UPFRONT

The Mad Doctor?

Peter K. Kaiser, MD

Nothing in retina evokes the same visceral reaction to changes in technique than how to perform macular hole surgery. From the very first reports of successful surgery, the techniques have been controversial

I can vividly remember my attending explaining to us during our residency how macular hole surgery does not work and then being surprised when I arrived at Bascom Palmer for my fellowship and seeing the success that surgery offered patients.

Then, during fellowship, I was taught how important it was to nick the edges of the hole and have two weeks of face down positioning with a C₃F₈ gas bubble. When I arrived as junior faculty at the Cole Eye Institute, my chair laughed at anyone who did not use autologous serum and told me I was crazy to peel ILM. My same chair then told me that combination surgery was wasteful and did not improve outcomes.

Meanwhile, the list of controversial maneuvers during macular hole surgery continued unabated: silicone oil and no positioning; changing the gas to SF₆; decreasing the time of face-down positioning; deciding face-down requirements based on OCT evaluation of hole closure; using dyes to stain the ILM; dye toxicity; draining in the hole or not; and even using flaps of ILM to help close holes.

During this time, our success rate at closing holes, especially smaller ones, is approaching 100%, making it truly one of most successful vitreoretinal procedures. The interesting thing is that, unlike AMD or DME, no randomized studies have been done actually proving which of these techniques actually makes a difference.

Professional societies have tried with retrospective registries to see what matters, and smaller studies have been performed. But for the most part, we perform this surgery based on our own biases.

Now, one of the pioneers of macular hole surgery offers another change in thinking — no face-down positioning. I can tell you, in my fellowship, my mentors would have laughed at this idea because patients were put into traction for two weeks. But now, the idea does not seem so far-fetched. In this issue, we explore this new idea.

Will Dr. Tornambe be known as nuts or a genius? Only time will tell …