Surgical management of macular holes: results using gas tamponade alone, or in combination with autologous platelet concentrate, or transforming growth factor beta 2

Platelet concentrates in macular hole surgery. A journey through the labyrinth of terminology, preparation, and application: a comprehensive review

The surgical management of macular holes is undergoing continuous evolution, with recent focus on the utilization of platelet concentrates as a promising adjunctive intervention. Currently, they present a valid surgical approach for achieving anatomical and functional success with a non-inferiority comparably to the alternative surgical techniques. Nonetheless, the utilization of varied platelet concentrates terminologies, coupled with the lack of standardization in their preparation methodologies, engenders both lexical confusion and challenges in comparing scientific studies published up until now. In this review, we summarized the published evidence concerning the application of platelet concentrates in macular holes surgery, aiming to clarify the terminology and methodologies employed and to establish a common consensus facilitating further development and diffusion of this promising technique.

Autologous anterior lens capsule flap and serum transplant in managing idiopathic and refractory full-thickness macular holes

PURPOSE

To report the results of pars plana vitrectomy (PPV) with inner limiting membrane (ILM) peeling alongside phacoemulsification and intraocular lens (IOL) implantation with autologous anterior lens capsule flap (ALCF) and autologous serum transplantation (AST) into full-thickness macular holes (FTMH) and 14% perfluoropropane (C3F8) tamponade for idiopathic and refractory FTMHs.

METHODS

Retrospective study involving eleven patients with idiopathic FMTHs and seven with refractory FMTHs after standard surgery with PPV, ILM peeling, and gas tamponade. All eyes underwent a 'combination procedure' of PPV with ILM peeling alongside phacoemulsification and IOL implantation with autologous ALCF and AST into the FTMH and 14% C3F8 tamponade. A face-down position for one week was recommended.

RESULTS

The mean preoperative FMTH size was 558.95 ± 186.30 µm. Seven patients aged 64 ± 5 years had a refractory FMTH and eleven patients with a mean age of 63.72 ± 4.97 years had an idiopathic FMTH. The main BCVA improvement six months postoperatively was 0.3 ± 0.29 logMAR. Seventeen macular holes fully closed six months postoperatively, with one FTMH closure failure because of a retinal detachment.

CONCLUSIONS

ALCF transplantation alongside AST may help to improve the closure rate and visual outcomes in both idiopathic and refractory FMTHs.

Autologous platelet concentrate in epiretinal membrane surgery: A single-centre prospective comparative non-inferiority study

PURPOSE

The purpose of the study was to compare the anatomical and functional results including reading ability after epiretinal membrane (ERM) surgery in patients with and without the use of autologous platelet concentrate (APC).

METHODS

Design: Prospective, comparative non-inferiority series.

SETTING

Institutional.

PATIENTS

51 eyes of 51 patients, who underwent pars-plana vitrectomy (PPV) for ERM surgery. 29 eyes additionally received intraoperative APC, 22 eyes underwent standard procedure without APC use.

OBSERVATIONS

anatomical and functional outcome parameters (central retinal thickness (CRT), best corrected visual acuity (BCVA) and reading ability (RA)) were compared between the two groups at 6 weeks and 6 months postoperatively. Subjective assessment of visual acuity and reading ability was also analysed.

MAIN OUTCOME MEASURES

BCVA, RA and CRT.

RESULTS

Both groups showed significant CRT reduction and RA improvement, while BCVA improvement was significant only in eyes with intraoperative APC use during the follow-up time of 6 months. There was no statistically significant difference between CRT reduction, BCVA and RA improvement between the groups.

CONCLUSION

Intraoperative APC use for ERM surgery results in similar anatomical and functional outcomes compared with standard ERM surgery without APC use.

THERAPEUTIC EFFECT OF USING AUTOLOGOUS PLATELET CONCENTRATE IN VITRECTOMY FOR MACULAR HOLE: A Systematic Review and Meta-Analysis

PURPOSE

To summarize the current evidence regarding the therapeutic effect of using autologous platelet concentrate (APC) in vitrectomy for macular hole (MH).

