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Retinal Physician

Article

Management of Complicated Macular Holes

New alternatives are available that could increase closure rates.

By: Sruthi Arepalli, MD
Retinal Physician March 1, 2022 Vol 19, Issue March 2022 Page(s): 22-24, 26

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Prior to the first successful report of macular hole (MH) closure in 1991 with pars plana vitrectomy and posterior hyaloidal removal, macular holes (MHs) were generally considered untreatable.1 Since then, advances in surgical technique have led to the successful closure in more than 90% of MHs with a combination of pars plana vitrectomy, internal limiting membrane (ILM) peel, and gas tamponade.2-4 In certain cases, such as hole chronicity, larger hole size, residual vitreoretinal and epiretinal traction, high myopia, or absence of edema on the macular hole edges (known as a flat-open configuration), closure may be unsuccessful or require further surgery and advanced techniques.3,5

Ingenious methods to increase chances of successful closure have been described in the literature, including enlargement of a prior ILM peel, ILM flaps, or scaffold materials, such as posterior capsule, amniotic membrane, or an autologous transplantation, which may facilitate in the increased amount of growth factor and cytokine release. Additionally, the implementation of subretinal blebs along with retinal incisions relaxation can be effective. These techniques are described below.

INTERNAL LIMITING MEMBRANE PEELING, RUG TECHNIQUE, AND FLAPS

Despite initial staining and peeling of the ILM, reports have shown success with repeated vitrectomy, additional ILM staining, and peeling. Indocyanine green or brilliant blue may reveal residual areas of traction from the ILM or areas to enlarge around the previously peeled area.6 Studies have shown success rates ranging from 47% to 100%.6,7 Other surgical maneuvers have also focused on tension reduction of the MH edges. Tian et al described a technique in which the surgeon creates a large ILM flap by beginning in the inferior macula and peeling upward, ending with a hinge superior to the MH. Perfluoro-N-octane (PFO) is then injected to lay the flap over the MH. This process releases ILM tension, but also facilitates the restoration of the Müller footplates, which improves foveal contour. This method can also be performed without PFO, and has been described by Rao and colleagues as the rug technique.8,9 However, in patients with concurrent epiretinal membrane, this practice should be avoided, as it can result in regrowth and reopening of the MH.

Use of a scaffold for tissue and Müller cell proliferation to induce gliosis has been successful for larger diameter MHs in particular (400 μm or greater). Michalewska et al first described the inverted ILM flap technique in 2010 with a 98% closure rate.10 This technique requires a wide peripheral ILM peel while maintaining attachment to the edges of the MH, after which the flap is inverted into the hole with fluid–air exchange (Figure 1).10

Figure 1. A 71-year-old female with a 680-μm macular hole treated with an inner limiting membrane flap displaced on intraoperative optical coherence tomography. Image courtesy of Thomas Mendel, MD, and Alex Yuan, MD, Cole Eye Institute, Cleveland Clinic.
Figure 1. A 71-year-old female with a 680-μm macular hole treated with an inner limiting membrane flap displaced on intraoperative optical coherence tomography. Image courtesy of Thomas Mendel, MD, and Alex Yuan, MD, Cole Eye Institute, Cleveland Clinic.

Several studies have since reported similar results in large or myopic holes.11,12 Multiple adaptations of the ILM flap have been described, including flap insertion from the temporal, superior, or nasal edges.13-15 In certain circumstances, where a prior complete ILM peel still results in a persistent or recurrent MH, a free ILM flap is an option. Morizane et al described this technique with 90% anatomical success rate along with visual improvement.16 The use of PFO or viscoelastic injections may assist in the placement of the flap during the fluid–air exchange.17,18

ALTERNATIVE OPTIONS

In some patients, ILM peels are not feasible, or the tissue is not conducive for flapping. Alternative options exist for scaffold creation, such as transplants, autologous platelet concentrate, growth factors, and laser.

Lens Capsule Transplant

Chen et al initially described the lens capsule transplant technique, which requires the placement of anterior capsule in the MH after cataract surgery in phakic patients, and the posterior capsule in pseudophakic patients. Half of the patients obtained MH closure with posterior-capsular transplantation, and 100% achieved closure with anterior-capsular usage.19 Other series have also shown high rates of success.20

Amniotic Membrane Transplant

Amniotic membrane transplants are well tolerated by the retina and promote MH healing with the release of cytokines and growth factors.21 First described by German researchers, and more recently by Rizzo et al, the placement of human amniotic membrane in a subretinal fashion with fluid–air exchange and gas tamponade achieved MH closure in 100% of cases.22,23 Impressively, the retina overlying the membrane developed normal stratification.22 Others have described the utilization of amniotic grafts in both subretinal and preretinal manners with the use of a dermal punch to create the correct graft size.5 Amniotic membrane is less likely to migrate compared to ILM or capsule flaps during the fluid–air exchange.5

