Surgical closure of macular hole using an absorbable macular plug

Background: The surgical management of macular holes has been a subject of controversy in recent years. Various techniques such as vitrectomy, membrane peeling, and gas tamponade with or without transforming growth factor-beta 2, and recently the use of autologous platelets have produced closure rates from 58% to 96%, depending on the stage of the hole. Methods: The authors present preliminary results in a study of 19 consecutive patients with stage 3 or stage 4 macular hole who underwent vitrectomy followed by placement of an absorbable partially cross-linked gelatin plug in the macular hole. The vitreous cavity was filled with a nonexpanding gas or air alone; the patient was instructed to maintain prone positioning for 2–3 days. Results: Anatomic attachment of the edges of the macular hole was achieved in 19 out of 19 patients with a minimum follow-up period of 6 months (average 11.5 months). Conclusions: A cross-linked gelatin plug can effectively reattach the edges of macular holes of stages 3 and 4. Its use is recommended only in macular holes in high myopes with posterior staphyloma or recurrent macular hole. This revised version was published online in September 2006 with corrections to the Cover Date.     

Idiopathic macular holes. Observations, stages of formation, and implications for surgical intervention

The authors have reviewed 158 eyes with evolving or completed idiopathic macular holes. Observations of these patients suggest that prefoveal vitreous cortex contraction is probably the cause of idiopathic macular holes. The earliest sign of an impending macular hole (stage 1) appears to be the development of a yellow spot or halo associated with loss of the normal anatomic foveal depression. No vitreous separation is present. This may resolve or progress to a small, early macular hole (stage 2). This hole gradually enlarged to a diameter of approximately 485 micron. The vitreous usually remained attached or a vitreofoveal separation developed (stage 3). Some eyes had complete posterior vitreous separation (stage 4). The implications for surgical intervention are discussed. A prospective study should be undertaken to confirm these findings and to investigate the feasibility of vitrectomy intervention to peel the prefoveal vitreous cortex in eyes with a stage 1 lesion.     

Nonprogressive extrafoveal retinal hole after foveal epiretinal membrane removal

PURPOSE: To report an extrafoveal posterior retinal hole after surgical removal of foveal epiretinal membrane. DESIGN: Observational case reports. METHODS: We describe two patients who underwent vitrectomy surgery with an epiretinal membrane removal. Five months after vision improving surgery, a small retinal hole outside the macular area developed. RESULTS: Fundus photography and optical coherence tomography showed a full-thickness retinal hole with a surrounding cuff of subretinal fluid smaller than described in stage III or IV macular holes. The hole has been stable in shape and dimension, has not progressed to retinal detachment, and is not associated with an epiretinal membrane; the fluid is not impinging on the macular area. CONCLUSIONS: Asymptomatic full-thickness extrafoveal retinal holes, which do not progress to neurosensory detachment, can develop after epiretinal membrane peeling. These appear stable and have substantially smaller cuffs of subretinal fluid than typical macular holes.     

Internal limiting membrane: ultrastructural relationships, with clinical implications for macular hole healing

BACKGROUND: Recent data on macular hole formation have changed our understanding of the mechanisms involved. However, the mechanisms of macular hole closure, despite the introduction of internal limiting membrane (ILM) removal, are not fully understood. We reviewed the charts of patients who underwent surgery for macular hole with and without intentional removal of ILM and reviewed the basic science literature on the components and relationships of the ILM-glial cell interface to help interpret our surgical data. METHODS: We reviewed the records of 205 eyes with a clinical diagnosis of macular hole at a university centre in Montreal between 1998 and 2002. Of these, 117 eyes of 108 patients were included. Vitrectomy with intentional ILM removal was done under indocyanine green (ICG) staining. Macular hole stage and rates of hole closure, failure and reopening were recorded, comparing the eyes with intentional ILM peeling versus no ILM peeling. Anatomic success was defined as a flat/closed configuration. A basic science literature review was done through the PubMed search engine with the key words "internal limiting membrane," "internal limiting lamina," "macular hole," "retinal glial cells" and "retinal Müller cells." RESULTS: Eighty-four eyes had ICG-guided ILM removal (26 stage 2 macular holes, 45 stage 3 holes and 13 stage 4 holes), and 33 eyes had no ILM removal (10 stage 2 holes and 23 stage 3 holes). Of the 117 eyes 110 (94.0%) were successfully closed. Four (3.6%) of the closed holes reopened (none had ILM peeling), and 7 (6.0%) of the 117 eyes had primary failure. Ten of the 11 eyes that had primary failure or hole reopening were reoperated, and 8 were successfully closed after the second procedure. One patient refused reoperation. Including second procedures, the final anatomic closure rate was 97.4% (114/117). INTERPRETATION: Intentional ILM peeling is not mandatory for all macular holes to close but does play a role in preventing reopening. Removal of ILM increases the rate of flat/closed hole configuration on reoperation without the need for biologic adjuvants. Review of the basic science evidence helped clarify the possible role of ILM removal.     

