Internal Limiting Membrane Flap Techniques for the Repair of Large Macular Holes: a Short-Term Follow-up of Anatomical and Functional Outcomes

Repeat Surgery following Temporal Inverted ILM Flap Technique: Next Step after Primary Failure

PURPOSE

We aimed to report our surgical experience with repeat surgery as the next step after an unsuccessful hole closure with the primary single-layered temporal inverted flap technique (IFT).

METHODS

We identified cases with persistent macular holes by reviewing the records of eyes that underwent IFT between October 2018 and October 2021. These cases were evaluated for hole features, anatomical closure, and visual improvement before and after the first and second surgeries. In addition, the technique applied in repeat surgery was recorded. Optical coherence tomography (OCT) images at follow-up were used to evaluate the flap position.

RESULTS

A persistent hole was identified in 11 (6.4%) of 172 patients who underwent IFT. An inferotemporal displacement was observed in seven eyes, while no flap could be identified in the OCT images of the other four eyes. In the second surgery, the old flap was reinverted in one eye, and a new flap was created from the superior region in five eyes and the nasal region in the other five eyes and was stabilized under perfluorocarbon liquid. A gas tamponade (C3F8/SF6) was used in all patients at the end of surgery. The minimum hole diameter was > 400 µm in all eyes and 100% closure was achieved after the second surgery. Visual acuity gain of ≥ 3 lines was observed in 9 of the 11 eyes (81.8%). The mean visual acuity increase at the last follow-up was significant (p = 0.008).

CONCLUSION

With single-layer temporal IFT in the primary surgery of macular holes, unsuccessful results may be observed due to the flap displacement in the early period. In our series, IFT was applied again with the use of the old flap or the creation of a new flap in the second surgery of the persistent holes, and successful results were obtained.

Prognostic factors for visual recovery after successful large macular hole surgery using the inverted flap technique

PURPOSE

The goal of our study is to describe the functional results and preoperative factors predicting visual recovery after successful inverted flap technique and closure of large full-thickness macular holes (FTMH) and to evaluate the correlations between microstructural foveal changes and final visual acuity.

METHODS

Retrospective, descriptive, analytical study including 80 eyes of 78 patients with large FTMH; operated by inverted flap technique with successful closure of the macular hole after surgery. All eyes underwent a full preoperative ophthalmic examination and macular B-scan SD-OCT. We performed the classic inverted flap technique for all patients. Postoperatively, all patients were examined at 7 days, 1, 3, 6, 9 and 12 months after surgery. SD-OCT was performed for all patients on each follow-up. Preoperatively, best-corrected visual acuity (BCVA), FTMH size and basal hole diameter were the main outcome measures. Postoperatively, BCVA, macular thickness, integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) were recorded.

RESULTS

Mean age was 62±8.42 years with female predominance. Mean size of the FTMH was 692.59μm, and mean basal hole diameter was 1436.06μm. Mean BCVA improved from 1.06±0.491 LogMAR preoperatively to 0.52±0.32 at 9 months following surgery (P<0.001). At 9 months, the ELM was absent, partial or fully restored in 6.67, 10 and 83.33% respectively. The EZ was absent, partial or fully restored in 6.67, 33 and 63.33% respectively. ELM regeneration always preceded EZ regeneration at every point of follow-up. Final BCVA was statistically correlated with initial hole size (P=0.006, OR=1.056; CI [1.016-1.098]) and mean symptom duration prior to surgery (P=0.001. OR=0.987; CI [0.976-0.998]). Analysis of the ROC curve demonstrated that a hole diameter>478.5μm and symptom duration>5 weeks were correlated with non-improvement of visual acuity, with 81.3% sensibility and 18.7% specificity.

CONCLUSION

We report tomographic microstructural foveal changes and functional results following successful large idiopathic FTMH surgery using the classic inverted flap technique. Preoperative parameters such as initial FTMH diameter and mean symptom duration prior to surgery are crucial prognostic factors influencing final visual results.

Single Layered Free ILM Graft Technique in Large Macular Holes with Associated ERM

PURPOSE

We aimed to describe single layered free ILM graft technique (FIGT) and present results of this technique in the primary surgery of large macular holes (MHs).

