Inverted internal limiting membrane (ILM) flap technique for macular hole closure: patient selection and special considerations

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.

Relationship between lymphocytes and idiopathic macular hole

BACKGROUND

An idiopathic macular hole (IMH) is a full-thickness anatomic defect extending from the internal limiting membrane to the photoreceptor layer of the macula without any known cause. Recently, clinical laboratory markers of systemic inflammatory status derived from complete blood counts have been evaluated in ocular diseases. This study aimed to explore whether they could predict the development and progression of IMHs.

METHODS

A retrospective review of 36 patients with IMH and 36 sex-and-age-matched patients with cataracts was conducted. We collected complete blood counts of all participating individuals and calculated systemic immunoinflammatory indicators. The maximum base diameter of the IMH (BD), minimum diameter of the IMH (MIN), height of the IMH (H), area of the intraretinal cyst (IRC), and curve lengths of the detached photoreceptor arms were measured on optical coherence tomography (OCT) images. We used these values to calculate the macular hole index (MHI), tractional hole index (THI), diameter hole index (DHI), hole form factor (HFF), and macular hole closure index (MHCI). We performed a receiver operating characteristic (ROC) curve analysis of 30 patients with IMH who were followed up 1 month after surgery.

RESULTS

Lymphocyte counts were significantly higher in the IMH group. No other significant differences were observed between the IMH and control groups. Lymphocyte counts in the IMH group were significantly negatively correlated with MIN and BD and were significantly positively correlated with MHI, THI, and MHCI. However, lymphocyte counts were not significantly correlated with H, IRC, DHI, and HFF. In the ROC analysis, BD, MIN, MHI, THI, and MHCI were significant predictors of anatomical outcomes. According to the cut-off points of the ROC analysis, lymphocyte counts were compared between the above-cut-off and below-cut-off groups. Lymphocyte counts were significantly higher in the MIN ≤ 499.61 μm, MHI ≥ 0.47, THI ≥ 1.2, and MHCI ≥ 0.81 groups. There were no significant differences between the above-cut-off and below-cut-off BD groups.

CONCLUSIONS

Although inflammation may not be an initiating factor, it may be involved in IMH formation. Lymphocytes may play a relatively important role in tissue repair during the developmental and postoperative recovery phases of IMH.

Macular hole following scleral buckling for rhegmatogenous retinal detachment: a case series

BACKGROUND

Macular hole (MH) development following scleral buckling (SB) surgery for rhegmatogenous retinal detachment (RRD) repair is rare. This study presents both full-thickness MH (FTMH) and lamellar MH (LMH) cases following SB for the treatment of RRD.

METHODS

Clinical records of patients undergoing SB surgery for treatment of RRD at the Xi'an People's Hospital (Xi'an Fourth Hospital) from January 2016 to December 2021 were reviewed, and cases with postoperative MH were selected. Clinical features and follow-up data were summarised, and possible causes were analysed.

RESULTS

Among 483 identified cases (483 eyes), four eyes (three male patients, one female patient) had postoperative MH, with prevalence, mean age, and mean axial length of 0.83%, 43.5 ± 10.66 years, and 29.13 ± 3.80 mm, respectively. All patients did not undergo subretinal fluid (SRF) drainage. The mean time for detecting MH was 26 ± 15.5 days postoperatively. Macula-off RRD with high myopia and FTMH combined with retinal re-detachment were diagnosed in three patients. One patient had macula-on RRD with outer LMH. The average follow-up duration was 7.25 ± 1.5 months. The FTMH closed successfully after reoperation, while the outer LMH closed without intervention. Visual acuity insignificantly improved or slightly decreased in all patients.

CONCLUSIONS

Patients with high myopia combined with macula-off RRD might be more susceptible to FTMH, causing MH related retinal detachment. Additionally, LMH following SB was noted in patients with macula-on RRD. Therefore, we should raise awareness of MH following SB for RRD repair.

Surgical outcomes of petalloid multilayered inverted internal limiting membrane flaps in extra-large macular holes

PURPOSE

To analyze the surgical outcomes of petalloid multilayered inverted internal limiting flap using perfluorocarbon liquid (PFCL) in extra-large macular holes (MHs) (minimum linear diameter >550 µm and basal diameter [BD] >1000 µm).

METHODS

This was a prospective interventional series of 103 eyes of 99 patients with extra-large MHs which were treated with 25-gauge pars plana vitrectomy, petalloid multilayered inverted internal limiting membrane flaps under PFCL and 15% perfluoropropane (C3F8) gas tamponade. Intraoperative optical coherence tomography (i-OCT) was used to confirm correct positioning of flaps. Follow-up was at 1 week, 1 month, and 3 months postoperatively.

