Anatomical and Functional Outcomes of Relaxing Parafoveal Nasal Retinotomy for Refractory Macular Hole Repair

Abstract

Purpose: This work aimed to assess postoperative outcomes associated with relaxing parafoveal nasal retinotomy for refractory macular hole repair. Methods: This was a retrospective interventional study of patients with persistent or recurrent macular holes following 1 or more standard repair procedures with pars plana vitrectomy and internal limiting membrane peeling. Patients received an additional pars plana vitrectomy and relaxing parafoveal nasal retinotomy, followed by fluid-air and air-gas exchange. Key postoperative outcomes included the achievement of macular hole closure and changes in visual acuity from baseline. Results: Thirteen patients with refractory macular holes were included, with a median age of 65 years (range, 49-90 years). The aperture diameter of the 13 macular holes ranged from 180 to 799 µm (median, 538 µm). Vitrectomy and relaxing parafoveal nasal retinotomy were performed in all 13 eyes, and after a median follow-up of 12 months (range, 3-34 months), anatomical closure was achieved in 12 of 13 eyes (92.3%). Overall, visual acuity (mean ± SE) improved significantly from 1.20 ± 0.15 logMAR (approximate Snellen equivalent, 20/320) at baseline to 0.84 ± 0.11 logMAR (Snellen, ∼ 20/125) during postoperative follow-up ( P < .05). Central and paracentral scotomas were observed in 8 of 11 eyes with postoperative Humphrey visual field 10-2 and/or 24-2 data available. Conclusions: Relaxing parafoveal nasal retinotomy may be an effective method to promote anatomical closure and improve vision outcomes in patients with recalcitrant macular holes.

Relaxing Nasal Retinotomy Technique for Closure of a Macular Hole That Reopened After Primary Vitrectomy

“…After ILM peel failed to close the macular hole, superior and inferior arcuate retinotomies were performed, resulting in hole closure but limited functional improvement. Using the same nasal retinotomy technique as in our patient, Tsipursky 15 presented a small case series of patients who underwent repeat surgery for macular hole. Macular hole was successfully closed in four of five eyes with significant visual improvement in three of five eyes.…”

“…seem to be well-tolerated. 15 Future studies are warranted to assess the effectiveness of the relaxing retinotomy relative to alternative approaches and the optimal location of the incision.…”

Relaxing Retinotomy in Recurrent and Refractory Full-Thickness Macular Holes: The State of the Art

“…In 2021, the study of Tsipursky [ 32 ] extended on his previous work [ 35 ] and on Knight’s [ 33 ] case in order to illustrate the usefulness of nasal relaxing retinotomy in a more numerous cohort of patients with refractory FTMHs and a more extended follow-up. It was a multicenter, retrospective, interventional study of patients with refractory FTMHs who previously had undergone one or more pars plana vitrectomy with peeling of the internal limiting membrane.…”

“…First, intravitreal indocyanine green-stained residual ILM and, if present, a wider circumferential ILM peeling was carried out. Then, a gentle endodiathermy was performed with a 25G tapered tip to realize a small retinotomy ( Figure 3 ), displayed by a tiny area of whitening on the retina, at the midpoint between the optic disc and the fovea [ 32 ]. Next, gentle suction with a soft tip cannula was performed at the relaxing parafoveal nasal retinotomy site; finally, this was followed by FAX and further suction in order to drain completely the FTMH.…”

“…Concerning relaxing retinotomies [ 30 , 31 , 32 , 33 , 34 , 35 ], in different case series both the surgical technique and the position of retinotomies vary considerably. We present a comprehensive and structured overview of the relaxing retinotomy technique, a surgical approach available nowadays for the secondary repair of recurrent and refractory FTMHs.…”