TREATMENT OF PERSISTENTLY OPEN MACULAR HOLES WITH HEAVY SILICONE OIL (DENSIRON 68) VERSUS C2F6. A PROSPECTIVE RANDOMIZED STUDY

Closure rates and patterns after light silicone oil tamponade for persistent full-thickness macular holes

PURPOSE

To report outcomes of re-vitrectomy using light silicone oil (SO) tamponade for persistent macular holes (MHs).

METHODS

We reviewed cases of patients with full-thickness MHs that underwent pars plana vitrectomy (PPV) with air/gas and were re-vitrectomized using light SO tamponade after primary non-closure (persistent MHs). Outcome measures included anatomic closure rates and patterns confirmed by optical coherence tomography (OCT) and changes in best-corrected visual acuity (BCVA).

RESULTS

A total of 42 eyes of 41 patients with unsuccessful primary PPV with air/gas were included. After re-vitrectomy with light SO (1000-centistoke), 29 (69%) eyes demonstrated type 1 closure without neurosensory defects in OCT scans, whereas 9 eyes (21%) showed type 2 closure with persisting neurosensory defects. Available data (n = 21) showed a significant mean improvement of BCVA from 0.99 logMAR (SD 0.25, range 0.7-1.3) preoperatively to 0.74 logMAR (SD 0.42, range 0.2-1.5) postoperatively (p = 0.035).

CONCLUSION

The treatment of persistent MHs with PPV and light SO tamponade resulted in high closure rates.

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.

Update on surgical management of complex macular holes: a review

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.

Persistent macular holes - what is the best strategy for revision?

PURPOSE

This study aims to analyze the success rate and functional outcome after revision surgery of persistent idiopathic full-thickness macular holes in a large patient cohort and to identify the optimal tamponade strategy and the value of new adjunctive manipulation techniques for persistent macular hole (pMH) closure.

METHODS

Retrospective, comparative, non-consecutive case series of all revisional surgeries for idiopathic pMH between 2011 and 2019 at the Eye Clinic Sulzbach were identified. Of 1163 idiopathic MH surgeries, 74 eyes of 74 patients had pMH. Of those, group 1 (n = 38) had vitrectomy with tamponade alone (20% sulfur hexafluoride gas, 15% hexafluoroethane gas, silicone oil 5000, Densiron®), while group 2 (n = 36) included tamponade with adjuvant manipulation (internal limiting membrane (ILM) translocation, subretinal fluid injection, epiretinal amniotic membrane, free retina graft, or autologous blood). Main statistical outcomes were anatomic closure rate, visual acuity (VA), minimum linear diameter (MLD), and base diameter (BD).

RESULTS

Overall total anatomical success rate was 81.1% and mean VA improved 3.5 lines from LogMAR 1.03 ± 0.30 to 0.68 ± 0.38 (p < .001). Preoperative MLD or BD had no effect on total anatomic success (p = 0.074, p = 0.134, respectively). When comparing the two groups, slightly better anatomic success rates were achieved in group 1 (84.2%) compared to that in group 2 (77.8%) (p = 0.68). Final VA in group 1 (LogMAR 0.67 ± 0.39) outperformed group 2 (LogMAR 0.86 ± 0.38) (p = 0.03).

CONCLUSIONS

Revisional surgery for persistent idiopathic MH with tamponade alone had comparable anatomical closure but better VA outcomes, compared to tamponade with adjuvant manipulation.

FIRST FAILED MACULAR HOLE SURGERY OR REOPENING OF A PREVIOUSLY CLOSED HOLE: Do We Gain by Reoperating?-A Systematic Review and Meta-analysis

Repeated idiopathic full-thickness macular hole surgery after primary failure or reopening of a previously closed hole seems beneficial both in terms of anatomical closure and improvement in best-corrected visual acuity.

To evaluate repeated surgery for idiopathic full-thickness macular hole that failed to close (FTC) after first surgery or reopened (RO) once originally closed.

Silicone oil tamponade for persistent macular holes

BACKGROUND

A variety of treatment strategies have been proposed for macular holes that persist or recur after surgery, and the debate about the best re-treatment approach is ongoing. To allow for a comparison with alternative surgical therapies, we assessed the anatomical and functional outcome of a temporary tamponade with conventional silicone oil in persistent or recurrent full-thickness macular holes.