METHODS

The PubMed, Web of Science, and Embase databases were searched according to the PROSPERO protocol (CRD42022366202). Controlled trials comparing whether APC was used in the vitrectomy of MH were included. The primary outcome was the closure rate of MH and postoperative best-corrected visual acuity, and the secondary outcome was the incidence of different types of complications.

RESULTS

Seven studies that included 634 eyes were eligible. For the primary outcome, the usage of APC significantly improved the closure rate of MH in vitrectomy (odds ratio [OR] = 5.34, 95% confidence interval, 2.83-10.07, P < 0.001). Postoperative visual acuity did not significantly differ between the APC group and similar baseline controls (SMD = -0.07, 95% confidence interval, -0.35 to 0.22, P = 0.644). For the secondary outcome, using APC did not result in additional complications regarding postoperative retinal detachment or the recurrence of MH.

CONCLUSION

The use of APC in vitrectomy was associated with a superior closure rate of the hole and no additional complications; therefore, it is effective and safe in MH surgery.

Plasma Rich in Growth Factors (PRGF) Increases the Number of Retinal Müller Glia in Culture but Not the Survival of Retinal Neurons

Plasma rich in growth factors (PRGF) is a subtype of platelet-rich plasma (PRP) that stimulates tissue regeneration and may promote neuronal survival. It has been employed in ophthalmology to achieve tissue repair in some retinal pathologies, although how PRGF acts in the retina is still poorly understood. As a part of the central nervous system, the retina has limited capacity for repair capacity following damage, and retinal insult can provoke the death of retinal ganglion cells (RGCs), potentially producing irreversible blindness. RGCs are in close contact with glial cells, such as Müller cells, that help maintain homeostasis in the retina. In this study, the aim was to determine whether PRGF can protect RGCs and whether it increases the number of Müller cells. Therefore, PRGF were tested on primary cell cultures of porcine RGCs and Müller cells, as well as on co-cultures of these two cell types. Moreover, the inflammatory component of PRGF was analyzed and the cytokines in the different PRGFs were quantified. In addition, we set out to determine if blocking the inflammatory components of PRGF alters its effect on the cells in culture. The presence of PRGF compromises RGC survival in pure cultures and in co-culture with Müller cells, but this effect was reversed by heat-inactivation of the PRGF. The detrimental effect of PRGF on RGCs could be in part due to the presence of cytokines and specifically, to the presence of pro-inflammatory cytokines that compromise their survival. However, other factors are likely to be present in the PRGF that have a deleterious effect on the RGCs since the exposure to antibodies against these cytokines were insufficient to protect RGCs. Moreover, PRGF promotes Müller cell survival. In conclusion, PRGF hinders the survival of RGCs in the presence or absence of Müller cells, yet it promotes Müller cell survival that could be the reason of retina healing observed in the in vivo treatments, with some cytokines possibly implicated. Although PRGF could stimulate tissue regeneration, further studies should be performed to evaluate the effect of PRGF on neurons and the implication of its potential inflammatory role in such processes.

The Effect of Plasma Rich in Growth Factors on Microglial Migration, Macroglial Gliosis and Proliferation, and Neuronal Survival

