AUTOLOGOUS NEUROSENSORY RETINAL TRANSPLANTATION: Bridging the Gap

Modified autologous neurosensory retinal transplantation and bevacizumab injection in primary extra-large chronic macular holes

Purpose

To investigate the outcome of primary idiopathic extra-large full-thickness macular holes (FTMH) treated with a modified autologous neurosensory retinal transplantation (ART) adjuncted by bevacizumab (BCZ) injection.

Methods

In this retrospective interventional case series, five consecutive patients with primary extra-large chronic FTMHs were investigated. The ART procedure included internal limiting membrane (ILM) peeling of both donor and macular hole (MH) areas, placement of the harvested tissue under the edges of MH and use of silicone oil tamponade.

Results

The median age was 64 (60-77) years. The first patient developed choroidal neovascularization one month after surgery, which was treated with BCZ injections. Subsequent patients received injection of BCZ (1.25 mg/0.05 mL) into the silicone oil at the end of the initial surgery. At the last follow-up, complete anatomical closure of the MH was achieved in all patients. With the exception of the first patient, all other patients achieved either a final ellipsoid zone (EZ) defect of zero (three cases) or a reduction to 100 μm (one case). The external limiting membrane (ELM) was completely reconstructed in all of patients. All patients demonstrated an improvement in best corrected distant visual acuity (BCDVA) one month after ART surgery, which was sustained throughout the follow-up period (12-42 months). The median LogMAR BCDVA at baseline was 1.4 (1.3-1.4) which decreased to 1.1(1.0-1.1) (P = 0.041) at the first month and 1.0 (0.7-1.2) (P = 0.043) at the last follow-up.

Conclusions

The use of ART surgery accompanied by BCZ injection appears to be an effective method for primary extra-large chronic FTMHs.

Treatment approaches for refractory full-thickness macular holes

PURPOSE OF REVIEW

Full-thickness macular holes (FTMH) can result in significant visual impairment if untreated. Although conventional treatment achieves high closure rates, FTMH can persist or reopen in some cases. This review examines recent advances in surgical approaches for managing refractory FTMH and highlights their effectiveness and limitations.

RECENT FINDINGS

Approaches to refractory FTMH aim to relieve traction, encourage glial cell proliferation, improve RPE pump efficiency, increase retinal compliance, and/or provide replacement tissue. A variety of techniques targeting these mechanisms, including various autologous or allogeneic transplants such as internal limiting membrane (ILM) or human amniotic membrane grafts, or surgical manipulations such as macular detachment or relaxing retinotomies, have been proposed. These techniques are reviewed here.

SUMMARY

Multiple techniques have shown promise for refractory FTMH. Choice of technique should be guided by characteristics of the FTMH, including size and chronicity, availability of desired tissue or instrumentation, and surgeon familiarity.

Autologous retina transplantation for refractory highly myopic macular holes: a long-term follow-up

PURPOSE

To evaluate long-term anatomical and functional outcomes of autologous retinal transplantation (ART) in refractory highly myopic macular holes (HMMHs).

STUDY DESIGN

Retrospective interventional analysis of 9 eyes with refractory HMMH undergoing ART.

METHODS

Best-corrected visual acuity (BCVA, Snellen) and optical coherence tomography (OCT) were performed at baseline and each follow-up visit (1, 3, 6, 12, 24 months and the most recent). Preoperatively, we collected minimum linear diameter (MLD) and basal diameter (BD). Post-operatively, central macular thickness (CMT), external limiting membrane (ELM)/ellipsoid zone (EZ) visibility, macular edema (ME) and retinal pigmented epithelium (RPE) atrophy were evaluated.

RESULTS

Mean follow-up duration was 46.0 ± 19.6 months. Anatomical success was reached in 7/9 eyes (78%). Median BCVA went from 0.05 (IQR 0.065) at baseline to 0.075 (IQR 0.069) at final follow-up (p = 0.25). Only one eye showed a 2-lines improvement, while BCVA was stable in 4/9 (44%) and worsened in 1 eye (12%). CMT progressively thickened in the first 6 months (177 ± 68 μm), but then decreased to 122 ± 50 μm at final follow-up. Graft merging with the surrounding retina was visible in two eyes, showing partial ELM/EZ recovery and good outcomes. Microcystic-like refractory ME (33%) and long-term RPE atrophy (22%) were reported, while delayed displacement of the graft was seen in one case 6 months after first surgery.