RESULTS

Mean age of patients was 58.282 ± 16.3 years. Mean preoperative best corrected visual acuity (BCVA) was logarithm of minimum angle of resolution (logMAR) 1.206 ± 0.384, and the value at the third month was logMAR 0.793 ± 0.337. Mean minimum linear diameter (MLD) was 711.96 ± 270.744 µm. MLD ranged from 557µm (minimum MLD) to 2657 µm (maximum MLD). Mean BD was 1301.165 ± 425.914 µm. Type 1 closure was seen in 92.2% eyes, 5.8% eyes had type 2 closure, and 1.9% eyes had type 3 closure. Eyes with both type 1 closure (P = 0.001) and type 2 closure (P = 0.009) showed a significant improvement in BCVA postoperatively at 3 months.

CONCLUSION

Petalloid multilayered inverted internal limiting membrane flap under PFCL technique with adjunctive use of i-OCT showed improved morphological and functional outcomes in the treatment of extra-large MHs. We present here a large series of extra-large MHs, in which a novel technique of petalloid multilayered inverted ILM flaps was used.

Trends and Hotspots Concerning Macular Hole between 2002 and 2021: A 20-Year Bibliometric Study

BACKGROUND

Macular hole (MH) can severely impair central vision. Although it can be treated with vitrectomy surgery, avoiding recurrence and improving visual acuity are still priorities to be addressed. This study aims to reveal the trends and hotspots about MH.

METHODS

The Web of Science Core Collection (WOSCC) was used to perform a bibliometric analysis investigating trends of MH research from 2002 to 2021. We evaluated the details of associated regions, institutions, authors, and journals. To construct and overlay network visualizations, VOSviewer software was used.

RESULTS

In total, 1518 publications were collected. Our analysis showed that MH research is becoming increasingly relevant, with Japan achieving the largest number of publications (291), largest number of citations (7745 in total), and highest h-index value (48). Retina published the most publications on this topic, totaling more than the next two journals combined. An analysis of keyword co-occurrence was evaluated, highlighting several novel keywords of interest, such as flap technique, transplantation, epiretinal proliferation (EP), foveal microstructure, and retinal sensitivity.

CONCLUSIONS

Details on MH research were uncovered by comprehensively analyzing the global trends and hotspots over the past two decades, presenting valuable information for future MH research. Japan, the USA, and China hold leading positions in research on this topic. Amendable surgical methods are a potential focus for improving prognosis.

Xen45 gel stent ab interno trimming for ostium occlusion: case report

BACKGROUND

Despite the XEN gel stent low-risk profile, various complications following the implant have been described, including internal and external occlusion, with a consequent postoperative rise in intraocular pressure (IOP). In this case report we aimed to present a XEN45 stent internal occlusion successfully treated by trimming in situ its proximal end with a 25 G vitreous scissors using a bimanual technique.

CASE PRESENTATION

A 63-year-old male patient affected by primary open angle glaucoma (IOP = 25 mmHg) and a full thickness macular hole in his right eye, underwent ab-interno Xen gel stent implantation and, 1 month later, a 25 G vitrectomy surgery. Despite a significant IOP reduction after stent implant, 6 days after vitrectomy, IOP increased (25 mmHg) and the conjunctival bleb flattened following occlusion of stent internal ostium by a clot of presumed fibrinous material. The Nd:YAG laser failed to remove the clot, so that we decided to snip a small bit of the proximal end of the Xen tube (about 0,5 mm length) with a 25 G vitreous scissors, using a bimanual technique. In the postoperative day 1 and month 1, the IOP was 8 mmHg and 12 mmHg, respectively. The Anterior Segment OCT confirmed a functional, layered, filtering bleb, and the normal appearance and patency of the XEN proximal segment. No side effects from the intervention were observed.

CONCLUSIONS

Ab interno trimming with vitreous scissors of the occluded proximal end of the XEN stent may represent a safe, rapid and efficient method to restore aqueous humor subconjunctival drainage.

Inverted Internal Limiting Membrane Flap Technique without Post-operative Face-down Positioning for Macular Hole Repair

PURPOSE

To describe the outcomes of the inverted internal limiting membrane (ILM) flap technique without post-operative face-down positioning for MH closure.

METHODS

This retrospective longitudinal study identified patients who had undergone surgical repair for large (>400 µm), idiopathic macular holes and did not maintain face-down positioning post-operatively. Outcome measures included anatomical success, defined as confirmation of hole closure by OCT scan and functional success, defined as improved best-corrected visual acuity (BCVA) from baseline at the last follow-up.

RESULTS

Of the 63 eyes enrolled in the study, 94% (59 of 63) patients achieved anatomical success and 91% (57 of 63) patients achieved functional success. Fifteen (15) of these patients presented with a MH >600 µm. This subgroup achieved an anatomical success rate of 93% and a functional success rate of 87%. Statistically significant improvement in BCVA was demonstrated for all subgroups of MH size (p < 0.001).

CONCLUSIONS

We report a high success rate of large, idiopathic macular hole closure with the inverted ILM flap technique without post-operative face-down positioning. The results described in this study are favourable. However, larger studies with prospective design are warranted to explore this further.

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.

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

Background

Large, 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.

Methods

This 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.

Results

8 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.

Conclusion

Free 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.