Plasma rich in growth factors (PRGF) is a subtype of platelet-rich plasma that has being employed in the clinic due to its capacity to accelerate tissue regeneration. Autologous PRGF has been used in ophthalmology to repair a range of retinal pathologies with some efficiency. In the present study, we have explored the role of PRGF and its effect on microglial motility, as well as its possible pro-inflammatory effects. Organotypic cultures from adult pig retinas were used to test the effect of the PRGF obtained from human as well as pig blood. Microglial migration, as well as gliosis, proliferation and the survival of retinal ganglion cells (RGCs) were analyzed by immunohistochemistry. The cytokines present in these PRGFs were analyzed by multiplex ELISA. In addition, we set out to determine if blocking some of the inflammatory components of PRGF alter its effect on microglial migration. In organotypic cultures, PRGF induces microglial migration to the outer nuclear layers as a sign of inflammation. This phenomenon could be due to the presence of several cytokines in PRGF that were quantified here, such as the major pro-inflammatory cytokines IL-1β, IL-6 and TNFα. Heterologous PRGF (human) and longer periods of cultured (3 days) induced more microglia migration than autologous porcine PRGF. Moreover, the migratory effect of microglia was partially mitigated by: 1) heat inactivation of the PRGF; 2) the presence of dexamethasone; or 3) anti-cytokine factors. Furthermore, PRGF seems not to affect gliosis, proliferation or RGC survival in organotypic cultures of adult porcine retinas. PRGF can trigger an inflammatory response as witnessed by the activation of microglial migration in the retina. This can be prevented by using autologous PRGF or if this is not possible due to autoimmune diseases, by mitigating its inflammatory effect. In addition, PRGF does not increase either the proliferation rate of microglial cells or the survival of neurons. We cannot discard the possible positive effect of microglial cells on retinal function. Further studies should be performed to warrant the use of PRGF on the nervous system.

Ophthalmic use of blood-derived products

There is a wide spectrum of blood-derived products that have been used in many different medical and surgical specialties with success. Blood-derived products for clinical use can be extracted from autologous or allogeneic specimens of blood, but recombinant products are also commonly used. A number of blood derivatives have been used for a wide range of ocular conditions, from the ocular surface to the retina. With stringent preparation guidelines, the potential risk of transmission of blood-borne diseases is minimized. We review blood-derived products and how they are improving the management of ocular disease.

Recovery of photoreceptor layer on spectral-domain optical coherence tomography after vitreous surgery combined with air tamponade in chronic idiopathic macular hole

BACKGROUND AND OBJECTIVE

Studies using sterilized air in chronic idiopathic macular holes show varying success rates, and the impact of a shorter duration of tamponade on photoreceptor layer recovery is not fully elucidated.

PATIENTS AND METHODS

Surgical outcomes of 35 cases (seven in stage 3 and 28 in stage 4) were assessed for best corrected visual acuity and with spectral-domain optical coherence tomography.

RESULTS

The primary closure rate was 91.4%, and the closed cases and unclosed cases were significantly different in the preoperative (P = .042) and postoperative (P = .040) diameter of the photoreceptor layer defect. After surgery, there was a significant improvement in best corrected visual acuity and a decrease in the photoreceptor layer defect. The postoperative logarithm of the minimal angle of resolution was significantly correlated with the preoperative hole diameter (P = .003) and the postoperative diameter of the photoreceptor layer defect (P = .005).

CONCLUSION

Air tamponade is a safe and effective treatment for chronic and severe macular holes, with several spectral-domain optical coherence tomography parameters highly predictive of postoperative visual acuity.

Idiopathic macular hole: analysis of visual outcomes and the use of indocyanine green or brilliant blue for internal limiting membrane peel

BACKGROUND

Our aim was to analyze outcomes of idiopathic macular hole surgeries in relation to staging and the use of indocyanine green (ICG) or brilliant blue (BB) for internal limiting membrane (ILM) peel.

METHODS

Baseline, surgical, and outcome data for 351 consecutive primary macular hole surgeries was prospectively collected using electronic medical record software between 2001 and 2011. The outcomes for these cases were analysed in relation to staging and the use of ICG (0.5 mg/ml) or BB for ILM peel.