METHODS

We retrospectively investigated consecutive patients with full-thickness macular holes that persisted or recurred following vitrectomy with internal limiting membrane peeling and gas tamponade. All patients received re-treatment by temporary tamponade of silicone oil and were allowed free postoperative positioning. Anatomical closure rate was assessed by optical coherence tomography, and change of best-corrected visual acuity (BCVA) was analyzed.

RESULTS

A total of 33 eyes of 33 consecutive patients were included. Macular hole closure following silicone oil tamponade was achieved in 30 of 33 eyes (90.9%). Median BCVA improved from 1.00 logMAR (interquartile range, 0.60-1.00) to 0.65 logMAR (0.49-1.00; p = 0.010) after silicone oil removal. In patients with macular hole closure, 61.3% exhibited functional improvement with median BCVA changing from 1.00 logMAR (0.70-1.00) to 0.60 logMAR (0.49-1.00; p = 0.0005). Mean minimal linear diameter of macular holes before primary surgery was 391.0 µm (±137.8; range 133-630), and 48.5% of macular holes were >400 µm in diameter.

CONCLUSIONS

Treatment of persistent or recurrent full-thickness macular holes by temporary conventional silicone oil tamponade without postoperative positioning results in a high closure rate and a significant mean improvement of visual acuity.

Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study

INTRODUCTION

Persisting macular holes (PMH) after surgical release of any epiretinal traction of the vitreous and adjacent membrane may rely on secondary firm adhesions between the retracted retina and adjacent retinal pigment epithelium. Secondary application of subretinal (SR)-fluid may release these adhesions followed by an anatomical closure.

METHODS

Twelve surgeons applied in a consecutive case series SR-fluid in 41 eyes with PMH and reported retrospectively their initial surgical, anatomical and functional experience with this approach.

RESULTS

The mean duration of the MH prior to SR-fluid application was 17 months (6-96 months). The mean age of the patients at the time of surgery was 72 years (54-88). The mean preoperative aperture diameter of the opening was 1212 μm (239-4344 μm), base diameter 649 μm (SD 320 μm). The mean preoperative BCVA prior to surgery was 0.1 (0.01-0.3). All patients (41/41) complained about reduced BCVA and a significant central scotoma (negative scotoma) in their central field of vision. The secondary closure rate for our PMH was 85.36% (35 out of 41 eyes) at 6 weeks after surgery. The postoperative BCVA improved to 0.22 (0.02-0.5). The application of SR-fluid was not associated with major intraoperative adverse effects.

CONCLUSION

Remaining SR-adhesions may inhibit PMH closure. Their release by application of SR-fluid will lead to a fast and immediate anatomical closure in many cases without serious adverse events.

Infracyanine Green vs. Brilliant Blue G in Inverted Flap Surgery for Large Macular Holes: A Long-Term Swept-Source OCT Analysis

Background and Objectives: To compare the long-term toxicity of infracyanine green (IFCG) to brilliant blue G (BBG) in inverted internal limiting membrane flap surgery (I-ILMFS) for large, full-thickness macular holes (FTMHs). Materials and Methods: Prospective randomized study including 39 eyes with ≥ 400 µm idiopathic FTMH who underwent I-ILMFS with either IFCG or BBG. Postoperative 6- and 12-month corrected distance visual acuity (CDVA), closure rate, and swept-source optical coherence tomography parameters, including ellipsoid zone (EZ) and external limiting membrane (ELM) mean defect length, central foveal thicknesses (CFT), parafoveal macular thickness (MT), ganglion cells and inner plexiform layer (GCL++) thickness, and peripapillary nerve fiber layer (pRNFL) thickness, were compared. Results: Nineteen eyes were included in the IFCG group and 20 eyes in the BBG group. In all cases a FTMH closure was found. CDVA improved at 6 and 12 months in both groups (p < 0.0005); the increase at 12 months was greater in the BBG group (p = 0.036). EZ and ELM defects did not differ between groups at either follow-up time. CFT at 12 months was greater in the BBG group (p = 0.041). A 12-months compared to 6-months MT decrease was present in both groups (p < 0.01). The GCL++ superior inner sector was thicker in the BBG group at 12 months (p = 0.036), as were the superior outer sector (p = 0.039 and p = 0.027 at 6 and 12 months, respectively) and inferior outer sector (p = 0.011 and p = 0.009 at 6 and 12 months, respectively). Conclusion: In our study BBG in I-ILMFS exhibits better long-term CDVA and retinal thickness than does IFCG, suggesting a lesser toxicity from BBG. These findings support the use of BBG over IFCG in I-ILMFS.