CONCLUSION

ART offered acceptable anatomical success but no visual improvement in our cohort. Lack of graft merging with the surrounding retina, persistent microcystic-like ME, RPE atrophy and hole recurrence were the most frequent shortfalls.

Autologous Neurosensory Retinal Flap Transplantation in a Porcine Model of Retinal Hole

Purpose

Autologous retinal transplantation has been successfully employed in the treatment of large and myopic macular holes that are refractory to standard surgical treatments. Patients transplanted with a peripheral neurosensory retinal graft have shown unexpected improvements in visual acuity. The study aims to investigate if neural integration of the graft takes place in a porcine model of retinal hole.

Design

Experimental animal study.

Subjects

Left eyes of 10 Danish landrace pigs.

Methods

The pigs underwent vitrectomy under general anesthesia, and a subretinal bleb was created within the visual streak on both sites of the optic disc. A retinal hole, approximately 1900 to 4000 microns in size, was cut temporally using a vitrector. A graft of matching size was harvested from the nasal retina. The graft was gently moved toward the retinal hole under perfluoro-n-octane and placed within it. Endolaser was applied around the donor site, and either air or oil tamponade was used. OCT and color fundus photography were performed 2 and 6 weeks after surgery. At the end of follow-up, the eyes were enucleated for histological examination, including immunohistochemical analysis with antibodies against retinal glial cells, photoreceptors, and inner retinal neurons.

Main Outcome Measures

The primary outcome measures were the morphology of the graft and the junctional area between the host and the graft.

Results

Retinal hole closure was achieved in 9 of 10 cases, with the graft remaining in situ in 6 cases. In 4 cases, OCT scans indicated preservation of the outer retinal layers, and in 2 of these cases, there was apparent integration with the adjacent host retina. Corresponding histology confirmed the preservation of the photoreceptor layer in 3 cases, but there was no evidence of graft integration with degeneration of the inner retina in all cases. The distance between the margins of the retinal hole decreased during follow-up, suggesting that the graft contracts and drags the surrounding retina toward the center.

Conclusions

The outer retina of a retinal graft can be preserved, while the inner retina degenerates. No evidence of neuroretinal integration of the graft was observed. The retinal graft serves as a scaffold, promoting the centripetal migration of the edges of the hole, resulting in closure of large retinal holes.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Subretinal Amniotic Membrane Transplantation in a Porcine Model of Retinal Hole

Purpose

To investigate the histopathological changes following subretinal amniotic membrane transplantation in an in vivo porcine model of retinal holes.

Methods

Left eyes of 12 Danish Landrace pigs were vitrectomized under full anesthesia. A subretinal bleb was created before excising a retinal hole (1154-2934 µm) using a 23-gauge vitrector. The pigs underwent transplantation of human freeze-dried amniotic membrane into the subretinal space, with no tamponade applied. Optical coherence tomography and color fundus photography were performed just after surgery and at 2 and 4 weeks post-surgery. At the end of follow-up, the eyes were enucleated for hematoxylin and eosin staining and fluorescence immunohistochemistry, using antibodies against retinal glial cells and inner retinal neurons.

Results

The amniotic membrane sheets facilitated hole closure by gliosis and centripetal migration of the edges of the hole. Immunohistochemical examination showed that the cells within the closed hole expressed anti-glial fibrillary acidic protein (GFAP) and anti-S100B, but not anti-glutamine synthetase (GS), suggesting that astrocytes were the predominant glial cells involved in hole closure. Gliosis was observed between the amniotic membrane sheet and the overlying photoreceptors of the surrounding retina. Morphological restoration of the retinal layers within the closed retinal hole was not observed.

Conclusions

The amniotic membrane acted as a stimulator for retinal hole closure by inducing glial cell proliferation and providing a scaffold for the centripetal migration of the edges of the hole. No morphological restoration was observed.

