hole by Spontaneous Retinal Detachment around the Macular Hole and Gas Tamponade

Introduction

Here, we present a case of full-thickness macular hole (FTMH) recurrence following two vitrectomies, accompanied by additional internal limiting membrane (ILM) peeling and gas tamponade. Ultimately, FTMH closure was accomplished by spontaneous retinal detachment around the macular hole and gas tamponade alone.

Case Presentation

The patient, a 54-year-old woman with a lamellar macular hole, had a visual acuity of 20/100 in her left eye. The treatment regimen included cataract surgery, a 25-gauge pars plana vitrectomy involving ILM peeling, application of the lamellar hole epiretinal proliferation embedding technique, and subsequent gas tamponade. Closure of the lamellar macular hole was observed a month post-surgery, improving visual acuity to 20/40. However, FTMH developed 3 months after the initial surgery, resulting in visual acuity decline to 20/100. A 25-gauge pars plana vitrectomy was performed with extensive ILM peeling and 20% sulfur hexafluoride gas tamponade. FTMH closure was noted within 19 days after reoperation, enhancing visual acuity to 20/66. Approximately 1.5 months after reoperation, a pinhole-shaped macular hole was identified, and the patient opted for follow-up observation due to her refusal to undergo additional surgery. As the macular hole gradually enlarged resembling retinal detachment, outpatient fluid-gas exchange with 14% perfluoropropane was performed 3.5 months after reoperation. The FTMH closed within a week post-gas injection and remained closed for more than 1 year. Consequently, visual acuity in the left eye was sustained at 20/50.

Conclusion

We encountered a case that might highlight the significance of releasing subretinal adhesions surrounding a FTMH for successful closure.

A three-step approach to close refractory persistent macular holes: a releasing-closing-tapping approach

PURPOSE

The aim of this study was to assess the efficacy and safety of a novel releasing-closing-tapping approach in the treatment of persistent macular holes (PMHs) after initial surgery with internal limiting membrane (ILM) peeling.

METHODS

We retrospectively analyzed patients with PMHs after initial surgery with ILM peeling who were treated with a novel releasing-closing-tapping approach. After repeated pars plana vitrectomy (PPV), the surgeon effectively released the adhesion between the edges and retinal pigment epithelium (RPE) by gently scraping the retinal neuroepithelium. Then, the hole was converted into a transverse slit, and the edges were gently tapped flat so that they attached to the RPE, and no space was left under the edges. Finally, air tamponade was carried out. The primary outcome measures included MH closure and the change in best-corrected visual acuity (BCVA) from preoperatively to postoperatively.

RESULTS

The study included 11 PMH patients with a mean age of 63.82 ± 3.31 years. The mean minimum linear diameter of PMHs was 666.3 ± 208.1 μm, and the mean basal diameter was 1547.2 ± 351.8 μm. MH closure was achieved in 90.9% (10/11) of eyes, with significant improvement of visual acuity from 1.19 ± 0.30 logMAR to 0.65 ± 0.29 logMAR postoperatively.

CONCLUSION

The releasing-closing-tapping approach with repeated PPV is a simple, effective, and safe surgical procedure for refractory PMHs after initial surgery with ILM peeling that can significantly improve the visual outcome and achieve a high surgical success rate.

Repeat Surgery following Temporal Inverted ILM Flap Technique: Next Step after Primary Failure

PURPOSE

We aimed to report our surgical experience with repeat surgery as the next step after an unsuccessful hole closure with the primary single-layered temporal inverted flap technique (IFT).

METHODS

We identified cases with persistent macular holes by reviewing the records of eyes that underwent IFT between October 2018 and October 2021. These cases were evaluated for hole features, anatomical closure, and visual improvement before and after the first and second surgeries. In addition, the technique applied in repeat surgery was recorded. Optical coherence tomography (OCT) images at follow-up were used to evaluate the flap position.

RESULTS

A persistent hole was identified in 11 (6.4%) of 172 patients who underwent IFT. An inferotemporal displacement was observed in seven eyes, while no flap could be identified in the OCT images of the other four eyes. In the second surgery, the old flap was reinverted in one eye, and a new flap was created from the superior region in five eyes and the nasal region in the other five eyes and was stabilized under perfluorocarbon liquid. A gas tamponade (C3F8/SF6) was used in all patients at the end of surgery. The minimum hole diameter was > 400 µm in all eyes and 100% closure was achieved after the second surgery. Visual acuity gain of ≥ 3 lines was observed in 9 of the 11 eyes (81.8%). The mean visual acuity increase at the last follow-up was significant (p = 0.008).