METHODS

In this retrospective study, we identified MHs with a minimum hole diameter >400 μm that underwent FIGT by a single surgeon. Nineteen eyes were found to have an associated epiretinal membrane (ERM) and four eyes demonstrated a patchy ILM staining intraoperatively. A single layered FIGT was performed first by peeling the ILM around the hole and then creating a free ILM flap and transplanting it to cover the hole. All cases were evaluated for anatomical closure and visual improvement.

RESULTS

Twenty-three eyes of 22 patients (mean age 68.7 ± 7.4 years) were included in the study. The mean follow-up was 9.6 ± 4.9 months. Flap closure was observed in two eyes (8.6%) at week 1, while all eyes (100%) showed a complete closure at month 1. Mean preoperative visual acuity of 1.42 ± 0.66 LogMAR increased to 1.11 ± 0.51, 0.99 ± 0.34, 0.92 ± 0.38, 0.74 ± 0.37, 0.52 ± 0.28, 0.64 ± 0.39 respectively at week 1, month 1, month 3, month 6, year 1 and final follow-up postoperatively (p < .05 for all). In none of the eyes ERM recurred, nor flap contraction developed.

CONCLUSION

The study showed encouraging results using free ILM graft in the primary surgery of large MHs. This technique might be considered in large MHs that are associated with ERM or demonstrate patchy ILM staining. Further studies are needed to prove the effectiveness also in the long-term.

Modified inverted internal limiting membrane flap technique for macular hole closure

PURPOSE

To investigate the efficacy of modified internal limiting membrane (ILM) flap technique combined with vitreous surgery for treating macular holes and examine the outcomes in visual function and anatomic macular hole closure.

STUDY DESIGN

Retrospective, observational.

METHODS

Between July 1, 2015, and October 1, 2019, the modified inverted ILM flap technique combined with vitreous surgery was used to treat idiopathic macular holes, postoperative progression was then followed for at least 6 months in 96 participants (98 eyes). We modified the method by removing the lower half of the ILM while peeling and inverting the upper half. The mean age of the participants was 65.9 ± 11.9 years (41 men (42.7%) and 55 women (57.3%)). Retrospective evaluations of macular hole diameter, corrected visual acuity, and macular hole closure rates were performed using data from medical records.

RESULTS

The mean macular hole diameter was 623.6 ± 207.4 μm. The mean corrected visual acuity (logMAR) was 0.79 ± 0.27 before surgery and 0.46 ± 0.35 at 1, 0.35 ± 0.39 at 3, and 0.31 ± 0.36 at 6 months Post surgery, showing significant differences before and after surgery (p = 2.30 × 10^- 2). The macular hole closure rate was 98%.

CONCLUSION

The modified inverted ILM flap technique combined with vitreous surgery was an effective method for treating macular holes, resulting in improvement in closure and visual acuity.

Refractory full thickness macular hole: current surgical management

This review aims to collect the proposed surgical techniques for treating full thickness macular hole (FTMH) refractory to pars plana vitrectomy and internal limiting membrane (ILM) peeling and to analyse and compare anatomical and functional outcomes in order to evaluate their efficacy. The articles were grouped according to the surgical techniques used. Refractory FTMH closure rate and best-corrected visual acuity (BCVA) gain were the two analysed parameters. Thirty-six articles were selected. Ten surgical technique subgroups were defined: autologous platelet concentrate (APC); lens capsular flap transplantation (LCFT); autologous free ILM flap transplantation (free ILM flap); enlargement of ILM peeling, macular hole hydrodissection (MHH), autologous retinal graft (ARG), silicon oil (SO), human amniotic membrane (hAM), perifoveal relaxing retinotomy, arcuate temporal retinotomy. Refractory FTMH closure rate was similar among subgroups, not significant heterogeneity emerged (p = 0.176). BCVA gain showed a significant dependence on surgical technique (p < 0.0001), significant heterogeneity among subgroups emerged (p < 0.0001). Three sets of surgical technique subgroups with a homogeneous BCVA gain were defined: high BCVA gain (hAM); intermediate BCVA gain (APC, ARG, LCFT, MHH, SO); low BCVA gain (free ILM flap, enlargement of peeling, arcuate temporal retinotomy). In terms of visual recovery, the most efficient technique for treating refractory FTMH is hAM, lens capsular flap and APC that allow to obtain better functional outcomes than free ILM flap. MHH, ARG, perifoveal relaxing and arcuate temporal retinotomy require complex and unjustified surgical manoeuvres in view of the surgical alternatives with overlapping anatomical and functional results.

