ANTERIOR LENS CAPSULE IN THE MANAGEMENT OF CHRONIC FULL-THICKNESS MACULAR HOLE

Advances in management strategies for large and persistent macular hole: An update

The standard of care to treat small- and medium-sized macular holes (<400 µm diameter) consists of a conventional transconjunctival sutureless pars plana vitrectomy followed by ILM peeling and endotamponade, mainly with gas or in some cases with silicone oil, resulting in closure rates of over 90% and good functional results. Large (>400 µm diameter), chronic and persistent macular holes remain a surgical challenge since closure rates and functional results decrease with larger macular hole diameters. Various modifications of the conventional surgical technique were introduced to improve anatomic and functional success in refractory cases not suitable for conventional macular hole surgery. These techniques comprise the positioning of tissue at the top of the hole to improve closure as performed by an inner limiting membrane flap and free flap preparation or the transplantation of autologous retinal tissue, lens capsule or amniotic membrane. For the treatment of very large and persistent macular holes, the induction of a localized retinal detachment at the posterior pole by subretinal injection of balanced salt solution and a subsequent attenuation of the rim of the hole during fluid-air exchange has been suggested as a promising surgical technique. In particular, accurate patient education about the expected surgical outcome in this specific group of patients appears important.

Severe Gliosis Over a Closed Macular Hole Following Anterior Lens Capsular Flap Closure

Various management strategies, including the use of autologous and allogenic materials, are described for the management of persistent macular holes. An anterior lens capsular flap can be used, especially when cataract surgery is also planned, for a persistent full-thickness macular hole. We report a case of a gentleman in his 60s who underwent anterior lens capsular flap closure for a persistent macular hole. There was an improvement in visual acuity. However, he developed severe gliosis over the closed hole in the postoperative period. This could be due to the proliferation of residual epithelial cells in the lens capsule, micro damage to the retina, or an exaggerated inflammatory response to a foreign tissue placed over the retinal surface.

Development of an Eccentric Macular Hole Followed by Reopening of the Original Macular Hole as a Long-term Sequelae of Internal Limiting Membrane Peeling and Focal Laser Photocoagulation: A Case Report

A macular hole (MH) is a widely known disease among ophthalmologists. Vitrectomy with internal limiting membrane (ILM) peeling is a standard technique for full-thickness MHs. However, the recurrence of MHs is sometimes seen. In addition, an eccentric MH is known to rarely occur after vitrectomy. An eccentric MH has been considered to require no therapeutic intervention because of its lack of increase in size. This study reports a case of two MHs (a recurrent MH and an enlarged eccentric MH) developed after laser photocoagulation around the injured retina caused by ILM peeling at the initial surgery. A 56-year-old woman presented with an idiopathic MH in her left eye and best-corrected visual acuity (BCVA) was decreased to 20/80. She underwent phacoemulsification and vitrectomy combined with posterior hyaloid removal, ILM peeling, and 20% sulfur hexafluoride gas tamponade.  During the ILM peeling, we performed laser photocoagulation around the injured retina within the arcade. The MH was successfully closed and her BCVA was improved to 20/20 one month after surgery. Eight months after surgery, an eccentric MH occurred next to the photocoagulation spots. However, her BCVA remained 20/20; thus, we just followed up on her eye. Six years after surgery, her BCVA was decreased to 20/200. The eccentric MH increased in size and the original MH re-opened. The second vitrectomy was performed, but ILM had been already peeled within the arcade during the previous surgery and a usable sufficient size of ILM which could be auto-transplanted to the holes was not obtained. Thus, free flaps of the posterior lens capsule were harvested and placed within each hole. Two holes were successfully closed and her BCVA improved to 10/20 at three months after the surgery. Laser photocoagulation around the injured retina derived from ILM peeling may be a risk for recurrent MHs. .