Autologous Retina Transplantation

First introduced by Grewal and Mahmoud in 2016, the full-thickness retinal transplant provides a scaffold, similar to lens capsule and amniotic membrane transplants.24 A full thickness retina flap is harvested after creating a barrier of endolaser and diathermy around the area of the peripheral retina. This flap is then placed in the MH and tamponade is achieved via three possible ways: direct PFO to silicone oil exchange, fluid–air exchange with silicone oil or gas, or short term PFO.24,25 In a multicenter review of 41 eyes that failed prior vitrectomy and ILM peeling, 88% obtained closure of the MH after retinal transplantation, with improvement or stabilization of vision in 78%.

Autologous Platelet Concentrate, Growth Factors, and Laser

Autologous platelet concentrate (APC) contains growth factors and cytokines, which can improve the healing response, as demonstrated by Paques et al.26 The injection of APC during MH repair (with or without ILM peel) resulted in a significantly higher rate of closure than repairs without APC, but visual outcomes remained insignificant between the groups.27,28 In a series evaluating ILM peeling vs ILM peeling with APC, despite the latter having a larger baseline MH diameter, 100% of the combination treatment group achieved closure. The visual acuity was significantly higher in the APC treated group as well.29

Obtaining APC may be difficult, and clinicians have tested autologous blood for MH closure as an alternative, with mixed results.30,31 Specific growth factors, such as TGFβ2 have been used with success, with an 83% closure rate for persistent or recurrent MHs.32 Laser therapy is also linked to the release of cytokines and growth factors integral to the closure of MHs. In a series of large MHs over 400 μm, a low level of laser was applied in the preoperative period followed by ILM peel and compared to traditional MH surgery. The laser group resulted in higher levels of closure and improved visual outcomes.33

Subretinal Blebs and Relaxing Retinal Incisions

Mechanical manipulation of the retina with the goal of increasing tissue flexibility also facilitates the successful closure of MHs. Oliver and Wojcik first described this procedure in 2011.34 The technique relies on the creation of a controlled, localized macular detachment surrounding the MH using small-gauge cannulas (38-gauge or 41-gauge) connected to either a viscous fluid injection kit or syringe to administer balanced salt solution blebs contiguous with the MH (Figures 2 and 3). The edges of the MH can be brushed with a Tano diamond dusted scraper (Synergetics), a Flex Loop (Alcon), or a passive extrusion to further encourage closure. In some instances, to avoid creating additional defects in the retina, fluid can be refluxed through the macular hole into the subretinal space.35 The manipulation of the tissue is thought to release adhesions between the photoreceptors and retinal pigment epithelium, and may be particularly useful in situations with scarring which limits tissue mobility.34,36-38 Other methodologies rely on full-thickness retinal incisions. Charles et al first described an arcuate retinotomy technique, which requires full-thickness arcuate cuts temporal to the macular hole. Eighty-three percent of patients had successful closure of their MH and 50% had visual improvement.39 Other iterations of this protocol involve 5 perifoveal radial incisions, ending at the edge of the hole, or double arcuate relaxing retinotomies near the inferiortemporal and superotemporal arcades.40,41

Figure 2. Recurrent macular hole in a 63-year-old female who had previous failed repeat vitrectomy with inner limiting membrane peel and free inner limiting membrane flap. Macular hole closure was obtained with 38-gauge administration of balanced salt solution subretinally, confirmed with intraoperative optical coherence tomography. Image courtesy of Jessica Cao, MD, and Sumit Sharma, MD, Cole Eye Institute, Cleveland Clinic.
Figure 3. Preoperative optical coherence tomography with vision 20/100 and postoperative month 1 vision is 20/80. Image courtesy of Sumit Sharma, MD, Cole Eye Institute, Cleveland Clinic.

CONCLUSIONS

Although most MHs are closed with primary surgery, certain factors can lead to unresponsiveness to traditional peeling methods. There is a plethora of surgical interventions available with desirable anatomic and visual outcomes. RP

Sruthi Arepalli, MD, is a retina specialist with Tennessee Retina Associates in Nashville, Tennessee. She reports no relevant disclosures. Reach her at sruthiarepalli@gmail.com.