Petaloid technique and prognostic significance of macular hole shapes by optical coherence tomography for full thickness macular hole

Surgical advancements for full-thickness macular hole (FTMH) treatment include vitrectomy, membrane peeling, and the inverted flap technique (IFT). IFT, which involves inverting the internal limiting membrane (ILM) flap over the macular hole (MH) or into the MH, improves success rates and visual recovery. However, issues like mis-aspiration during flap handling have been problematic. We introduce the petaloid technique, to position the ILM flap under air during FTMH surgery to evaluate its outcomes. This retrospective study included 28 eyes, with a mean minimum linear diameter (MLD) 472.04 ± 199.7 μm and basal diameter (BD) of 834.95 ± 593.54 μm. Primary closure of MH was achieved in 96.42% of patients, with 3.57% showing persistent MH during the 6-month follow-up. The VA improved significantly from preoperative levels at each postoperative stage, with notable increases at 3 months (0.86 ± 0.49 logMAR; p = 0.0132) and 6 months (0.77 ± 0.41 logMAR; p = 0.000081). The new closure patterns showed Type A in 28.6%, B in 14.3%, C in 28.6%, and D in 25%. Among different types of closure patterns, although VA improved in all types, significant improvement in VA was noted for type A and type C, with notable improvements at the 6-month follow-up for Type A (0.60 ± 0.23 logMAR; p = 0.02) and at the 1-month follow-up for Type C (0.62 ± 0.28 logMAR; p = 0.02). For macular hole retinal detachment in 5 eyes, the average preoperative VA was 1.86 ± 0.19 logMAR, while the final mean postoperative VA showed a significant improvement to 1.1 ± 0.40 logMAR (p = 0.021, paired t-tests). Retinal reattachment was achieved in all cases (5/5) without recurrent detachment post-silicone oil removal. For the prognostic significance of MH shapes identified by OCT, it can be concluded that the shape of macular holes significantly influences visual acuity outcomes at 6 months post-surgery (p = 0.037). The shape of macular holes, particularly Flask-shaped, significantly impacts visual acuity compared to other shape. The modified petaloid technique for treating FTMH proved safe and effective, with no significant complications noted.

Large macular hole and autologous retinal transplantation: a systematic review and meta-analysis

INTRODUCTION

Macular holes are breaks in the retinal tissue at the center of the macula, affecting central vision. The standard treatment involves vitrectomy with membrane peeling and gas tamponade. However, for larger or chronic holes, alternative techniques like autologous retinal graft have emerged. This meta-analysis evaluates the efficacy and safety of retinal transplantation in managing large macular holes.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines. The study was prospectively registered in PROSPERO (CRD42024504801). We searched PubMed, Web of Science, Cochrane, and Embase databases for observational studies including individuals with large macular holes with or without retinal detachments and retinal transplantation as the main therapy. We used a random-effects model to compute the mean difference with 95% confidence intervals and performed statistical analysis using R software.

RESULTS

We conducted a comprehensive analysis of 19 studies involving 322 patients diagnosed with various types of macular holes (MHs). These included cohorts with refractory MH, high myopia associated with MH, primary MH, and MH with retinal detachment (RD). The findings were promising, revealing an overall closure rate of 94% of cases (95% CI 88-98, I2 = 20%). Moreover, there was a significant improvement in postoperative visual acuity across all subgroups, averaging 0.45 (95% CI 0.33-0.58 ; I2 = 72%; p < 0.01) overall. However, complications occurred with an overall incidence rate of 15% (95% CI 7-25; I2 = 59%).

CONCLUSION

ART for large MH shows promising results, including significant improvements in visual acuity and a high rate of MH closure with low complication risks overall and for subgroups.

Comparison of the therapeutic effects of lens capsular flap transplantation and autologous retinal transplantation in the management of refractory macular holes

PURPOSE

To report the comparison of the therapeutic effects of lens capsular flap transplantation (LCT) and autologous retinal transplantation (ART) in refractory macular hole (MH) treatment.