Optical Coherence Tomography Angiography in Macular Holes Autologous Retinal Transplant

In this paper, we compare the post-operative macular microvascular parameters (vascular density and foveal avascular zone) in eyes with refractory macular hole (MH) that underwent pars plana vitrectomy and autologous retinal transplant (ART) with the fellow unoperated eye. We conducted a retrospective case control study of six consecutive patients who underwent pars plana vitrectomy and ART with at least six months of post-operative follow-up. Pre-operatively, all eyes underwent SD-OCT (Spectral Domain Optical Coherence Tomography) examination. Post-operative OCT-A analyses included vascular density (VD) and the foveal avascular zone (FAZ) area. Six patients with a mean age of 63.7 ± 14.3 years were included. The mean follow-up was 24 months (range 6–30 months). The pre-operative BCVA (best-corrected visual acuity) was 0.99 ± 0.46 logMAR and 1.02 ± 0.23 logMAR at the last post-operative visit (p = 1.00). The mean MH diameter was 966 ± 620 µm. VD in the MH group was 28.1 ± 7.3% compared to 20.2 ± 2.9% in the fellow eyes group (p < 0.05). The mean post-operative FAZ area in the MH group was 109.8 ± 114.6 mm2 compared to 41.5 ± 10.4 mm2 in the control group (p < 0.05). In all six eyes, MH closure was obtained. The post-operative visual acuity did not improve after ART. Eyes with a closed MH showed a bigger FAZ with a higher VD compared to the fellow healthy eye.

Results of large macular hole surgery using different interposition techniques. A report on 9 cases

OBJECTIVE

To describe the long-term anatomical and functional restoration observed in patients operated on for a large macular hole (MH) using different macular interposition techniques.

METHOD

Retrospective analysis of the results obtained in a series of 9 patients undergoing large MH surgery (≥450μm) performing 4 different macular interposition techniques: inverted internal limiting membrane flap in 4 cases, autotransplantation of internal limiting membrane in 2, amniotic membrane graft in 2, and autologous anterior capsule graft in one. The mean follow-up time was 11 months. Anatomically, the outcome measures explored were the restoration of the outer layers of the retina and the pattern of MH closure. The final visual acuity and visual quality were functionally assessed.

RESULTS

The restoration of the outer layers was partial in 6 cases. The macular closure rate was 100%, showing an incomplete pattern in 4 cases. Visual acuity improved in 7 patients, remaining stable in 2. Three cases showed an eccentric fixation pattern and/or metamorphopsia.

CONCLUSIONS

The development of new surgical techniques has increased the rate of macular closure in large MHs. However, the anatomical and functional restoration remains unpredictable. In this work, macular closure was achieved in all patients and a higher rate of complete closure using inverted internal limiting membrane flap. The restoration of the outer layers was more favorable in the groups in which internal limiting membrane had been used. Functional recovery was independent of the technique used.

Autologous Retinal Transplant for Macular Hole

We aim to review scientific literature concerning published studies on autologous retinal transplantation to treat macular hole patients. The following databases were searched: Medline and Medline Non-Indexed Items, Embase (1990–2020), Ovid Medline® (1990 to November 2020), Embase (1990 to November 2020), Ovid Medline® and Epub Ahead of Print, in-Process and Web of Science (all years). Search keywords included “autologous”, “retinal transplant”, “autologous neurosensory retinal free flap” “transplantation”, “macular hole”, and “macular hole surgery”. Eighteen case series and single case reports were reviewed.

Preoperative and final best-corrected visual acuity, microperimetry and multifocal electroretinogram findings, macular hole closure rate, preoperative and postoperative ellipsoid zone, and external limiting membrane defects were obtained and analyzed. Indications of autologous retinal transplantation for macular hole surgery included refractory macular holes, conventional techniques, and large macular holes. The number of cases included in the different case series ranged from 2 to 130 cases, and prior macular hole surgeries of the patients ranged from 0 to 3. Overall, the published case series of autologous retinal transplants have reported a macular hole closure rate of 66.7 to 100%, as well as a significant improvement in best-corrected visual acuity. The most frequently reported complications included considerable intraoperative bleeding and postoperative dislocation of the graft. The presence of functionality in the graft area has also been documented by microperimetry and multifocal electroretinogram.