Autologous Retinal Transplantation for Primary and Refractory Macular Holes and Macular Hole Retinal Detachments: The Global Consortium

PURPOSE

To report the anatomic and functional outcomes of autologous retinal transplantation (ART).

DESIGN

Multicenter, retrospective, interventional, consecutive case series.

PARTICIPANTS

One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019.

METHODS

All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed.

MAIN OUTCOME MEASURES

Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT.

RESULTS

One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P < 0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n = 35), for refractory MH in 58% of patients (n = 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n = 19). Mean maximum MH diameter was 1470 ± 160 μm, mean minimum diameter was 840 ± 94 μm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P = 0.02) and ANL (P = 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred.

CONCLUSIONS

In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane (ILM) peeling is popular for the treatment of macular hole (MH). However, the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs. Currently, the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate. The ILM flap technique has many variations, including the difference of the size, shape, number, and manner in which the flaps put on the MHs. The ILM flap technique also has some auxiliary means including perfluoro-n-octane (PFO), dye, autologous blood and adhesive viscoelastics. There is controversy about the effects between several technique variations of ILM flap, and it needs to be explored in the future.

PLASMA RICH IN GROWTH FACTORS FOR PERSISTENT MACULAR HOLE: A PILOT STUDY

PURPOSE

Persistent macular hole (PMH) is a challenge for retina surgeons. There are limited surgical techniques described achieving PMH closure. For more than a decade, techniques with blood derivatives have been described without optimal outcomes. The aim of this article is to report the usefulness of the plasma rich in growth factors (PRGF) as a new way to improve PMH closure.

METHODS

This is an observational study. Two patients with PMH were chosen at the FOSCAL Internacional, Floridablanca, Colombia. For each patient, a complete ophthalmological examination before and after treatment was performed. It included best-corrected visual acuity and fundus examination. Features of swept-source optical coherence tomographic angiography (Topcon) at baseline and after treatment were included. Preoperative evaluation included the following: previous vitreoretinal surgery for macular hole, macular hole measurement and classification, and dissociated optic nerve fiber layer in en-face map, confirming a prior internal limiting membrane peeling. Plasma rich in growth factors-Endoret technology is characterized by moderate platelet concentration and absence of leukocytes, which requires calcium chloride for platelet activation. It is obtained from each patient's blood sample, submitted to a series of processes to acquire a three-dimensional fibrin scaffold, rich in hundreds of proteins, which seems to have therapeutic potential. This PRGF membrane is placed into the macular hole with forceps through a pars plana vitrectomy after complete air-fluid exchange. Supernatant was placed on the macula and left it for 2 minutes. It is then aspirated, and gas or silicone oil was left as a tamponade.

RESULTS

Follow-up period was of 12 months for each patient. Complete macular hole closure was achieved in both cases. Best-corrected visual acuity changed from 20/200 preoperatively to 20/100 postoperatively in Patient #1 and from 20/1,500 to 20/100 in Patient #2.

CONCLUSION

Plasma rich in growth factors has been primarily investigated for ocular surface diseases. This is a pilot study using this technology for PMH treatment. The use of PRGF may be an effective and safe surgical technique with satisfactory anatomical and functional results for PMH. Because of its own biomaterials and proteins, PRGF not only allows anatomical closure but also seems to stimulate tissue regeneration.

Incomplete fluid-air exchange technique for idiopathic macular hole surgery

AIM

To explore an improved procedure involving incomplete fluid-air exchange for idiopathic macular hole (IMH), and the closure rate, visual function, and the visual field of macular holes (MHs) were evaluated.

METHODS

This prospective randomized controlled study, included 40 eyes of 40 patients with IMH who were treated with pars plana vitrectomy and peeling of the internal limiting membrane. They were grouped by random digital table. Twenty-one eyes underwent incomplete fluid-air exchange (IFA) and 19 eyes underwent traditional complete fluid-air exchange (CFA) as the control group. Outcomes included best-corrected visual acuity (BCVA), intraocular pressure, and optical coherence tomography, light adaptive electroretinography, and visual field evaluations.