METHODS

Thirty-one patients (31 eyes) with refractory MH were retrospectively reviewed. The patients were divided into two groups based on the surgical procedures: the LCT group (13 eyes) and the ART group (18 eyes). Patients were monitored for a minimum of 6 months. Best corrected visual acuity (BCVA), hole closure rate, postoperative central foveolar thickness (CFT), and some complications (e.g. graft loss or dislocation, postoperative retinal detachment, or postoperatively elevated intraocular pressure) were the primary outcome measures.

RESULTS

The mean preoperative MH diameter was 1104 ± 287 μm in the LCT group and 1066 ± 297 μm in the ART group (t = 0.353, P = 0.727). The MH was closed in 12 patients (92.3%) of the LCT group and 17 patients (94.4%) of the ART group (χ2 = 0.057, P = 0.811); the MHs of 10 patients (76.9%) in the LCT group and 11 patients (61.1%) in the ART group were completely closed (χ2 = 0.864, P = 0.353). The BCVA improved from 2.3 ± 1.0 logMAR preoperatively to 1.3 ± 0.9 logMAR postoperatively in the LCT group and 2.3 ± 0.9 logMAR preoperatively to 1.0 ± 0.6 logMAR postoperatively in the ART group (postoperative BCVA vs preoperative BCVA in the LCT group: t = 4.374, P = 0.001; postoperative BCVA vs preoperative BCVA in the ART group: t = 5.899, P = 0.000018). The visual improvement was 1.3 ± 0.9 logMAR in the ART group and 1.0 ± 0.8 logMAR in the LCT group (t = - 1.033, P = 0.310). The postoperative CFT was 139.7 ± 48.3 μm in the LCT and 199.2 ± 25.1 μm in the ART group (t = - 4.062, P = 0.001). Graft dislocation emerged in 2 patients (15.4%) in the LCT group and 1 patient (5.6%) in the ART group.

CONCLUSIONS

Applications of LCT and ART may both enhance anatomical and visual outcomes in refractory MH cases. The ART group exhibited a more optimal postoperative CFT than the LCT group one.

Outcomes of revision surgery for idiopathic macular hole after failed primary vitrectomy

Persistent idiopathic macular hole (PIMH), the occurrence of idiopathic macular holes that have failed to close after standard pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling, has become a global health threat to the aging population. Because postoperative anatomic closure or restoration of visual acuity is more difficult to achieve in PIMH, surgical approaches that would yield the best outcomes remain to be elucidated. On paper, extended ILM peeling combined with silicone oil (SiO) tamponade is believed to be a feasible option for excellent macular hole closure. However, no studies on this combined treatment for PIMH is compared with simple air tamponade have been conducted. Thus, in this retrospective case series, we used spectral-domain optical coherence tomography (SD-OCT) and other technologies to investigate real-world evidence for the anatomical and functional outcomes of revisional PPV with either SiO or air tamponade for failed primary idiopathic macular hole surgery. We included the records of 76 patients with PIMH who had SD-OCT examinations and best-corrected visual acuity (BCVA). Regression analysis was performed to find factors affecting PIMH fracture closure. Seventy-six participants were allocated to a SiO group (n = 21, with an extended ILM peeling and SiO tamponade) or an air group (n = 55, with extended ILM peeling and air tamponade). Anatomical success was achieved in 18 (85.7%) and 40 (72.7%) eyes in the SiO and air groups, respectively (p = 0.37). BCVA was significantly improved in both subgroups of closed PIMH (SiO group: p = 0.041; air group: p < 0.001). Minimum linear diameter (MLD) was closely related to the closure rate (OR, 1.0; 95% CI (0.985-0.999); p = 0.03). MLD = 650 μm seemed like a cut-off point for closure rate (MLD ≤ 650 μm vs. MLD > 650 μm; 88.4% vs. 52%, p = 0.002). In conclusion, we demonstrated that extended ILM peeling combined with SiO or air tamponade is effective in PIMH treatment. Moreover, though not statistically significant herein, the anatomic closure rate was better for silicone-operated eyes than for air-operated eyes. MLD is the best predictor of PIMH closure; MLD ≤ 650 μm could achieve a significantly higher closure rate.