In conclusion, the autologous retinal transplantation technique for macular hole patients has emerged as another surgical option, with a high macular hole closure rate and visual improvement.

Comparison of platelet-rich plasma and inverted internal limiting membrane flap for the management of large macular holes: A pilot study

Purpose:

To compare the safety and efficacy of 25-gauge pars plana vitrectomy (PPV) with either platelet-rich plasma (PRP) or inverted internal limiting membrane (ILM) flap for the treatment of large macular hole.

Methods:

Pseudophakic patients with idiopathic macular holes with a minimum diameter (MD) of 600–1500 μm were randomized into two groups (30 patients each): 25-gauge PPV with either inverted ILM flap (group A) or PRP (group B).

Results:

Mean MD in groups A and B were 803.33 ± 120.65 μm and 784.73 ± 120.10 μm, respectively (P = 0.552). Mean base diameter in groups A and B was 1395.17 ± 240.57 μm and 1486.90 ± 281.61 μm, respectively (P = 0.180). The median presenting best-corrected visual acuity (BCVA) was logMAR 0.78 (range 0.78–1.00) and logMAR 0.78 (Range 0.60–1.00) in groups A and B, respectively (P = 0.103). Anatomical closure was achieved in 90% (n = 27/30) and 93.3% (n = 28/30) eyes in groups A and B, respectively (P = 0.158). Type 1 closure was achieved in 76.7% (n = 23/30) and 83.3% (n = 25/30) eyes in groups A and B, respectively. Median BCVA at postoperative 3-month in groups A and B was logMAR 0.60 (range 0.48–0.60) and logMAR 0.60 (range 0.48–0.78), respectively (P = 0.312). The average visual improvement was 2.0 and 2.5 early treatment diabetic retinopathy study (ETDRS) lines in groups A and B, respectively (P = 0.339). None of the patients developed postoperative exaggerated inflammatory reactions.

Conclusion:

Using platelets for the treatment of large macular holes is as safe and effective as an inverted ILM flap.

Anterior lens capsule: biomechanical properties and biomedical engineering perspectives

Anterior lens capsule, as the thickest basement membrane in the body, has its unique physiology characteristics. In ophthalmology, many attempts have been made to culture different kinds of cells including iris pigment epithelial cells, retinal pigment epithelial cells, corneal epithelium and endothelium cells, trabecular meshwork cells etc and anterior lens capsule has been confirmed to be served as an excellent scaffold for the growth and expansion of different ocular cells. Furthermore, anterior lens capsule also has unique potential in gestation evaluation and the treatment of various ocular diseases, including corneal ulcer, glaucoma, age-related macular degeneration and macular hole, etc. Here, we provide an overview of the biomechanical properties and biomedical engineering perspectives of anterior lens capsule.

INTRAOPERATIVE AND POSTOPERATIVE MONITORING OF AUTOLOGOUS NEUROSENSORY RETINAL FLAP TRANSPLANTATION FOR A REFRACTORY MACULAR HOLE ASSOCIATED WITH HIGH MYOPIA

PURPOSE

To describe the intraoperative and postoperative morphological and functional outcomes after autologous neurosensory retinal flap transplantation (ART) for a high myopia-related refractory macular hole (MH).

METHODS

This prospective interventional study enrolled five eyes of five patients (age range 54-84 years) with highly myopic refractory MHs who underwent ART. All cases were evaluated with intraoperative optical coherence tomography and postoperative optical coherence tomography, optical coherence tomography angiography, and microperimetry for at least 6 months postoperatively.