Prognostic Factors in Patients with Persistent Full-Thickness Idiopathic Macular Holes Treated with Re-Vitrectomy with Autologous Platelet Concentrate

PURPOSE

To identify the predictors for anatomical and functional outcome after re-vitrectomy with application of autologous platelet concentrate (APC) in eyes with persistent idiopathic macular hole (MH).

METHODS

Retrospective study of 103 eyes with persistent MHs after vitrectomy with peeling of internal limiting membrane (ILM) and expansive gas. All patients underwent re-vitrectomy with APC and endotamponade. The anatomical MH closure rate and postoperative best-corrected visual acuity (BCVA) were evaluated. Further, predictive factors influencing the success of the surgery were analyzed.

RESULTS

Median BCVA (logMAR) before the surgery was 1.00 (interquartile range [IQR] 0.80-1.30) and the median of minimum diameter between hole edges was 508 µm (IQR 387-631). The final closure rate after re-vitrectomy with APC was 60.2% (62 of 103 eyes). The following predictors were identified to significantly influence the closure rate: tractional hole index (THI), axial length, time between first and second surgery, and the experience of the surgeon (p < 0.05).

CONCLUSIONS

Re-vitrectomy with APC led to the closure of 60.2% of the persistent MHs. The closure rate negatively correlates with increasing axial length, time between the first and second surgery, and the decreased THI. Further, experienced surgeons (with a history of >100 pars plana vitrectomies with ILM peeling) had significantly higher closure rates.

An Internal Limiting Membrane Plug and Gas Endotamponade for Recurrent or Persistent Macular Hole

Introduction

Recurrent or persistent macular holes (MHs) are rare today due to the tendency to carefully peel the internal limiting membrane. Conversely, their treatment is still a challenge for a vitreoretinal surgeon.

Materials and Methods

This is a retrospective, consecutive, and nonrandomized study of patients affected by recurrent or persistent MHs treated using small-gauge pars plana vitrectomy (25- or 23-gauge) and an autologous ILM plug, at the Eye Clinic of Azienda Ospedaliera Universitaria Careggi (Florence, Italy) between January 2016 and May 2018. We included 8 eyes of 8 patients in the study. Five patients had a recurrent MH while 3 had a persistent MH. The case series includes patients with myopic eyes and with large macular holes (>400 μ). Patients were followed up with ophthalmoscopic examinations and swept-source optical coherence tomography (SS-OCT).

Results

The mean age of the patients was 74 years (±4.81 standard deviation (SD)), 3 patients were men and 5 women. The average axial length was 26.28 mm (±2.84 SD). Four patients had an AL ≧ 26 mm. The mean MH diameter was 436.5 (±49.82 SD). Average preoperative best-corrected visual acuity (BCVA) was 0.81 logMAR (±0.16 SD) and 20/125 Snellen. The ILM plug has been found integrated in the MH in all the follow-ups.

Conclusion

In our study, an ILM autologous macular transplant was used successfully in 5 cases of macular hole recurrence and 3 cases of macular hole persistence. The anatomical success was achieved in all the cases; 4 patients improved their BCVA, and 4 patients maintained it. No macular alterations such as RPE or retinal atrophy/dystrophy were observed after 6 months.

Perspectives of Autologous Mesenchymal Stem-Cell Transplantation in Macular Hole Surgery: A Review of Current Findings

The main treatment available for idiopathic macular holes is represented by pars plana vitrectomy with internal limiting membrane peeling. However, late-stage macular holes are affected by a higher risk of surgical failure. Although adjuvant techniques can be employed, a satisfactory functional recovery is difficult to achieve in refractory macular holes. Given their neuroprotective and antiapoptotic properties, mesenchymal stem cells (MSCs) may represent an appealing approach to treat these extreme cases. The purpose of this review is to highlight the findings regarding healing mechanisms exerted by mesenchymal stem cells and preliminary application in cases of refractory macular holes. When compared with MSCs, MSC-derived exosomes may represent a feasible alternative, given their reduced risk of undesired proliferation and easiness of use.