A retrospective, multicenter study on the management of macular holes without residual internal limiting membrane: the refractory macular hole (ReMaHo) study

Purpose

To evaluate the surgical management, outcomes and prognostic factors of full thickness macular holes without residual internal limiting membrane (NO-ILM FTMHs).

Methods

We performed a multicenter, retrospective study of 116 NO-ILM FTMHs. Human amniotic membrane (hAM) plug, autologous ILM free flap transplantation (AILMT), and autologous retinal graft transplantation (ART) were performed in 58, 48, and 10 patients, respectively. Data were collected before and up to 12 months after surgery. The primary outcomes were hole closure and final best-corrected visual acuity (BCVA).

Results

The final BCVA (0.78 ± 0.51 logMAR) was significantly better than and correlated with the initial BCVA (p < 0.0001 and p = 0.004, respectively). Hole closure was achieved in 92% of eyes. The minimum FTMH diameter was wider and final BCVA was lower in the ART group than in the other groups (p < 0.003 and p < 0.001, respectively). FTMHs with diameter > 680 μm had a higher closure rate with hAM than with AILMT (p = 0.02).

Conclusions

AILMT and hAM were the most frequently performed surgeries with both high closure rate and significant functional improvement. Preoperative BCVA was correlated with final BCVA. The minimum FTMH diameter may guide the treatment choice.

Advances in Vitreoretinal Surgery

Advances in vitreoretinal surgery provide greater safety, efficacy, and reliability in the management of the several vitreoretinal diseases that benefit from surgical treatment. The advances are divided into the following topics: scleral buckling using chandelier illumination guided by non-contact visualization systems; sclerotomy/valved trocar diameters; posterior vitrectomy systems and ergonomic vitrectomy probes; chromovitrectomy; vitreous substitutes; intraoperative visualization systems including three-dimensional technology, systems for intraoperative optical coherence tomography, new instrumentation in vitreoretinal surgery, anti-VEGF injection before vitrectomy and in eyes with proliferative diabetic retinopathy, and new surgical techniques; endoscopic surgery; the management of subretinal hemorrhages; gene therapy; alternative techniques for refractory macular hole; perspectives for stem cell therapy and the prevention of proliferative vitreoretinopathy; and, finally, the Port Delivery System. The main objective of this review is to update the reader on the latest changes in vitreoretinal surgery and to provide an understanding of how each has impacted the improvement of surgical outcomes.

Comparison of three techniques of harvesting full-thickness retinal tissue for large or persistent macular holes

Purpose

To evaluate the success rate of autologous retinal graft (ARG) for the closure of full-thickness macular holes (MHs) and compare the outcomes of three different techniques of harvesting the graft.

Methods

Clinic files of all patients who had undergone ARG for MH using intraocular scissors, membrane loop, or retinal punch to harvest retinal tissue were retrospectively reviewed. All patients were evaluated for MH closure, retinal reattachment, and visual improvement.

Results

Twenty-two eyes of 22 patients were included. ARG was done for 16 eyes (72.7%) with failed, large persistent MH, and six eyes (27.3%) also underwent simultaneous repair of retinal detachment. The basal diameter of MH was 1103.67 ± 310.09 (range 650-1529) μm. Intraocular scissors were used in 10 eyes (45.5%), a membrane loop in five eyes (22.7%), and a retinal punch in seven eyes (31.8%). Silicone oil tamponade was used in seven (31.8%) eyes and gas in 15 (68.1%) eyes. The follow-up ranged from 6 to 18 months. The hole closure rate was 72.7% (16/22). Visual improvement was noted in 18 eyes (81.8%). Retinal reattachment was seen in all eyes. Good graft integration with the surrounding area was seen in 17 eyes (77.3%). Graft retraction was seen in four eyes (18.18%) and graft loss in one eye (4.55%). No significant differences were noted among the three groups.

Conclusion

ARG is successful in closing large, failed MH with and without retinal detachment. A membrane loop and retinal punch are equally useful in harvesting the graft, but scissors are preferable in case the retina is detached. With all three techniques, integration of the graft with the surrounding tissue can be achieved.