RESULTS

Intraoperatively, the MH was covered by an ART flap with a persistent small subretinal space that was filled with the ART flap after 4 days to 6 days. Optical coherence tomography discriminated the original from the transplanted retina. The mean basal diameter of the original MH decreased from 1,504 ± 684 µm preoperatively to 1,111 ± 356 µm postoperatively. The best-corrected visual acuity improved in two cases, was stable in two cases, and deteriorated in one case. Microperimetry demonstrated no obvious postoperative changes in the fixation points and the absolute scotoma corresponding to the base of MHs with chorioretinal atrophy. In two eyes, choroidal neovascularization developed beneath the transplanted retinas.

CONCLUSION

Transplanted tissue was in a fixed position by 1 week postoperatively with a decreased diameter of the original MH. Postoperative fixation points were on the original retina at the MH edge. Because choroidal neovascularization may develop, detailed monitoring is required.

Autologous Lens Capsule Flap Transplantation for Persistent Macular Holes

Purpose

To analyze the anatomical and functional outcomes after autologous lens capsule transplantation in patients with persistent macular hole.

Methods

This is a retrospective observational study of five eyes of five patients treated with vitrectomy and autologous lens capsular flap transplantation. Complete ophthalmic examination was performed preoperatively and seven days and 1, 3, 6, 12, and 18 months after surgery.

Results

Successful macular hole closure was achieved in all patients. The mean minimum macular hole diameter before the surgery was 666.8 µm, and the mean basal diameter was 1086.4 µm. The mean visual acuity before lens capsular flap transplantation was 20/200, while after surgery, it was 20/125.

Conclusions

Autologous lens capsular flap transplantation is a potential alternative treatment for patients with large persistent macular holes after other operative techniques have failed.

Autologous full-thickness retinal transplant for refractory large macular holes

Background

Despite the constant refinement of techniques and surgical aids, extremely large and refractory macular holes continue to have poor surgical outcomes with the current standard of care. The objective of the present study is to assess the anatomical and functional outcomes, as well as the structural change through time, of the optical coherence tomography of patients with refractory macular holes treated with a full-thickness autologous retinal transplant.

Methods

Prospective, case series. We include patients with a clinical diagnosis of refractory macular holes with a minimum diameter of at least 500 µm. All the patients had a comprehensive ophthalmological examination, which included a best-corrected visual acuity assessment, fundus examination, and optical coherence analysis. All the patients underwent a 23-gauge pars plana vitrectomy with a full-thickness retinal transplant and silicone oil tamponade (5000 cs<). Follow-up was done at 1, 3, 6, and 12 months. Statistical analysis was done with a test for repeated measurements and Bonferroni correction, with an alpha value of 0.05 for statistical significance and a Mann-Whitney U test for nonparametric continuous variables.

Results

We enrolled 13 eyes from 13 patients (mean age: 67.15 years) with refractory macular holes, with a mean base diameter of 1615.38 ± 689.19 µm and a minimum diameter of 964.08 ± 709.77 µm. The closure rate after 12 months of follow-up was 76.92%. Six patients with a closed macular hole at the end of the follow-up had complete recovery of the myoid/ellipsoid layer. The remaining showed a 44.9% reduction of the initial gap. Most patients formed a pseudofovea and normalization of the internal retinal layers. Despite a positive trend toward visual recovery (p = 0.034), after the correction of the alpha value, the change lost its statistical significance. During follow-up, one patient developed mild proliferative vitreoretinopathy and epiretinal membrane without anatomical or functional consequences.

Conclusions

An autologous full-thickness retinal transplant may improve the anatomical and structural outcome of patients with refractory macular holes. The full safety profile of this new technique is still unknown. More studies are needed in order to assess functional changes through time.