REFERENCES

  1. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991;109(5):654-659. doi:10.1001/archopht.1991.01080050068031
  2. Brooks HL Jr. Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology. 2000;107(10):1939-1949. doi:10.1016/s0161-6420(00)00331-6
  3. Kumagai K, Furukawa M, Ogino N, Uemura A, Demizu S, Larson E. Vitreous surgery with and without internal limiting membrane peeling for macular hole repair. Retina. 2004;24(5):721-727. doi:10.1097/00006982-200410000-00006
  4. Sheidow TG, Blinder KJ, Holekamp N, et al. Outcome results in macular hole surgery: an evaluation of internal limiting membrane peeling with and without indocyanine green. Ophthalmology. 2003;110(9):1697-1701. doi:10.1016/S0161-6420(03)00562-1
  5. Kuriyan AE, Hariprasad SM, Fraser CE. Approaches to refractory or large macular holes. Ophthalmic Surg Lasers Imaging Retina. 2020;51(7):375-382. doi:10.3928/23258160-20200702-02
  6. Hagiwara A, Baba T, Tatsumi T, Sato E, Oshitari T, Yamamoto S. Functional and morphologic outcomes after reoperation for persistent idiopathic macular hole. Eur J Ophthalmol. 2017;27(2):231-234. doi:10.5301/ejo.5000857
  7. D’Souza MJ, Chaudhary V, Devenyi R, Kertes PJ, Lam WC. Re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel. Br J Ophthalmol. 2011;95(11):1564-1567. doi:10.1136/bjo.2010.195826
  8. Tian T, Chen C, Peng J, Jin H, Zhang L, Zhao P. Novel surgical technique of peeled internal limiting membrane reposition for idiopathic macular holes. Retina. 2019;39(1):218-222. doi:10.1097/IAE.0000000000001745
  9. Meizner D, Lee J, Rao P. Three ways to tackle tough macular holes. Retina Today. 2021.
  10. Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology. 2010;117(10):2018-2025. doi:10.1016/j.ophtha.2010.02.011
  11. Narayanan R, Singh SR, Taylor S, et al. Surgical outcomes after inverted internal limiting membrane flap versus conventional peeling for very large macular holes. Retina. 2019;39(8):1465-1469. doi:10.1097/IAE.0000000000002186
  12. Kuriyama S, Hayashi H, Jingami Y, Kuramoto N, Akita J, Matsumoto M. Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia. Am J Ophthalmol. 2013;156(1):125-131.e1. doi:10.1016/j.ajo.2013.02.014
  13. Michalewska Z, Michalewski J, Dulczewska-Cichecka K, Adelman RA, Nawrocki J. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study. Retina. 2015;35(9):1844-1850. doi:10.1097/IAE.0000000000000555
  14. Major JC Jr, Lampen SIR, Wykoff CC, et al. The Texas taco technique for internal limiting membrane flap in large full-thickness macular holes: a short-term pilot study. Retina. 2020;40(3):552-556. doi:10.1097/IAE.0000000000002431
  15. Ghassemi F, Khojasteh H, Khodabande A, et al. Comparison of three different techniques of inverted internal limiting membrane flap in treatment of large idiopathic full-thickness macular hole. Clin Ophthalmol. 2019;13:2599-2606. Published 2019 Dec 27. doi:10.2147/OPTH.S236169
  16. Morizane Y, Shiraga F, Kimura S, et al. Autologous transplantation of the internal limiting membrane for refractory macular holes. Am J Ophthalmol. 2014;157(4):861-869.e1. doi:10.1016/j.ajo.2013.12.028
  17. Shin MK, Park KH, Park SW, Byon IS, Lee JE. Perfluoro-n-octane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery. Retina. 2014;34(9):1905-1910. doi:10.1097/IAE.0000000000000339
  18. Lai CC, Wu AL, Chou HD, et al. Sub-perfluoro-n-octane injection of ocular viscoelastic device assisted inverted internal limiting membrane flap for macular hole retinal detachment surgery: a novel technique. BMC Ophthalmol. 2020;20(1):116. Published 2020 Mar 21. doi:10.1186/s12886-020-01393-1
  19. Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies. Retina. 2016;36(1):163-170. doi:10.1097/IAE.0000000000000674
  20. Cisiecki S, Bonińska K, Bednarski M. Autologous lens capsule flap transplantation for persistent macular holes. J Ophthalmol. 2021;2021:8148792. Published 2021 Feb 27. doi:10.1155/2021/8148792
  21. Tseng SC, Espana EM, Kawakita T, et al. How does amniotic membrane work? Ocul Surf. 2004;2(3):177-187. doi:10.1016/s1542-0124(12)70059-9