CONCLUSION

With single-layer temporal IFT in the primary surgery of macular holes, unsuccessful results may be observed due to the flap displacement in the early period. In our series, IFT was applied again with the use of the old flap or the creation of a new flap in the second surgery of the persistent holes, and successful results were obtained.

Relaxing Retinotomy in Recurrent and Refractory Full-Thickness Macular Holes: The State of the Art

The prevailing standard of care for primary repair of full-thickness macular holes (FTMHs) is pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade, as it gives a high closure rate of roughly 90%. On the other hand, the surgical management of recurrent and refractory FTMHs represents, so far, a demanding and debated subject in vitreoretinal surgery since various approaches have been proposed, with no consensus concerning both adequate selection criteria and the best surgical approach. In addition, the existence of multiple case series/interventional studies showing comparable results and the lack of studies with a direct comparison of multiple surgical techniques may lead to uncertainty. We present an organized overview of relaxing retinotomy technique, a surgical approach available nowadays for the secondary repair of recurrent and refractory FTMHs. Besides the history and the description of the various techniques to perform relaxing retinotomies, we underline the results and the evidence available to promote the use of this surgical approach.

The Role of Subretinal Injection in Ophthalmic Surgery: Therapeutic Agent Delivery and Other Indications

Subretinal injection is performed in vitreoretinal surgery with two main aims, namely, the subretinal delivery of therapeutic agents and subretinal injection of fluid to induce a controlled and localized macular detachment. The growing interest in this technique is mainly related to its suitability to deliver gene therapy in direct contact with target tissues. However, subretinal injection has been also used for the surgical management of submacular hemorrhage through the subretinal delivery of tissue plasminogen activator, and for the repair of full-thickness macular holes, in particular refractory ones. In the light of the increasing importance of this maneuver in vitreoretinal surgery as well as of the lack of a standardized surgical approach, we conducted a comprehensive overview on the current indications for subretinal injection, surgical technique with the available variations, and the potential complications.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

BACKGROUND

The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making.

METHODS

We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups.

RESULTS

Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases.

CONCLUSIONS

The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400-550 µm) and X-Large (550-800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Internal Limiting Membrane Peeling and Gas Tamponade For Full-Thickness Macular Holes of Different Etiology - Is It Still Relevant?

Background

Despite the abundance of novel surgical approaches proposed for full thickness macular hole (FTMH) treatment, the choice of the optimal technique remains debatable Vitrectomy with «classic» internal limiting membrane peeling and gas tamponade remains the standard of FTMH surgery in many cases, but there are still very limited recent publications on the outcomes of such surgery.

Purpose

To investigate the anatomical and functional result and to analyze the significance of outcome-related risk factors of the classic 25-gauge pars plana vitrectomy (PPV) with ILM peeling and gas tamponade (GT) for treatment of FTMH of different etiology.

Patients and methods

Thirty-eight eyes of thirty-seven patients with FTMH who underwent 25-gauge PPV, ILM peeling and GT were recruited for this retrospective, consecutive, interventional study. Four eyes with persistent holes underwent a re-operation. Outcome-related factors were discussed.

Results

The primary closure rate was 89.5% (34/38). All eyes that underwent the repeated surgery (4 cases) 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 general group (N = 38), the duration of symptoms directly correlated with age (ρ = 0.34; p = 0.04), size of the hole (ρ = 0.66; p ˂ 0.001) and BCVA before surgery (ρ = 0.59; p ˂ 0.001), after 1 month (ρ = 0.36; p = 0.03), and after 3 months (ρ = 0.35; p = 0.03). Preoperative BCVA was better in initially closed cases (Group 1) (U = 26.0; 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 such eyes were 12.5 times less (2/34) 5.9% (F = 0.004; φ = 0.63; р ˂ 0.01). The ELM recovery rate at 3 months was 92% (35/38 eyes) and the restoration of EZ at 3 months was 47% (18/38 eyes). Best-corrected visual acuity of all individuals improved significantly from 0.72 ± 0.35 (logMAR) (Me = 0.7; IQR: 0.5-0.8) to 0.25±0.14 (logMAR) (Me = 0.2; IQR: 0.2 - 0.3) at 1 month and 0.17 ± 0.13 (logMAR) (Me = 0.2; IQR: 0.1 - 0.2) at 3 months after surgery (P = 0.0001).

Conclusion

25G PPV with ILM and GT for FTMH of different etiology 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.

