Refractory Myopic Retinal Detachment and Macular Hole Closure with Autologous Neurosensory Retinal Free Flap

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.

AUTOLOGOUS NEUROSENSORY RETINAL TRANSPLANTATION: Bridging the Gap

PURPOSE

To review the autologous retinal transplantation surgical technique, indications, rationale, and current outcomes of data published to date.

METHODS

Review of surgical technique, preoperative and postoperative best-corrected visual acuity, and macular hole (MH) closure rate in studies with at least five eyes.

RESULTS

The weighted average macular hole closure rate is 88%, with a MH closure rate ranging from 66.7% to 100%. The weighted average best-corrected visual acuity improved from mean logarithm of the minimum angle of resolution 1.35 (Snellen equivalent of 20/450) preoperatively to mean logarithm of the minimum angle of resolution 1.02 (Snellen equivalent of 20/210) postoperatively. From the largest autologous retinal transplantation case series, 37% of patients gained 3 or more lines of visual acuity after autologous retinal transplantation for primary or refractory MHs and 74% gained 3 or more lines of visual acuity after autologous retinal transplantation for MH-retinal detachments. Functional improvement including negative Watzke-Allen sign and conversion from positive to negative scotoma was reported in large case series.

CONCLUSION

Autologous retinal transplantation is a promising technique for closure of large and refractory MHs otherwise difficult to repair with conventional techniques. This technique may allow for replacement of neural tissue in the macula through cell rehabilitation and regeneration through presumed ectopic synaptogenesis, retinal progenitor cell differentiation and integration, and/or retinal progenitor cell material transfer to host neurons.

MANAGEMENT OF LARGE OR RECURRENT MACULAR HOLES

Purpose of Review

To review and critically appraise the recent literature about new surgical techniques for the management of large or recurrent macular holes.

Recent Findings

A variety of surgical approaches have recently been developed ranging from autologous retinal grafts to amniotic membrane transplant with varying levels of anatomical and visual success.

Summary

More data is needed to determine if one technique is superior to others. However, with a variety of grafts, adhesives, and tamponades at their disposal, vitreoretinal surgeons have an extensive array of options to approach complex macular holes.