RESULTS

Mean age was 68.9 years (range 39-87) with 66.4 % females and 54.1 % right eyes. Follow-up duration was median 0.55 years. Vision was significantly improved from logMAR 0.97 (SD 0.45) (Snellen equivalent 20/185) preoperatively to 0.65 (SD 0.51) (20/90) at final follow-up. One hundred and eighteen patients had stage 2 macular holes, 185 stage 3, and 48 stage 4. Mean duration of symptoms varied with stage of hole: stage 2 0.53 years (SD 0.43), stage 3 0.79 years (SD 0.68), and stage 4 1.20 years (SD 1.26), p = 0.0002. Closure rates of the holes were significantly different, with stage 2 closing in 95.8 %, stage 3 in 73.0 %, and stage 4 in 56.3 %, p < 0.0001. At final follow-up, mean visual acuity (VA) was 0.42 (SD 0.33) (20/50) for stage 2, 0.75 (SD 0.53) (20/110) for stage 3, and 0.87 (SD 0.60) (20/145) for stage 4 holes, p < 0.0001. Postoperative VA was 0.71 (SD 0.53) (20/100) for patients in whom ICG was used, and 0.52 (SD 0.43) (20/70) for BB, p = 0.003. The proportion of patients who achieved a closed hole was less for ICG (73.2 %) than BB (89.9 %), p = 0.0005. For those patients with stage 2 hole who achieved hole closure, mean improvement in VA was significantly better for BB (0.47, SD 0.36) than for ICG (0.30, SD 0.31), p = 0.01.

CONCLUSIONS

Macular hole stage is a useful measure to help predict the chance of postoperative hole closure and visual outcome. The relationship between duration of symptoms and increasing stage suggests macula hole patients require prompt referral for consideration of early surgery. Better visual outcomes were achieved with BB for ILM peel than with ICG.

Efficacy of autologous platelets in macular hole surgery

The introduction of optical coherence tomography has allowed accurate measurement of the size of macular holes. A retrospective consecutive review was performed of 21 patients undergoing macular hole repair with vitrectomy, gas tamponade, and autologous platelet injection and we assessed the effect of macular hole parameters on anatomic and functional outcomes. We looked at the demographic features, final visual outcome, and anatomical closure. Twenty-one patients were included in the study. They underwent routine vitrectomy with gas tamponade (C3F8) and injection of autologous platelets. All patients were advised to maintain a facedown posture for 2 weeks. Anatomical closure was confirmed in all cases and 20 out of 21 of patients had improved postoperative visual acuity by two or more lines. In our series, the macular hole dimensions did not have much effect on the final results. The use of autologous platelets and strict facedown posture seems to be the deciding factor in good anatomical and visual outcome irrespective of macular hole dimensions.

Management of Stage IV Macular Holes: When Standard Surgery Fails

Purpose

To report the surgical outcomes of reoperation of unclosed macular holes after initial vitrectomy with internal limiting membrane peeling.

Procedures

Seven eyes of 7 patients were submitted to a second procedure in which five radial retinal incisions were made, as deep as the retinal pigment epithelium, beginning one hole diameter away from its borders and extending centripetally until the hole's margins, avoiding the papilomacular bundle. Gas tamponade was performed and face-down positioning was recommended.

Results

Anatomical closure was achieved in all cases with the second procedure. Functional success was achieved in every patient; there was no loss of best corrected visual acuity (BCVA) lines. Mean line score gain was 5.6 lines (range 1–9 lines), with a mean final BCVA of 0.42 (range 0.05–0.5).

Conclusions

Perifoveal relaxing incisions in stage IV macular holes that remained unclosed after internal limiting membrane peeling vitrectomy seem to have a positive effect on MH closure rates. Larger case series and an extended follow-up period are necessary in order to assess the efficacy and safety profile of this so far promising technique.

Spontaneous traumatic macular hole closure in a 50-year-old woman: a case report

Introduction

Traumatic macular holes (TMH) are well-known complications of ocular contusion injury. Spontaneous closure occurs in approximately 50% of cases, but rarely after the age of thirty. We report a case of spontaneous closure of a full thickness macular hole due to a blunt trauma and we suggest possible mechanisms for this closure.

Case presentation

A 50-year-old Greek woman was referred with a history of reduced best-corrected visual acuity after blunt trauma to her right eye. Diagnosis was based on fundoscopic, optical coherence tomography as well as fluorescein angiography findings with follow-up visits at two days, 20 days and five months. Fundoscopy revealed a full-thickness TMH with a minor sub-retinal hemorrhage and posterior vitreous detachment. The presence of a coagulum in the TMH base was observed. Subsequently, TMH closure was observed.

