Removal of Subfoveal Massive Hard Exudates through an Intentional Macular Hole in Patients with Diabetic Maculopathy: A Report of Three Cases

Abstract

Recently, good postoperative visual acuity has been reported using surgical removal of hard exudates (HEs) through an intentional macular hole (iMH). We report 3 cases of subfoveal HE secondary to diabetic maculopathy (DM) treated with HE removal via an iMH. Pars plana vitrectomy (PPV) was performed in three eyes of 3 patients with subfoveal HE secondary to DM. In all eyes, after PPV, internal limiting membrane (ILM) peeling of the lower half was performed within the range of papilla diameter 2 centered on the fovea, leaving the upper half for subsequent inverted ILM flap technique. Then, by grabbing the inner layer of the fovea using ILM forceps, an iMH was created. The HE was then flushed from the iMH with a balanced salt solution as much as possible. Finally, the inverted ILM flap technique was performed using the upper half of the ILM that was left during the previous maneuver. At the end of the surgery, the eyes were flushed with 50 mL of 20% sulfur hexafluoride (SF6) after the fluid-air exchange of the vitreous cavity. After surgery, HE was adequately removed, iMH was completely closed, and visual acuity improved in all eyes. This surgical procedure did not cause a central scotoma but rather improved the central sensitivity of the visual field in all eyes. No serious surgery-related complications occurred. In conclusion, HE removal via an iMH hole can be one of the treatment options for patients with subfoveal HE secondary to DM.

Surgical Drainage of Large Macular Cystoid Spaces in Coats Disease

“…Surgical removal of hard exudates in DME has been previously reported but more often is done by subretinally injecting a balanced salt solution through a retinotomy followed by aspiration to remove the exudates, although the impact on visual function has been variable. [13][14][15][16][17] The benefit of surgical drainage of a large macular cystoid space to one's vision is unproven. Although the patient in our case did not regain vision, this may have been the result of the chronicity of the subretinal exudates over many years that were incompletely treated, resulting in photoreceptor degeneration and loss of the outer retinal layers, as seen on postoperative OCT. Based on the eventual resolution of the retinal fluid and dense exudates after surgery, we speculate that earlier surgical intervention might have resulted in better functional outcomes.…”