Current Management of Macular Hole

Abstract

In this issue's Practical Retina column, Sumit Randhir Singh, MD, and Raja Narayanan, MD, MBA, from the LV Prasad Eye Institute in Hyderabad, India, discuss the current therapeutic options for repairing macular holes (MHs). We are all aware that there is great discussion and wide variability in thinking among our colleagues regarding approaches to close a MH. Common controversies include when and if internal limiting membrane peeling is necessary, as well as what to do with it after it is peeled (fully or partially to create a flap). Other discussions include choice of tamponade, duration of positioning, and use of retinal grafts. Choice of adjuvants have also been discussed and will be addressed in this article. Drs. Singh and Narayanan tackle this topic in a concise and logical manner. They will provide a thorough review of the literature and provide opinions based on the strength of the evidence in the literature. I am certain that their insights will be very valuable for maximizing outcomes in patients with MHs.

The Clinical and Safety Outcomes of 27 Gauge Pars Plana Vitrectomy in Eyes With Macular Hole

“…The mean age in our data is 61.9 ± 17.31 (11-93) years which is almost similar to reported in the literature [ 13 , 15 ] indicating no significant age difference in this pathology in the Asian population. The total mean operating time reported in our data is slightly longer compared with the 25-gauge system [ 15 ], a finding reported before as well [ 4 ].…”

“…None of the eyes developed sclerotomy site leakage, post-operative early or late hypotony, and endophthalmitis, a major concern previously [ 5 - 7 ]. None of the eyes in our study developed RRD as reported previously [ 13 , 29 ] so we recommend meticulous complete vitreous shaving with scleral depression. Mean BCVA has significantly improved in our study as reported previously as well [ 15 , 1 ].…”

“…MH is a defect in the macula that can be caused by age, trauma, or vitreoretinal disease resulting in impaired central vision, metamorphopsia, and central scotoma [ 13 ]. Currently, the standard treatment of choice for MH is vitrectomy with posterior hyaloid face (PHF) removal with ILM peeling with tamponade agent but posturing is still a debatable topic [ 14 ].…”

Approaches to Refractory or Large Macular Holes

“…In ad- Practical Retina dition to providing a scaffold, the ILM tissue may contain Müller cell fragments, which has been postulated to induce gliosis, and in turn may enhance MH closure. 9,14,15 The inverted ILM flap technique for large MHs, which was first described by Michalewska et al, utilizes a wide ILM with care to detach the peripheral macular ILM while keeping the ILM attached around the MH. 14 The detached ILM is then inverted and placed into the MH, followed by fluid-air-exchange.…”

Answer to the Letter to the Editor relating: Lytvynchuk LM, Falkner-Radler CI, Krepler K, Glittenberg CG, Ahmed D et al. “Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery” Graefe’s Arch Clin Exp Ophthalmol 2019 May 29; https://doi.org/10.1007/s00417-019-04364-5 written by Michalewska Z. and Nawrocki J.

“…Being relatively new technique, inverted ILM flap technique, which was first proposed and described by Michalewska et al, became very popular among vitreoretinal surgeons due to its efficacy and favorable postoperative results [1]. Up until now, the variety of modifications of the technique with the use of ILM flap was proposed [2]. The differences between these technique modifications shall be without any doubt appreciated and well distinguished.…”