Conclusion

The clot in the TMH base, potentially a hemorrhage by-product containing a significant quantity of platelets, may have simulated the clot observed after autologous serum use, thus facilitating a similar effect. This may have stimulated glial cell migration and proliferation, thus contributing to spontaneous hole closure.

Equivalent tamponade by room air as compared with SF(6) after macular hole surgery

BACKGROUND

To evaluate the effect of tamponade by room air after vitrectomy for the treatment of idiopathic macular hole (MH).

METHODS

There were 156 eyes of 151 patients studied. The patients' ages ranged from 35 to 88 years old (mean: 65.1 years). After conventional pars plana vitrectomy with internal limiting membrane peeling, fluid air exchange was performed using 20% SF(6) (Gas group: 91 eyes) or room air (Air group: 65 eyes). Surgical outcomes were retrospectively analyzed.

RESULTS

Mean preoperative hole diameter was 352 microm in the Gas group and 370 microm in the Air group (P = 0.558). The closure rate of all cases was 91.0% after first surgery and 98.7% at last follow-up. The primary closure rate was 90.1% in the Gas group after 7.44 +/- 1.66 (mean +/- SD) days prone positioning period, and 92.3% in the Air group after 3.83 +/- 0.97 days of prone positioning. There was significant difference in prone positioning period (P < 0.0001), but not in the first closure rate (P = 0.132).

CONCLUSION

This study suggests that room air may have an equivalent tamponade effect, in spite of the shorter prone positioning period, than SF(6) after MH surgery.

Internal Limiting Membrane Removal during Macular Hole Surgery

PURPOSE

To evaluate the effect of internal limiting membrane (ILM) peeling and other variables in hole closure and functional success rate after idiopathic macular hole surgery.

DESIGN

Retrospective, multicenter, observational study.

METHODS

The records of 1627 patients operated on for idiopathic macular hole were collected retrospectively from 28 surgeons. All patients underwent a single pars plana vitrectomy and were divided into 2 groups: with and without ILM peeling. Preoperative, intraoperative, and postoperative variables were evaluated.

RESULTS

The overall rate of macular hole closure was 94.1% in the ILM peeling group and 89.0% in the no ILM peeling group (P<0.001). The probability of achieving hole closure after surgery is 2.59 times higher if the ILM is peeled (95% confidence interval [CI], 1.71-3.92; P<0.001), 3.12 times higher for holes lasting less than 6 months (95% CI, 1.70-5.71; P<0.001), 4.94 (95% CI, 2.39-10.20) for stage 2 holes, and 2.34 (95% CI, 1.55-3.53) for stage 3 holes than that of patients with a stage 4 hole (P<0.001).

CONCLUSIONS

Internal limiting membrane peeling seems to improve hole closure for stage 3 and 4 holes and for long-lasting holes. Higher-stage macular holes and longer duration of symptoms are risk factors for surgical failure. In patients obtaining hole closure, there is no difference in functional results between pseudophakic peeled and not peeled patients, whereas in phakic patients, a better functional result in not peeled patients was seen.

Duration of face-down positioning after macular hole surgery: a comparison between 1 week and 3 days

PURPOSE

To investigate whether shortening the duration of face-down positioning from 1 week to 3 days affects the anatomical success rate of macular hole surgery.

METHODS

A total of 53 consecutive eyes in 50 patients with full thickness macular holes of 2-24 months' (average 10 months) duration were included in the study. In 20 eyes (37.7%) the hole had been present for more than 1 year. All patients were operated with vitrectomy, removal of the posterior hyaloid and a complete fluid-gas exchange. Peeling of the internal limiting membrane (ILM) was not performed. Postoperatively, the duration of face-down positioning differed between two consecutive groups of patients. The first group (29 patients) was instructed to keep their heads face-down for 7 days, while the second group (24 patients) maintained face-down positioning for only 3 days.

