Update on surgical management of complex macular holes: a review

Abstract

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.

Comparison of outcomes of idiopathic macular holes treated by vitrectomy with air or silicone oil tamponade based on the hole size

“…In the range of MMHD>400 μm (MMHD2) there were 7 eyes in air group and 29 eyes in silicone oil group; the average of MMHD were (491.6±70.8) and (525.4±103.6) μm respectively; the average of BCVA were 1.41±0. 32 all closed in 16 eyes in silicone oil group, and the closure rate was 100.0%, there was no significant difference between the two groups (P>0.05). In MMHD2, IMHs were closed in four eyes out of seven eyes in air group (57.14%), and in 27 eyes out of 29 eyes in silicone oil group (93.1%), so the silicone oil group showed a better result than the air group (P<0.05).…”

“…Through this study, it can be concluded that for smaller IMH, choosing air can obtain better vision with similar closure rate, and relieve patients from pain and complications; for larger IMH, choosing silicone oil can achieve better closure efficacy with similar postoperative vision. Except for the size of IMH, age, axial length, epiretinal membrane, etc [30][31][32] , may be the influenced factors to the closure of IMH. It has to say that was a defect in this research.…”

Macular hole Delphi consensus statement (MHOST)

“…Full thickness macular holes and LMHs are macular diseases for which VR surgeons deploy a wide spectrum of approaches, with plenty of variants and nuances are still school‐ or hospital‐related (Abdul‐Kadir & Lim, 2021; Danielescu et al, 2020; Ittarat et al, 2020; Mohammed & Pai, 2017).…”

A Titanium Macular Buckle Implant Designed for an Easy Placement in Myopic Macular Holes

“…5 Furthermore, the success rate of hole closure in recurrent macular holes is lower, and additional surgical techniques such as inverted ILM flap, autologous retinal transplant to the hole, and detachment of perifoveal area by injection of subretinal fluid are often practiced. [6][7][8] Another accessory step to provide better surgical success in macular holes with pathologic myopia, particularly if recurrent, is the placement of a macular buckle. 2,[9][10][11][12][13] Several different designs and placement techniques of macular buckles have been described in the literature.…”