Vitrectomy in diabetic macular edema - A swept-source optical coherence tomography (OCT) angiography study

Purpose

The foveal avascular zone (FAZ) has been reported to decrease after anti-VEGF injections in diabetic macular edema (DME) in the long term. This study aimed to present the changes in swept-source OCT angiography after vitrectomy in patients with DME.

Design

Retrospective interventional study.

Participants

Thirty-five eyes were included (mean age: 62 years).

Methods

Patients were followed for 12 months after vitrectomy with internal limiting membrane peeling for DME.

Main Outcome Measures

The following parameters were measured: central retinal thickness (CRT), central choroidal thickness, superficial FAZ, deep FAZ (dFAZ), and vessel density in the superficial and deep retinal layers (dVD).

Results

The CRT and superficial FAZ significantly decreased after surgery (401 μm–338 μm; P < 0.00, 401 μm–293 μm; P < 0.001, respectively). Initial visual acuity (VA) improved from 20/160 (0.97 logarithm of the minimum angle of resolution [LogMAR]) to 20/80 (0.62 LogMAR) (P < 0.001). The vessel density in the superficial retinal layers rate was 42.3% and decreased after surgery, reaching 41.6% at the end of the follow-up. The dVD rate 1 week after surgery was 28.9% and remained stable throughout the observation period. The most important prognostic factors for the final VA were preoperative VA and preoperative CRT, while the dFAZ and dVD at the time of edema resolution also correlated with the final VA.

Conclusions

The superficial FAZ decreases after vitrectomy, which might indicate that vitrectomy has a protective effect on DME, similar to anti-VEGF injections. Prognostic factors for better final functional results are better initial VA and lower CRT before vitrectomy, in addition to a lower dFAZ diameter and a higher dVD at the moment of edema resolution.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Macular Holes: Main Clinical Presentations, Diagnosis, and Therapies

Macular holes are a spectrum of retinal diseases that comprehends full-thickness macular holes (FTMHs), refractory/recurrent macular holes, lamellar macular holes (LMHs), myopic macular holes (MMHs), traumatic macular holes, and macular holes secondary to other retinal pathologies or injuries. There are various classifications of the subtypes of macular hole, and only in recent times researchers defined a common nomenclature, especially thanks to the evolution in retinal imaging, offered by new instruments like the swept-source OCT. The proposed therapies for macular holes are different and range from a “wait-and-see” approach to the vitrectomy, with different results in each subtype of macular hole. This narrative review has the purpose to investigate the available evidence in literature to give a summary of the knowledge about these retinal pathologies.

A Modified Surgical Technique for Submacular Injection

BACKGROUND AND OBJECTIVE

To describe a modified simple surgical technique for submacular injection.

PATIENTS AND METHODS

The technique involves pars plana vitrectomy, a viscous fluid control (VFC) system for semi-automatic subretinal injection of tissue plasminogen activator (tPA), bevacizumab, and air and intravitreal gas injection for submacular hemorrhage (SMH), or subretinal balanced salt solution (BSS) for submacular perfluorocarbon (PFC) bubbles or persistent macular holes.

RESULTS

This technique was successfully performed for SMH (five patients), a subfoveal PFC bubble (two patients), and persistent full-thickness macular hole (FTMH) (one patient). The single surgical complication was an FTMH in a PFC bubble. Four SMH patients had postoperative displacement of the hemorrhage. The FTMH was partially closed.

CONCLUSIONS

Semi-automatic subretinal injection of tPA, bevacizumab, and air with the VFC system promoted displacement and clearance of SMH without complications. A subretinal BSS injection is effective for removing subfoveal PFC bubbles and for closing persistent FTMH. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:551-555.].

A 24 month follow-up of refractory macular holes treated with an autologous transplantation of internal limiting membrane versus retina expansion technique

BACKGROUND

To compare the functional and anatomic outcomes at 24 months of eyes with a primary macular hole that failed to close after a prior surgery and were treated with either an autologous transplantation of internal limiting membrane (AT-ILM) or the retina expansion (RE) technique.

METHODS

Retrospective, single center, comparative study of 28 eyes with a macular hole that failed to close after a prior vitrectomy. All eyes had a size of ≥ 500 μm. Participants were divided into two groups according to the type of intervention performed: AT-ILM group (n = 14) and RE group (n = 14). Main outcomes measured were the MH closure rate assessed by spectral-domain optical coherence tomography (SD-OCT) and the best-corrected visual acuity (BCVA) at 24 months after surgery.