  22. Rizzo S, Caporossi T, Tartaro R, et al. A human amniotic membrane plug to promote retinal breaks repair and recurrent macular hole closure. Retina. 2019;39 Suppl 1:S95-S103. doi:10.1097/IAE.0000000000002320
  23. Csapody I. Amnion-implantation gegen maculaloch [amnion implantation in therapy of macula hole]. Ophthalmologica. 1957;134(4):272-276. doi:10.1159/000303218
  24. Grewal DS, Mahmoud TH. Autologous neurosensory retinal free flap for closure of refractory myopic macular holes. JAMA Ophthalmol. 2016;134(2):229-230. doi:10.1001/jamaophthalmol.2015.5237
  25. Grewal DS, Charles S, Parolini B, Kadonosono K, Mahmoud TH. Autologous retinal transplant for refractory macular holes: multicenter international collaborative study group. Ophthalmology. 2019;126(10):1399-1408. doi:10.1016/j.ophtha.2019.01.027
  26. Idrees S, Sridhar J, Kuriyan AE. Proliferative vitreoretinopathy: a review. Int Ophthalmol Clin. 2019;59(1):221-240. doi:10.1097/IIO.0000000000000258
  27. Gaudric A, Massin P, Paques M, et al. Autologous platelet concentrate for the treatment of full-thickness macular holes. Graefes Arch Clin Exp Ophthalmol. 1995;233(9):549-554. doi:10.1007/BF00404704
  28. Paques M, Chastang C, Mathis A, et al. Effect of autologous platelet concentrate in surgery for idiopathic macular hole: results of a multicenter, double-masked, randomized trial. Platelets in Macular Hole Surgery Group. Ophthalmology. 1999;106(5):932-938. doi:10.1016/s0161-6420(99)00512-6
  29. Shpak AA, Shkvorchenko DO, Krupina EA. Surgical treatment of macular holes with and without the use of autologous platelet-rich plasma. Int Ophthalmol. 2021;41(3):1043-1052. doi:10.1007/s10792-020-01662-4
  30. Lyu WJ, Ji LB, Xiao Y, Fan YB, Cai XH. Treatment of refractory giant macular hole by vitrectomy with internal limiting membrane transplantation and autologous blood. Int J Ophthalmol. 2018;11(5):818-822. Published 2018 May 18. doi:10.18240/ijo.2018.05.17
  31. Purtskhvanidze K, Frühsorger B, Bartsch S, Hedderich J, Roider J, Treumer F. Persistent full-thickness idiopathic macular hole: anatomical and functional outcome of revitrectomy with autologous platelet concentrate or autologous whole blood. Ophthalmologica. 2018;239(1):19-26. doi:10.1159/000481268
  32. Smiddy WE, Sjaarda RN, Glaser BM, et al. Reoperation after failed macular hole surgery. Retina. 1996;16(1):13-18. doi:10.1097/00006982-199616010-00004
  33. Cho HY, Kim YT, Kang SW. Laser photocoagulation as adjuvant therapy to surgery for large macular holes. Korean J Ophthalmol. 2006;20(2):93-98. doi:10.3341/kjo.2006.20.2.93
  34. Oliver A, Wojcik EJ. Macular detachment for treatment of persistent macular hole. Ophthalmic Surg Lasers Imaging. 2011;42(6):516-518. doi:10.3928/15428877-20110825-01
  35. Felfeli T, Mandelcorn ED. Macular hole hydrodissection: surgical technique for the treatment of persistent, chronic, and large macular holes. Retina. 2019;39(4):743-752. doi:10.1097/IAE.0000000000002013
  36. Meyer CH, Borny R, Horchi N. Subretinal fluid application to close a refractory full thickness macular hole. Int J Retina Vitreous. 2017;3:44. Published 2017 Nov 27. doi:10.1186/s40942-017-0094-7
  37. Meyer CH, Szurman P, Haritoglou C, et al. Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study. Graefes Arch Clin Exp Ophthalmol. 2020;258(10):2151-2161. doi:10.1007/s00417-020-04735-3
  38. Szigiato AA, Gilani F, Walsh MK, Mandelcorn ED, Muni RH. Induction of macular detachment for the treatment of persistent or recurrent idiopathic macular holes. Retina. 2016;36(9):1694-1698. doi:10.1097/IAE.0000000000000977
  39. Charles S, Randolph JC, Neekhra A, Salisbury CD, Littlejohn N, Calzada JI. Arcuate retinotomy for the repair of large macular holes. Ophthalmic Surg Lasers Imaging Retina. 2013;44(1):69-72. doi:10.3928/23258160-20121221-15
  40. Reis R, Ferreira N, Meireles A. Management of stage IV macular holes: when standard surgery fails. Case Rep Ophthalmol. 2012;3(2):240-250. doi:10.1159/000342007
  41. Karacorlu M, Sayman Muslubas I, Hocaoglu M, Arf S, Ersoz MG. Double arcuate relaxing retinotomy for a large macular hole. Retin Cases Brief Rep. 2019;13(2):167-170. doi:10.1097/ICB.0000000000000551

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