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

Platelet-rich Fibrin Membrane Transplantation for the Treatment of Highly Myopic Macular Hole Retinal Detachment

INTRODUCTION

Highly myopic macular hole retinal detachment (MHRD) is often associated with a poor prognosis, and there is currently no optimal treatment. Platelet-rich fibrin (PRF), an autologous blood product, has been shown to promote tissue regeneration. This prospective, randomized, controlled study investigated the efficacy of conventional internal limiting membrane (ILM) peeling versus PRF membrane transplantation in highly myopic MHRD.

METHODS

Eyes with highly myopic MHRD were randomly assigned to either a conventional ILM peeling group (IP group, n = 19) or a PRF membrane transplantation group (PMT group, n = 21). The study followed participants for a period of 6 months. The primary outcome measure was macular hole (MH) closure assessed using optical coherence tomography. Secondary outcomes included best-corrected visual acuity (BCVA), central retinal thickness (CRT), superficial vascular density (SVD), deep vascular density (DVD), rate of retinal reattachment, and any complications encountered.

RESULTS

MH closure was achieved in a significantly greater proportion of eyes in the PMT group (21/21, 100.00%) compared to the IP group (15/19, 78.95%) (P = 0.042). Retinal reattachment was accomplished in all patients (100.00%) within both groups. Except for an insignificant difference in BCVA observed at 1 week post-surgery in the IP group, significant improvements in BCVA and CRT were documented in both groups across all other post-operative time points. Final BCVA (P = 0.040), CRT (P = 0.002), SVD (P = 0.002), and DVD (P = 0.013) were all significantly higher in the PMT group compared to the IP group. No serious complications were identified in either group.

CONCLUSIONS

This study demonstrated the superiority of PRF membrane transplantation compared to conventional ILM peeling in promoting MH closure and enhancing retinal vascular density in patients with highly myopic MHRD. Additionally, PRF membrane transplantation effectively restores retinal reattachment, improves visual function, and increases retinal thickness without introducing additional complications.

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gov , NCT06200727.

Long-term Visual Outcomes in Patients With Idiopathic Macular Hole Surgery

BACKGROUND AND OBJECTIVE

This study assesses long-term outcomes following surgical repair of idiopathic full-thickness macular holes (FTMHs) in patients with at least 5 years of postoperative follow-up.

PATIENTS AND METHODS

A retrospective study evaluated patients diagnosed with idiopathic FTMH who received surgical repair at a single tertiary center with at least 5 years of postoperative follow-up. Data collection included demographic and preoperative characteristics along with macular hole structural integrity as determined by spectral-domain optical coherence tomography (OCT). Functional and structural improvement were assessed by collection of visual acuity and findings on OCT at determined time points until 9 years of follow-up.

RESULTS

The study comprised 90 eyes of 80 patients with a mean age of 67.2 ± 6.8 years, with an average postoperative follow-up of 80.8 ± 17.4 months (range 54 to 130 months). The mean macular hole diameter was 239.7 µm ± 92.2. Macular hole reoperation occurred in four eyes (4%) at a mean duration of 5.5 ± 6 months (range 0.3 to 13 months). Over the study duration, ellipsoid zone (EZ) integrity was maintained in 67.8% of eyes, with an absence of intraretinal fluid (IRF) in 96% on final OCT. The preoperative mean Early Treatment Diabetic Retinopathy Study (ETDRS) best visual acuity (BVA) of 51 improved to a mean BVA of 76 at 5 years postoperatively, with an average gain of 24 letters at one year that remained stable over 5 years (P < 0.05). Eight years after surgical repair, more than 80% of patients achieved a BVA > 65.

CONCLUSIONS

Vitreoretinal surgery for idiopathic FTMH resulted in successful hole closure and sustained visual acuity improvement over long-term follow-up. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Effect of internal limiting membrane surgical techniques on the idiopathic and refractory management of macular holes: a systematic review and meta-analysis