RESULTS

Patients in the AT-ILM group experienced a statistically significantly improved post-operative BCVA (median 49.50 letters, range 20-66 letters) over the pre-operative BCVA (median 39 letters, range 18-52 letters) (p-value = 0.006 Wilcoxon paired sample test). In contrast, patients in the RE group did not achieve a statistically significant improvement (p-value = 0.328, Wilcoxon paired sample test). The median pre-operative BCVA was 35 letters (range 18-52 letters), whereas the median post-operative BCVA was 39 letters (range 16-66 letters). At 24 months of follow-up, 85.7% of patients in the AT-ILM group achieved closure compared to 57.1% in the RE group (p-value = 0.209, Fisher's exact test). Multivariate analysis showed that MH size and baseline BCVA were important determinants of post-operative BCVA. The baseline MH size was the only significant pre-operative factor that influenced MH closure.

CONCLUSIONS

This study demonstrates similar closure rates for both groups however better visual outcomes were obtained with the AT-ILM.

Surgical Management of Recurrent and Persistent Macular Holes: A Practical Approach

Primary surgery for macular hole (MH) closure has a high success rate with current methods of pars plana vitrectomy and internal limiting membrane (ILM) peeling. When primary surgery fails, there are several options available for secondary repair, including extension of the ILM peel, creation of an ILM flap, pedunculated ILM flap, lens capsule flap transplantation, autologous retinal transplantation, use of a human amniotic membrane plug, adjuvant autologous platelet concentrate, induction of macular detachments with subretinal blebs, and creation of retinal incisions. In this review, we discuss the practical approach to each of these surgical techniques for the management of recurrent or persistent MHs.

Combination of Inverted ILM Flap Technique and Subretinal Fluid Application Technique for Treatment of Chronic, Persistent and Large Macular Holes

Introduction

The choice of surgical treatment for chronic, persistent and large full-thickness macular holes (FTMH) continues to be undefined and challenging, as some of these cases remain refractory to the treatment. We report the efficacy of combination of inverted internal limiting membrane flap technique (IILMFT) and subretinal application of the fluid (SR fluid application) technique for treatment of refractory FTMHs.

Methods

Nine patients (nine eyes) were enrolled into this retrospective non-randomized exploratory consecutive case series study. All patients were diagnosed with chronic, persistent or large FTMH and were treated with a combination of IILMFT and SR fluid application technique. The following outcome parameters were analysed during 1- and 6-month follow-up visits: anatomical FTMH closure rate on spectral domain optical coherence tomography (SD-OCT), best-corrected visual acuity (BCVA), degree of postoperative retinal displacement.

Results

The mean preoperative diameter of FTMH was 542.0 μm (range 154–1930 μm). Final closure of FTMH was achieved in nine of nine cases (100%). In one case a second operation was required because of postoperative rhegmatogenous retinal detachment. The mean BCVA after the FTMH closure increased from 1.0 logMAR (0.7–1.3) to 0.4 logMAR (0.2–0.8 logMAR) (W = 2.67; p = 0.008). A positive correlation was revealed between preoperative BCVA and axial length (ρ = 0.67, p = 0.048), between preoperative BCVA and duration of the symptoms (ρ = 0.818, p = 0.007), as well as between postoperative BCVA at 1-month follow-up and BCVA at 6-month follow-up (ρ = 0.821, p = 0.007).

Conclusion

Combination of IILMFT with SR fluid application technique for refractory FTMH surgery appears to be effective and safe. Improvement of anatomical and visual outcomes after the single surgery benefits from and is ensured by the advantages of both novel surgical approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00361-2.

Persistent macular holes - what is the best strategy for revision?

PURPOSE

This study aims to analyze the success rate and functional outcome after revision surgery of persistent idiopathic full-thickness macular holes in a large patient cohort and to identify the optimal tamponade strategy and the value of new adjunctive manipulation techniques for persistent macular hole (pMH) closure.

METHODS

Retrospective, comparative, non-consecutive case series of all revisional surgeries for idiopathic pMH between 2011 and 2019 at the Eye Clinic Sulzbach were identified. Of 1163 idiopathic MH surgeries, 74 eyes of 74 patients had pMH. Of those, group 1 (n = 38) had vitrectomy with tamponade alone (20% sulfur hexafluoride gas, 15% hexafluoroethane gas, silicone oil 5000, Densiron®), while group 2 (n = 36) included tamponade with adjuvant manipulation (internal limiting membrane (ILM) translocation, subretinal fluid injection, epiretinal amniotic membrane, free retina graft, or autologous blood). Main statistical outcomes were anatomic closure rate, visual acuity (VA), minimum linear diameter (MLD), and base diameter (BD).