RESULTS

Overall, 90.6% of the macular holes closed with one operation. The macular hole closed successfully in 27 (93.1%) of the 29 eyes in the 1-week group and in 21 (87.5%) of the 24 eyes in the 3-day group (p > 0.05).

CONCLUSION

Although the frequency of hole closure differed slightly in the two study groups, the difference was far from statistically significant. Thus, the results indicate that 3 days of strict face-down positioning are sufficient to achieve closure of even longstanding macular holes without removal of the ILM.

Anatomical success rate of macular hole surgery with autologous platelet without internal-limiting membrane peeling

AIM

To describe our experience and success rate of macular hole surgery with pars plana vitrectomy with autologous platelet and without internal limiting membrane peel.

METHODS

Retrospective review of 56 consecutive patients who underwent macular hole surgery.

RESULTS

Anatomical success was achieved in 55 out of 56 patients (98.2%). Functional success was achieved in 37 out of 56 patients (66.1%). A total of 21 patients (37.5%) achieved postoperative visual acuity of 6/12 or better. No intraoperative complications were encountered. Postoperative complications included cataract progression in eight eyes and raised intraocular pressure in 20 eyes.

CONCLUSIONS

Our success rate was comparable to that reported in macular hole surgery incorporating internal limiting membrane (ILM) peel or with autologous platelet without ILM peel.

Results of vitrectomy and the no-touch-technique using autologous adjuvants in macular hole treatment

BACKGROUND

Anatomic and functional results of macular holes using vitrectomy and platelet-concentrate (PC) or autologous whole blood (WB) were investigated without peeling any epiretinal membrane in order to minimize retinal trauma.

METHODS

44 patients with macular holes stage II, III and IV underwent a vitrectomy with removal of posterior cortical vitreous (in stage II and III) and C2F6 gas endotamponade. No peeling of any epiretinal membrane or the ILM was performed. In 14 patients autologous WB was injected and in 30 patients autologous PC. The mean follow-up time was 9.3 months.

RESULTS

An anatomic closure was observed in 36.4% of patients in the WB-group and in 93.9% of patients in the PC-group. SLO-microperimetry showed a reduction of absolute scotomas in 80% of the WB- and in 75% of the PC-group. In the WB-group 1 retinal detachment and 1 branch vein occlusion occurred; in the PC-group 3 retinal detachments, 1 central artery occlusion, 1 macular pucker, 1 cystoid macular edema, 1 late reopening and 1 secondary glaucoma were observed. In both groups no endophthalmitis occurred.

CONCLUSION

If autologous platelet concentrate is available, high anatomic success rates can be achieved without aggressive membrane removal, which may cause retinal damage. Autologous whole blood cannot be recommended as an alternative adjunct for the treatment of macular holes without membrane removal.

Phacovitrectomy without prone posture for full thickness macular holes

AIMS

To investigate the role of phacovitrectomy surgery without prone posture for stage 2 and 3 macular holes.

METHODS

A pilot study was performed on 20 patients (20 eyes) having phacoemulsification lens removal and vitrectomy surgery with 20% C(2)F(6) tamponade. Patients were advised to avoid lying on their backs for 10 days following surgery but no other posturing instructions were given. Closure rates and improvement in visual acuity were compared with a group of historical controls in whom phacovitrectomy with gas tamponade and face down posturing was performed.

RESULTS

Anatomical hole closure was noted in 18 of the 20 eyes (90%). 19 eyes (95%) showed an improvement of at least 0.3 logMAR units. This compares favourably with the postured group in which anatomical hole closure was noted in 11 of 13 eyes (85%) and nine of 13 eyes (69%) showed an improvement of at least 0.3 logMAR units.

CONCLUSION

Combined surgery facilitates the use of a large gas bubble. Sufficient tamponade of the hole occurs for closure without prone posturing. Combined surgery prevents patients posturing and returning for cataract surgery.

Surgical management of macular holes: a report by the American Academy of Ophthalmology

OBJECTIVE

The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique.

METHODS

A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented.

RESULTS

There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%).

