Swept Source-Optical Coherence Tomography-Guided Facedown Posturing to Minimize Treatment Burden and Maximize Outcome after Macular Hole Surgery

Abstract

We evaluated the closure of full-thickness macular holes (MHs) the day after surgery in minimizing the burden and maximizing patient outcomes. Herein, 25-gauge pars plana vitrectomy, internal limiting membrane peeling, and fluid–gas (20% sulfur hexafluoride) were performed for the treatment. Patients were instructed to remain in the facedown position until the confirmation of MH closure, and the position was discontinued in cases where the closure was confirmed. In total, 43 eyes of 43 patients, whose average age was 69.7 ± 8.6 years, were enrolled in this study. We used swept source (SS)-optical coherence tomography (OCT) for the confirmation of MH closure for gas-filled eyes and used spectral domain (SD)-OCT for the reconfirmation of MH closure after the gas volume was reduced to less than half of the vitreous cavity. MH closure was confirmed in 40 eyes (93%, the closure group) on the next day after surgery. The time from surgery to SS-OCT imaging was 24.7 h. Although facedown positioning was terminated in cases where MH closure was confirmed, there were no cases in which the MH was re-opened afterward. The basal and minimum MH size was significantly larger in the non-closure group than that in the closure group (p = 0.027, p = 0.043, respectively). Therefore, checking with SS-OCT the day after surgery and terminating facedown positioning in cases where MH closure was confirmed would be a useful method, removing a great burden for the elderly without sacrificing the MH closure rate.

Successful closure of a refractory giant (15 sq mm) macular hole with amniotic membrane graft

“…While macular holes were initially considered untreatable 30 years ago [ 7 ], advancements in diagnostic tools and surgical techniques have revolutionized the management of macular holes, leading to improved outcomes and visual recovery [ 8 , 9 ]. The exact cause of macular holes remains unclear, but several risk factors have been identified.…”

“…Although most patients respond well to initial treatment, a subset of patients may develop refractory macular holes that require multiple surgeries for closure [ 11 ]. In particular, patients with larger macular holes (>650 μm) had worse closure rates [ 8 ]. For these patients, other approaches, such as the inverted ILM flap technique, macular plug, and autologous neurosensory retinal free flap, have emerged as viable alternatives, particularly for large and refractory holes [ 12–14 ].…”