[Surgery of large and persistent macular holes]

Modern macular hole surgery results in high closure rates of over 90% and good functional results especially in macular holes up to 400 µm in diameter. The standard of care in most of these cases consists of transconjunctival sutureless pars plana vitrectomy, peeling of the inner limiting membrane (ILM) around the hole, followed by gas tamponade and positioning of the patient. As closure rates and functional results decrease with larger macular hole diameters over approximately 400 µm, alternative surgical techniques have been introduced to improve anatomical and functional results in these cases. These techniques include the positioning of tissue within the macular hole to improve hole closure. This can be performed using an ILM flap or free flap technique and the transplantation of autologous retinal tissue, lens capsule or homologous amniotic tissue in or under the defect. An alternative promising approach is the attenuation of the rim of the hole by induction of a localized retinal detachment at the posterior pole which is achieved by subretinal injection of balanced salt solution (BSS) using a 41 gauge needle. The operation is completed by an endotamponade using gas or silicone oil.

Autologous Retinal Transplant for Refractory Macular Holes: Multicenter International Collaborative Study Group

PURPOSE

To report the structural and functional outcomes of autologous neurosensory retinal transplant for closure of refractory large macular holes (MHs).

DESIGN

Multicenter, retrospective, consecutive case series.

PARTICIPANTS

A total of 41 eyes of 41 patients with a full-thickness MH refractory to prior vitrectomy with internal limiting membrane (ILM) peel and tamponade.

METHODS

All patients underwent pars plana vitrectomy, autologous neurosensory retinal transplant with gas, silicone oil tamponade, or short-term perfluoro-n-octane heavy-liquid tamponade. All patients had at least 6 months' follow-up.

MAIN OUTCOME MEASURES

Anatomic closure of MH, change in ellipsoid zone (EZ) and external limiting membrane (ELM) defect on OCT, visual acuity (VA) recovery, and surgical complications were analyzed.

RESULTS

Mean number of prior surgeries was 1.5±0.94 (range, 1-3), and patients were followed for a mean of 11.1±7.7 months (range, 6-36 months). Complete anatomic closure of MH by OCT was achieved in 36 of 41 eyes (87.8%). Mean corrected VA (logarithm of the minimum angle of resolution [logMAR]) improved (P = 0.03) from 1.11±0.66 (range, 0.48-3) to 1.03±0.51 (range, 0.1-2) at the last postoperative visit. The VA improved (≥0.3 logMAR units) in 15 eyes (36.6%), was stable in 17 eyes (41.5%), and worsened in 9 eyes (21.9%). Among eyes with anatomic closure, VA improved in 52.3% and worsened in 13.8%, whereas in those without closure, VA worsened in 40% and improved in none. Mean preoperative largest basal diameter was 1468.1±656.4 μm (range, 621-2600 μm), and mean inner-opening diameter was 825±422.5 μm (range, 336-1649 μm). Mean preoperative EZ defect was 1777.3±513.8 μm (range, 963-2808 μm), which decreased to 1370±556.9 μm (range, 288-2000 μm) at final follow-up (P = 0.007). Mean preoperative ELM was 1681.5±429 μm (range, 1172-2606 μm), which decreased to 1408.5±571.2 μm (range, 200-2000 μm) at final follow-up (P = 0.017). Major postoperative complications were retinal detachment (n = 1) and vitreous hemorrhage (n = 1). There were no cases of proliferative vitreoretinopathy, endophthalmitis, suprachoroidal hemorrhage, or choroidal neovascularization.

CONCLUSIONS

The autologous retinal transplant technique offers a high degree of anatomic success and proved safe in this initial experience for closure of refractory MHs.

Autologous Neurosensory Retinal Free Flap Treatment for a Large Macular Hole

A patient presented with a large chronic macular hole (MH) of 700 μm. Best-corrected visual acuity (BCVA) was 20/200. Since the MHs edges were attached and stiff, an autologous neurosensory retinal flap was harvested and placed into the MH to close it. Perfluoro-n-octane heavy liquid (PFC) was instilled over the flap and exchanged with silicone oil (1,000 cs). Seven days postoperatively, the MH was closed, with a BCVA of 20/80 that improved to 20/60 at months 1 and 3. Optical coherence tomography and angiography showed patch incorporation with fovea formation and normal circulation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e89-e92.].

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.