RESULTS

All MHs <400 µm were successfully closed. BCVAs before and 6mo after surgery were 0.82±0.41 logMAR and 0.28±0.17 logMAR in IFA group and 0.86±0.34 logMAR and 0.34±0.23 logMAR in CFA group, respectively. The electroretinogram analysis of patients in IFA group revealed increases in b-wave amplitudes at 1, 3, and 6mo after surgery. Additionally, patients in IFA group showed an amplitude increase of 28.6% from baseline at 6mo (P<0.05), while no obvious improvements were noted in CFA group. Although there were no statistically significant improvements in either group, the IFA group showed a slight increase in mean sensitivity (P>0.05).

CONCLUSION

IFA is a reliable method that offers comparable closure rate to CFA and facilitates improvements in visual function.

A Review of Surgical Outcomes and Advances for Macular Holes

The surgical outcomes of macular holes (MHs) have improved greatly in recent years. The closure rate is as high as 90-100%, but the outcomes of some special types of MHs remain unsatisfactory. Internal limiting membrane (ILM) peeling dramatically improves the anatomic success rate, but recent studies have found that it could also cause mechanical and subclinical traumatic changes to the retina. Dyes are widely used, and apart from indocyanine green (ICG), the toxicities of other dyes require further research. Face-down posturing is necessary for MHs larger than 400 μm, and the duration of this posture is determined by the type of tamponade and the case. The ellipsoid zone has been shown to be highly correlated with visual outcome and recovery. New surgical methods include the inverted ILM flap technique and the ILM abrasion technique. However, they require further research to determine their effectiveness.

Microstructural retinal regeneration after internal limiting membrane flap surgery for repair of large macular holes: a 1-year follow-up study

PURPOSE

To evaluate long-term change in functional and structural outcomes after successful repair of large macular holes (MH) with internal limiting membrane (ILM) flap techniques.

METHODS

Eleven consecutive patients were reviewed over a 1-year time period after the successful repair of large MH with ILM flap techniques. SD-optical coherence tomography (SD-OCT) images were taken to assess the anatomical outcome after surgery, while the best-corrected visual acuity (BCVA) was tested using Snellen charts to evaluate the functional outcome. Each patient was evaluated at 1, 6 and 12 months after surgery, respectively.

RESULTS

All cases achieved complete anatomical closure. All patients showed a microstructural regeneration of the retina with a decrease in ellipsoid zone defects over the 1-year follow-up. Functionally, as compared to baseline, all of the patients showed improvements in best-corrected visual acuity of 1-4 lines at the final examination after 12 months post-operatively.

CONCLUSIONS

Long-term results show further improvement in the best-corrected visual acuity as well as further microstructural regeneration of the retina and decrease in ellipsoid zone defects over time. The exact mechanism, which promotes closure of the macular hole and reconstruction of the ellipsoid zone after internal Limiting Membrane autograft surgery, still remains unknown.

Inverted internal limiting membrane flap technique for large macular holes: a systematic review and single-arm meta-analysis

PURPOSE

The aim of this systematic review was to determine the anatomical outcome-macular hole (MH) closure rate-and functional outcome-visual acuity (VA) improvement rate-of the inverted internal limiting membrane (ILM) flap technique for large MH.

METHODS

We searched for articles on large MH (> 400 μm) treated with inverted ILM flap technique in databases as of December 1, 2017. And single-arm meta-analysis was performed for the primary outcome of MH closure rate and the secondary outcome of VA improvement rate. In addition, we searched and pooled studies treating large MH with indocyanine green (ICG)-assisted ILM peeling as the reference. R software (version 2.15.2) was used for analysis.

RESULTS

This review includes eight studies that used inverted ILM flap technique to treat large MH (> 400 μm). Based on the single-arm meta-analysis performed in R 2.15.2, the pooled MH closure rate and VA improvement rate following inverted ILM flap technique were 95% (95% CI, 88 to 98%) and 75% (95% CI, 62 to 85%), respectively, in fixed-effect models. There was no substantial methodological heterogeneity. In addition, we selected four studies on large MH treated with ICG-assisted ILM peeling as the reference. The fixed-model pooled MH closure rate and VA improvement rate were 87% (95% CI, 79 to 92%) and 57% (95% CI, 46 to 68%), respectively.

CONCLUSIONS

Inverted ILM flap technique should be an effective and safe method for treating large MH, with high closure rates and good VA improvement. However, further studies in large randomized controlled trials on minimizing surgical complications and understanding the mechanism of this technique are necessary.