Since repair of macular holes was first demonstrated in 1991, there have been tremendous advances in surgical as well as non-surgical techniques. The Macular Holes Symposium at the recent 2018 annual meeting for the American Society of Retina Specialists (ASRS) is always an interesting session since it brings together the latest updates in surgical management of macular holes.
Regular macular hole surgery now has more than a 90% success rate, yet more challenging, non-routine macular holes — such as myopic macular holes, recurrent and large macular holes or those associated with retinal detachment — have much poorer prognosis.
The Macular Holes Symposium this year highlighted several novel techniques to address such difficult cases, which I’ve listed below.
Multi-Layered Inverse Internal Limiting Membrane Peeling — Is ILM the Culprit or Savior in the Treatment of Large Macular Holes and Macular Hole RD?
Dr. Srinivas Joshi showed a technique of multilayered petalloid inverse ILM peel in a producing multiple ILM flaps to cover the hole in large macular holes and macular hole retinal detachments. Most patients received C3F8 gas tamponade while ones with a concurrent RD received silicone oil. All except one of the 45 holes closed in their series closed with this technique, which suggests its utility in these difficult cases.
Functional Outcome of Autologous Neurosensory Retinal Flap for Large and Refractory Macular Holes: Multicenter International Collaborative Study Group
Dr. Kazuaki Kadonosono and I had consecutive presentations on the structural and anatomical results of a collaborative, 4-center, retrospective interventional case series of autologous neurosensory retinal flaps for large and refractory macular holes with a total of 49 patients. This technique, pioneered by Tamer Mahmoud from Duke University, consists of harvesting the neurosensory retinal graft from the mid-periphery, placing it over the macular hole, under PFCL, and then exchanging it for a tamponade.
Anatomic closure was obtained in 89.8% of eyes with significant improvement in outer retinal anatomy on OCT. Vision improved in 42.8% of cases, remained unchanged in 40.8%, and decreased in 16.3%. There were 4 cases with a displaced flap. There were no major complications including choroidal neovascularization or proliferative vitreoretinopathy.
Overall, this large series demonstrates that this surgical technique is a very promising option in patients who have already failed conventional surgery with ILM peeling.
Comparative Study of Inverted ILM Flap and PRP as an Adjunct in Large Macular Holes
Dr. Naresh Kannan presented another approach for large macular holes– using platelet-rich plasma (PRP), or autologous blood obtained from patient at time of surgery. PRP is then centrifuged to obtain the supernatant rich in platelets to cover the inverted ILM flap or even just on the macular hole. They reported good results even without face down positioning.
Surgical Repair of Chronic Macular Holes: Functional and Anatomic Outcomes Using No Facedown Positioning
Maintaining face down positioning is one of the most challenging aspects of the postoperative period for patients and being able to avoid face down positioning is very attractive. Dr. Raymond Iezzi demonstrated his technique of no prone positioning post macular hole surgery.
Patients were instructed not to sleep on their back, and for the first week to face forward with their eyes down while reading, writing, or doing crafts, and to take long walks. Over 80% of eyes achieved closure with a single surgery and vision improved in all closed holes. C3F8 gas demonstrated greater efficacy in closing chronic macular holes.
Radial Retinal Incisions for the Treatment of Persistent Macular Holes
Dr. Christian Pruente presented a novel technique of radial retinal incisions for persistent macular holes wherein radial retinal incisions (retinotomies) using vertical scissors were performed with air tamponade and 3 days of facedown positioning. They achieved closure of 80% of holes in this series.
Retinal Function Assessment by Microperimetry-3 After Internal Limiting Membrane Peeling in Macular Hole Patients
Dr. Wu Liu tried to answer the question of whether mechanical trauma resulting from internal limiting membrane (ILM) peeling causes more harm than good.
They assessed retinal function by microperimetry-3 (MP-3) after ILM peeling in 44 MH patients. They found that the mean retinal sensitivity was significantly increased after ILM peeling (all without the use of dye: 22.92±3.71 dB pre-op vs 25.70±2.45 dB post-op. This suggests that ILM peeling does not impact retinal functional measurements and the next step would be to study the impact of vital dyes.
Visual Outcomes of Primary Versus Secondary Epiretinal Membrane Following Vitrectomy and Cataract Surgery
Dr. Mohamed Soliman looked at visual outcomes of primary vs secondary ERM post-membrane peel and cataract extraction. And concluced that secondary ERMs have potential to gain more vision compared to primary ERM, have a greater chance of developing cystoid macular edema and similar recurrence rates. More eyes with primary ERM (without associated ocular co-morbidity) are likely to achieve a final 20/40 vision.
Non Surgical Options
Effect of Baseline Ocular Characteristics on Vitreomacular Adhesion/Vitreomacular Traction Resolution With Ocriplasmin: ORBIT Study Subanalysis
Dr. David Boyer looked at real-world outcomes of ocriplasmin use from the phase 4 Ocriplasmin Research to Better Inform Treatment (ORBIT) trial. The results revealed that patients aged < 65 years, those with full thickness macular holes, a smaller area of focal adhesion, absence of epiretinal membrane (ERM), and phakic lens status have a greater chance of success post-ocriplasmin injection. These findings are useful to remind us of the nonsurgical options in this group of patients.
Treatment of Focal Vitreomacular Traction With Pneumatic Vitreolysis, an Emerging Surgical Technique
Dr. Calvin Mein described his experience with pneumatic vitreolysis (injecting a gas bubble in the vitreous cavity of the eye to release the vitreous adhesion) for treating focal VMT with a VMT release of 85%. Younger age and lack of diabetes were strong predictors of success. Complications included retinal tears in 2 eyes, retinal detachment in 2 eyes, and macular hole in 1 eye. Overall, pneumatic vitreolysis is another valuable tool in our non-surgical armamentarium for carefully selected cases and will be evaluated in more detail in upcoming DRCR.net protocols.
Overall, this was a very exciting session that demonstrated robust data for a variety of novel surgical techniques that now allow significantly improved outcomes in challenging macular holes as well as non-surgical interventions that may be a viable alternative for eyes with relatively small macular holes. The discussion following each talk and by the moderating panelists revealed a sense of excitement that we finally have viable procedures to improve the visual and anatomic outcomes of large and refractory macular holes and the adoption of these techniques should increase over time.
Dr. Dilraj S. Grewal is an ophthalmologist based in North Carolina.