CONCLUSIONS

The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

The macular hole: report of an Australian surgical series and meta-analysis of the literature

PURPOSE

To report an Australian series of macular hole surgery by pars plana vitrectomy and fluid-gas exchange, and to identify factors influencing the outcome of the surgery through meta-analysis of the literature.

METHODS

Fifty-six consecutive cases of macular hole were treated by pars plana vitrectomy, fluid-gas exchange and face-down positioning for at least 7 days, and prospectively followed for 3-12 months. Thirty-six reports of macular hole surgery were reviewed. A meta-analysis on the pre- and postoperative parameters was performed on 389 cases, in which case-specific data-points were available.

RESULTS

In the current series, anatomical closure was achieved in all (100%) of 16 stage 2, and in 35 (87.5%) of 40 stage 3 or 4 macular holes. At least 2 logMAR lines of improvement in visual acuity were seen in 10 (62.5%) stage 2 and 20 (50.0%) stage 3 or 4 holes. Postoperative visual acuity was 6/12 or better in 10 (62.5%) stage 2 and 17 (42.5%) stage 3 or 4 holes. In both the current series and the meta-analysis, favourable surgical outcomes were associated with stage 2 macular holes, better preoperative visual acuity, and shorter preoperative duration. Adjuvant use was associated with a higher rate of anatomical closure but there was no clear benefit in terms of postoperative visual acuity.

CONCLUSION

Our experience and the results of the meta-analysis suggest that macular hole surgery should be offered as early as possible once full-thickness neuroretinal defect occurs.

Internal limiting membrane removal in the management of full-thickness macular holes

PURPOSE

To determine the effectiveness of removal of the internal limiting membrane in the treatment of full-thickness macular holes.

METHODS

Data were reviewed from a prospective study on 47 consecutive eyes with full-thickness macular holes undergoing vitrectomy, internal limiting membrane maculorhexis, and fluid-gas exchange. No eye underwent repeat macular hole surgery. A meta-analysis was performed to compare the outcomes of different surgical techniques in the treatment of full-thickness macular holes.

RESULTS

The outcome measures were disappearance of the submacular fluid and the change in best-corrected visual acuity. The surgery was anatomically successful in 44 of the 46 eyes (96%) and 39 of the eyes (85%) showed an improvement of at least two Snellen lines. Best-corrected final vision was 20/40 in 18 (39%) eyes. No permanent complications specifically caused by the removal of the macular internal limiting membrane were detected; the minor hemorrhages and retinal edema seen in most eyes resolved spontaneously. Retinal detachment developed and was successfully treated in three eyes (7%). A meta-analysis on 1,654 eyes from published reports showed that internal limiting membrane maculorhexis appears to significantly (P <.0001) increase the anatomical and functional success rates in macular hole surgery.

CONCLUSIONS

Internal limiting membrane removal is an important development in the evolving field of macular hole surgery. A randomized, prospective, multicenter clinical trial should be performed to determine which surgical technique is the most beneficial in patients with full-thickness macular holes.

Surgery for full-thickness macular holes with short-duration prone posturing: results of a pilot study

PURPOSE

To see whether surgical success and complication rates in surgery for full-thickness macular holes (FTMH) followed by 5 days prone posturing are comparable to those obtained with longer posturing regimes recorded in the literature.

METHODS

A pilot study was carried out of pars plana vitrectomy, autologous platelet adjunct and 16% C2F6 tamponade followed by 5 days prone posturing in 38 eyes of 34 patients with idiopathic FTMH. A follow-up postal questionnaire was used to assess patients' perception of posturing and outcome.

RESULTS

Fifty-three per cent of eyes gained 2 or more lines of Snellen acuity. Twenty-four per cent of patients with symptom duration of 12 months or less (29 patients) achieved a visual acuity of 6/12. Fifty-eight per cent of patients achieved N8 or better near vision. The only significant predictor of post-operative Snellen acuity was the stage of the hole (p = 0.02). Eighty-six per cent of questionnaire respondents felt that surgery had improved their quality of life. Eighty-seven per cent of all patients reported a reduction in, or elimination of, metamorphopsia. Fifty-four per cent of patients described posturing for 5 days as difficult or very difficult. Five patients admitted to posturing for less than 12 h a day, but all stated that they had postured for the full 5 days. Cataract was the commonest complication observed in this series (42% of patients have had or been listed for cataract surgery).

