Management of Stage IV Macular Holes: When Standard Surgery Fails

Abstract

Purpose: To report the surgical outcomes of reoperation of unclosed macular holes after initial vitrectomy with internal limiting membrane peeling. Procedures: Seven eyes of 7 patients were submitted to a second procedure in which five radial retinal incisions were made, as deep as the retinal pigment epithelium, beginning one hole diameter away from its borders and extending centripetally until the hole’s margins, avoiding the papilomacular bundle. Gas tamponade was performed and face-down positioning was recommended. Results: Anatomical closure was achieved in all cases with the second procedure. Functional success was achieved in every patient; there was no loss of best corrected visual acuity (BCVA) lines. Mean line score gain was 5.6 lines (range 1–9 lines), with a mean final BCVA of 0.42 (range 0.05–0.5). Conclusions: Perifoveal relaxing incisions in stage IV macular holes that remained unclosed after internal limiting membrane peeling vitrectomy seem to have a positive effect on MH closure rates. Larger case series and an extended follow-up period are necessary in order to assess the efficacy and safety profile of this so far promising technique.

Radial Retinal Incisions for Complex Pediatric Traumatic Macular Holes

“…Reis et al reported a technique for addressing refractory macular holes in adults that involved making five radial retinal incisions with a 25-G needle or 25-G microvitreoretinal blade along the margin of the hole-a maneuver that, they postulated, relaxed the hole margin and allowed subsequent gliosis to close the hole. 24 Anatomical closure was achieved in seven of seven cases reviewed. 24 Similar techniques using full-thickness macular incisions have been described by both Smiddy 26 and Charles 27 to address refractory macular holes.…”

“…24 Anatomical closure was achieved in seven of seven cases reviewed. 24 Similar techniques using full-thickness macular incisions have been described by both Smiddy 26 and Charles 27 to address refractory macular holes.…”

“…24 The most consistent risk factor for poor surgical outcome, however, remains size: holes with a minimum diameter of less than 400 mm have an anatomical success of 92% to 97% closure, compared with holes with a diameter of greater than 500 mm, which have a success rate less than 50%. 8 Several treatment options exist when addressing these high-risk TMH in pediatric patients; as mentioned above, spontaneous closure of TMH is possible and has been reported with large holes.…”

Approaches to Refractory or Large Macular Holes

“…25 Reiss et al described performing five radial incisions centered on the MH, extending one hole diameter away from the MH border, followed by gas tamponade in seven patients with refractory MHs. 26 They reported 100% anatomic success rate with a mean gain of 5.6 lines of vision. 26…”

Viscostretch: A Novel Surgical Technique for Refractory Macular Holes

“…Likewise, there have been reports about arcuate retinotomies and relaxing radial retinal incisions aimed to move tissue to close refractory holes, although obviously these involve retinal incisions and associated risks. 12,13 We advocate use of a cohesive sodium hyaluronate ophthalmic viscosurgical device (OVD, Healon, Abbott Medical Optics Inc) to not only lyse retina-RPE adhesions but also maintain the potential subretinal space, stretching the adjacent retinal tissue until the conclusion of the air-fluid exchange.…”