Effects of mesenchymal stem cells and their exosomes on the healing of large and refractory macular holes

PURPOSE

To assess the efficacy of mesenchymal stem cells (MSCs) and MSC-derived exosomes (MSC-Exos) to promote the healing of large and refractory macular holes (MHs).

METHODS

Seven patients (age 51-75 years old) with large and long-standing idiopathic MHs underwent vitrectomy, internal limiting membrane peeling, MSC (two patients) or MSC-Exo (five patients) intravitreal injection, and heavy silicon oil, air, 20% SF6, or 14% C3F8 tamponade. The MSCs were isolated from human umbilical cord tissue, and MSC-Exos were isolated from the supernatants of cultured MSCs using sequential ultracentrifugation.

RESULTS

Five eyes underwent pars plana vitrectomy (PPV) only, while two underwent PPV combined with cataract surgery. Six MHs were closed, while one remained in a flat-open state. The best-corrected visual acuity (BCVA) was improved in five patients with MH closure and remained unchanged in one patient with MH closure who had a 4-year history of MH. A fibrotic membrane was observed on the surface of the retina in one patient who underwent MSC therapy. One patient who received a higher dose of MSC-Exos exhibited an inflammatory reaction.

CONCLUSIONS

MSC and MSC-Exo therapy may promote functional and anatomic recovery from MH. MSC-Exo therapy may be a useful and safe method for improving the visual outcomes after surgery for refractory MHs.

THE CURRENT SURGICAL MANAGEMENT OF LARGE, RECURRENT, OR PERSISTENT MACULAR HOLES

PURPOSE

To evaluate the current surgical options available for the management of large (>400 μm), recurrent, or persistent macular holes (MHs).

METHODS

A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and surgical treatments of large, recurrent, or persistent MHs. Based on this review, a comprehensive overview was provided regarding the topic of large, recurrent, or persistent MHs and focused on recent surgical management updates.

RESULTS

For large MHs, variations of the inverted internal limiting membrane flap technique demonstrated promising rates of primary hole closure and significant visual acuity improvements. For recurrent or recalcitrant MHs, early repeat vitrectomy with extension of the internal limiting membrane peel remains the most straightforward and optimal surgical technique to achieve secondary closure. Regardless of the surgical approach, the goal of each technique described is to induce or aid in stimulating gliosis within the MH to maximize closure.

CONCLUSION

Despite the high success rate of modern MH surgery, large, recurrent, or persistent MHs remain a challenge for retinal surgeons. This review provides a detailed summary on the rationality and efficacy of current surgical options.

Pars plana vitrectomy with silicone oil tamponade for primary and secondary macular hole closure: Is it still a useful procedure?

Purpose:

To evaluate usefulness of posterior vitrectomy with silicone oil tamponade for primary and secondary macular hole closure.

Methods:

We searched for publications on the surgical treatment of full-thickness idiopathic and recurrent macular hole. We divided reports into two groups: primary macular hole repair and recurrent macular hole repair with silicone oil tamponade.

Results:

In primary macular hole treatment, different authors confirmed effectiveness of silicone oil tamponade. They suggest that the most important factor for successful outcome was completeness of vitreous cavity filling with oil. Complications after this method were comparable to those after gas tamponade. However, even if good anatomical results are achieved in secondary macular hole closure, visual acuity is sometimes less rewarding.

Conclusion:

There are reports on good efficacy of silicone oil tamponade for primary and recurrent macular hole closure. Anatomical closure and visual acuity rates in pars plana vitrectomy with silicone oil and with gas filling are comparable. Gas tamponade seems to be safer and needs no more surgery. Postoperative complications in both methods are similar, but all patients with silicone oil filling need to undergo a reoperation to have the silicone removed. There are also other surgical techniques for primary macular hole closure as well as for unsuccessful primary macular hole procedures. We think that primary macular hole closure should be performed with gas tamponade, supported with different adjuvants, as a method of choice. Silicone oil tamponade could be still an alternative in cases, when there are no more efficient techniques or possibilities to treat with success recurrent macular hole.