CONCLUSIONS

Five days of prone posturing following vitrectomy for FTMH with autologous plaletet concentrate and C2F6 tamponade afforded success and complication rates comparable to those in published studies with longer posturing times.

Prevention of visual field defects after macular hole surgery

BACKGROUND/AIM

The pathogenesis of visual field loss associated with macular hole surgery is uncertain but a number of explanations have been proposed, the most convincing of which is the effect of peeling of the posterior hyaloid, causing either direct damage to the nerve fibre layer or to its blood supply at the optic nerve head. The purpose of this preliminary prospective study was to determine the incidence of visual field defects following macular hole surgery in cases in which peeling of the posterior hyaloid was confined only to the area of the macula.

METHODS

102 consecutive eyes that had macular hole surgery had preoperative and postoperative visual field examination using a Humphrey's perimeter. A comparison was made between two groups: I, those treated with vitrectomy with complete posterior cortical vitreous peeling; and II, those treated with a vitrectomy with peeling of the posterior hyaloid in the area of the macula but without attempting a complete posterior vitreous detachment. Specifically, no attempt was made to separate the posterior hyaloid from the optic nerve head. Eyes with stage II or III macular holes were operated. Autologous platelet concentrate and non-expansile gas tamponade was used. Patients were postured prone for 1 week.

RESULTS

In group I, 22% of patients were found to have visual field defects. In group II, it was possible to separate the posterior hyaloid from the macula without stripping it from the optic nerve head and in these eyes no pattern of postoperative visual field loss emerged. There were no significant vision threatening complications in this group. The difference in the incidence of visual field loss between group I and group II was significant (p=0.02). The anatomical and visual success rates were comparable between both groups.

CONCLUSION

The results from this preliminary study suggest that the complication of visual field loss after macular surgery may be reduced if peeling of the posterior hyaloid is confined to the area of the macula so that the hyaloid remains attached at the optic nerve head. The postoperative clinical course does not appear to differ from eyes in which a complete posterior vitreous detachment has been effected during surgery.

Update on current surgical management of idiopathic macular holes

Idiopathic macular holes were generally considered an untreatable condition until 1991 when the first papers reported successful closure of macular holes and visual improvement using pars plana vitrectomy, peeling of the cortical vitreous and face-down positioning. Since that time, the original pathogenesis theory has been refined as well as surgical methods and techniques. Currently, macular hole surgery is considered the most successful vitreoretinal surgery, with a greatly improved prognosis for patients. This article will review the general characteristics of macular holes and the clinical trials and outcomes that have led to the latest techniques in idiopathic macular hole surgery.

Intraoperative adjunctive agents in vitrectomy: serum, cytokines, and glue

The surgical goal in the treatment of retinal breaks is to seal the edges of the break, and traditionally, photocoagulation and cryocoagulation have been used to accomplish this. However, it is sometimes difficult in complicated retinal detachments to maintain the seal against tractional forces. Adhesion is achieved through a process of cell necrosis, inflammation and subsequent fibrovascular proliferation. This strategy, however, may not be appropriate in vision-sensitive areas such as macular holes. To improve the success rate of macular hole surgery, a number of authors have advocated the use of biological modifiers, such as transforming growth factor beta, human autologous serum, tissue glue, or platelet concentrates. These materials may enhance the adhesion of the detached retina and therefore lead to a better anatomical and functional success. We have reviewed the advances of intraoperative application of synthetic or biological adhesives. However, through the improvement of surgical techniques and surgeons' skills in recent years, the anatomical success rate of macular hole surgery has increased in most institutions without adjunctive additives. Thus, many surgeons believe that adjunctive additives may not be necessary for most idiopathic macular holes.