Macular holes (MHs), including atraumatic idiopathic and refractory MHs, affect central vision acuity due to full-thickness defects in the retinal tissue. The existing controversy regarding the pathophysiology and management of MHs has significantly improved with the implementation of internal limiting membrane (ILM) surgical techniques and improved MH closure rates. Thus, to determine the effect of ILM techniques on large idiopathic and refractory MH management, the present study systematically reviewed 5910 original research articles extracted from online literature databases, including PubMed, Cochrane, Google Scholar, and Embase, following the PRISMA guidelines. The primary outcome measures were MH closure rate and postoperative visual acuity. A total of 23 randomized controlled trials (RCTs) with adequate patient information and information on the effect of ILM peeling, inverted ILM flaps, autologous retinal transplantation (ART), and ILM insertion techniques on large idiopathic and refractory MH patients were retrieved and analyzed using RevMan software (version 5.3) provided by the Cochrane Collaboration. Statistical risk of bias analysis was also conducted on the selected sources using RoB2, which showed a low risk of bias in the included studies. A meta-analysis indicated that the inverted ILM flap technique had a significantly greater MH closure rate for primary MH than the other treatment methods (OR = 3. 22, 95% CI 1.34-7.43; p = 0.01). Furthermore, the findings showed that the inverted ILM flap group had significantly better postoperative visual acuity than did the other treatment options for patients with idiopathic MH (WMD = - 0.13; 95% CI = 0.22-0.09; p = 0.0002). The ILM peeling technique had the second highest statistical significance for MH closure rates in patients with idiopathic MH (OR = 2. 72, 95% CI: 1.26-6.32; p = 0.016). In refractory MHs, autologous retinal transplant (ART) and multilayer ILM plug (MIP) techniques improve the closure rate and visual function; human amniotic membrane grafting (hAMG) provides a high degree of anatomical outcomes but disappointing visual results. This study demonstrated the reliability and effectiveness of ILM techniques in improving the functional and anatomical outcomes of large idiopathic and refractory MH surgery. These findings will help clinicians choose the appropriate treatment technique for patients with idiopathic and refractory MH.

Severe Gliosis Over a Closed Macular Hole Following Anterior Lens Capsular Flap Closure

Various management strategies, including the use of autologous and allogenic materials, are described for the management of persistent macular holes. An anterior lens capsular flap can be used, especially when cataract surgery is also planned, for a persistent full-thickness macular hole. We report a case of a gentleman in his 60s who underwent anterior lens capsular flap closure for a persistent macular hole. There was an improvement in visual acuity. However, he developed severe gliosis over the closed hole in the postoperative period. This could be due to the proliferation of residual epithelial cells in the lens capsule, micro damage to the retina, or an exaggerated inflammatory response to a foreign tissue placed over the retinal surface.

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.

Human amniotic membrane graft for refractory macular hole: A single-arm meta-analysis and systematic review

PURPOSE

The treatment of refractory macular holes is controversial, with human amniotic membrane grafts emerging recently as an attractive option. We performed a meta-analysis and systematic review in this paper to assess the results of human amniotic membrane (hAM) in the treatment of refractory macular hole (MH).

METHODS

We searched the Cochrane Database of Systematic Reviews, Web of Science, PubMed, Embase, China National Knowledge Infrastructure databases, VIP database, Wanfang Data Knowledge Service Platform, Sinomed, Chinese Clinical Trial Registry, and Clinical Trials.gov. Studies reporting hAM for the treatment of refractory MH were included. The outcomes are MH closure rate, visual acuity (VA) improvement rate, and graft dislocation/contracture rate.

RESULTS

A total of 8 studies on 103 eyes were included, all of which had undergone failed vitrectomy and internal limiting membrane (ILM) peeling. In all studies, the VA improvement rate was 66% (95%CI: 45 to 84%), the MH closure rate was 94% (95%CI: 84 to 100%) and the hAM graft dislocation/contracture rate was 6% (95%CI: 0 to 15%). In the studies using cryopreserved hAM grafts, the MH closure rate was 99% (95%CI: 94 to 100%) and the hAM graft dislocation/contracture rate was 3% (0%, 10%). The VA improvement rates were 94% (95%CI: 79 to 100%) in the retinal detachment subgroup, 37% (95%CI: 20 to 56%) in the pathologic myopia subgroup, and 62% (95%CI: 14 to 100%) in the idiopathic MH subgroup.

CONCLUSION

Human amniotic membrane in the treatment of refractory MH results in visual improvement. It has a high macular hole closure rate and low dislocation/contracture rate. Cryopreserved hAM grafts might have better outcomes than dehydrated grafts.

Update on surgical management of complex macular holes: a review

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.