RESULTS

Overall total anatomical success rate was 81.1% and mean VA improved 3.5 lines from LogMAR 1.03 ± 0.30 to 0.68 ± 0.38 (p < .001). Preoperative MLD or BD had no effect on total anatomic success (p = 0.074, p = 0.134, respectively). When comparing the two groups, slightly better anatomic success rates were achieved in group 1 (84.2%) compared to that in group 2 (77.8%) (p = 0.68). Final VA in group 1 (LogMAR 0.67 ± 0.39) outperformed group 2 (LogMAR 0.86 ± 0.38) (p = 0.03).

CONCLUSIONS

Revisional surgery for persistent idiopathic MH with tamponade alone had comparable anatomical closure but better VA outcomes, compared to tamponade with adjuvant manipulation.

[Macular detachment for treatment of large, persistent and chronic macular holes]

Large, persistent or chronic macular holes still represent a surgical challenge, which can be addressed using the presented surgical technique. A subretinal injection of balanced salt solution (BSS) at the posterior pole of the macular region is performed during transconjunctival pars plana vitrectomy in order to induce an elevation of the neurosensory retina in the macular region. The hole is then attenuated during fluid-air exchange, followed by a gas or silicone oil tamponade. The presented technique appears to be useful for large and persistent macular holes, which are not suitable for conventional macular hole surgery. The exact patient information on the potential outcome of surgery in this specific group of patients seems particularly important.

Hints for Gentle Submacular Injection in Non-Human Primates Based on Intraoperative OCT Guidance

Purpose

Delivery of Advanced Therapy Medicinal Products to the submacular space is increasingly evolving into a therapeutic modality. Cell replacement for age-related macular degeneration (AMD) and gene therapy for RPE65 are recent successful examples. Herein, a nonhuman primate (NHP) model was used to investigate surgical means to detach the macula.

Methods

Sixteen eyes of 13 healthy macaques underwent a 25-gauge vitrectomy and subretinal injection of balanced salt solution monitored by microscope-integrated intraoperative optical coherence tomography (miOCT). The animals were followed with OCT and histology.

Results

The miOCT monitoring allowed a more precise definition of surgical trauma ranging from an initial full-thickness foveal tear, or induction of a cystoid macular edema (CME), until no foveal defect was discernible, as the technique improved. However, as the subretinal fluid wave detached the fovea, the aforementioned lesions formed, whereas persistent retinal adhesion reproducibly proved to remain in the distal parafoveal semi-annulus. Measures to reduce foveal trauma during submacular fluid injection included reducing intraocular pressure, injection volume, and velocity, as well as the retinal location for bleb initiation, use of a vitreous tamponade, and a dual-bore subretinal cannula.

Conclusions

A stable very low intraocular pressure and careful subretinal injection may avoid tangential macular stretching or mechanical CME formation, while vitreous tamponade may facilitate a more lamellar subretinal flow, all thereby reducing foveal trauma during submacular injection in NHP.

Translational Relevance

These results can be relevant to any submacular surgery procedure used today, as they synergistically reduce the risk of compromising foveal integrity.

Silicone oil tamponade for persistent macular holes

BACKGROUND

A variety of treatment strategies have been proposed for macular holes that persist or recur after surgery, and the debate about the best re-treatment approach is ongoing. To allow for a comparison with alternative surgical therapies, we assessed the anatomical and functional outcome of a temporary tamponade with conventional silicone oil in persistent or recurrent full-thickness macular holes.

METHODS

We retrospectively investigated consecutive patients with full-thickness macular holes that persisted or recurred following vitrectomy with internal limiting membrane peeling and gas tamponade. All patients received re-treatment by temporary tamponade of silicone oil and were allowed free postoperative positioning. Anatomical closure rate was assessed by optical coherence tomography, and change of best-corrected visual acuity (BCVA) was analyzed.

RESULTS

A total of 33 eyes of 33 consecutive patients were included. Macular hole closure following silicone oil tamponade was achieved in 30 of 33 eyes (90.9%). Median BCVA improved from 1.00 logMAR (interquartile range, 0.60-1.00) to 0.65 logMAR (0.49-1.00; p = 0.010) after silicone oil removal. In patients with macular hole closure, 61.3% exhibited functional improvement with median BCVA changing from 1.00 logMAR (0.70-1.00) to 0.60 logMAR (0.49-1.00; p = 0.0005). Mean minimal linear diameter of macular holes before primary surgery was 391.0 µm (±137.8; range 133-630), and 48.5% of macular holes were >400 µm in diameter.

CONCLUSIONS

Treatment of persistent or recurrent full-thickness macular holes by temporary conventional silicone oil tamponade without postoperative positioning results in a high closure rate and a significant mean improvement of visual acuity.