Macular hole surgery in 2000

Patient selection and surgical experience have increased the closure rates for idiopathic macular holes to more than 90%. The best surgical results are obtained in patients with acute idiopathic macular holes. Biologic adjuvants are not as useful as they were once thought to be. Internal limiting membrane peeling and endolaser are useful for failed macular holes, reopened macular holes, and chronic macular holes. Internal limiting membrane peeling may not be necessary for acute idiopathic macular holes, provided a complete posterior vitreous detachment is created. Silicone oil tamponade should be considered in patients who have positioning problems or air travel plans. Humidifying the infusion air may reduce postoperative visual field defects. Every patient with a macular hole should be given the opportunity to improve his or her vision with macular hole surgery.     

Vitrectomy in eyes at risk for macular hole formation

Fifteen eyes believed to be at increased risk for macular hole formation underwent vitrectomy in an attempt to prevent macular hole formation. Full-thickness macular holes have not developed in 10 of 11 eyes with stage 1 macular holes. Four eyes were noted to have small full-thickness foveal defects (stage 2 macular holes) at the time of vitrectomy. Two of the four eyes have not progressed to macular hole formation and have 20/25 visual acuity. All patients have been followed for a minimum of 13 months (median, 18 months). The 12 eyes that have not experienced macular hole formation have had a significant (P less than 0.001) improvement in vision with seven (58%) attaining visual acuity of 20/25 or better. The postoperative foveal electroretinogram (ERG) amplitude was higher than the preoperative amplitude in five of the six eyes tested.     

Stage 3 macular hole: role of optical coherence tomography and of B-scan ultrasonography

PURPOSE: To analyze the various aspects of Stage 3 macular hole with optical coherence tomography (OCT) and B-scan ultrasonography. DESIGN: Observational case series. METHODS: Patients referred for full-thickness macular hole were prospectively screened with OCT and B-scan ultrasonography. OCT examination analyzed the diameter of the hole, the posterior hyaloid, the surrounding retina, and the inconstant presence of a pseudo-operculum. B-scan ultrasonography permitted the distinction between stage 3 and stage 4 holes, based on the detachment of the posterior hyaloid. RESULTS: The study included 62 eyes with stage 3 holes. On OCT, the typical aspect with a hyaloid detached from the macular area was observed in 37% of the eyes (group 3C). In 42% of the eyes (group 3B), a focal adherence was visible at the margin of the hole, as in stage 2 macular hole, but the hole was long-standing, large, and noneccentric. In 21% of the eyes, the hyaloid was not visible anterior to the retina but was still adherent to it (group 3A). In the absence of B-scan ultrasonography, these OCT features could be confused with a stage 4 macular hole. No difference in the size of the hole was observed between subgroups. CONCLUSION: OCT can show various aspects of stage 3 macular holes. B-scan ultrasonography was useful for assessing the location of the posterior hyaloid and to distinguish stage 3 from stage 4 macular holes. These features may provide additional information on the pathogenesis of macular hole and may have therapeutic implications.     

Autologous platelets for macular hole surgery: the Sussex Eye Hospital experience

PURPOSE: To evaluate the anatomical and visual outcomes of patients managed by macular hole surgery with adjunctive use of autologous platelets at Sussex Eye Hospital, UK. METHODS: A retrospective non-comparative consecutive interventional case series was conducted. Standard macular hole vitrectomy surgery was combined with autologous platelets. No other adjuncts were used, nor internal limiting membrane peeling performed. The main outcome measure was anatomical closure of the macular hole. Secondary outcome measures included: visual outcome (best postoperative best corrected visual acuity [BCVA] and final BCVA), hole reopening and/or re-operation, complications, and time to and influence of cataract surgery. RESULTS: Seventy eyes of 65 patients underwent macular hole surgery with vitrectomy and autologous platelets. There were 14 stage 2 holes, 52 stage 3 holes and four stage 4 holes. Mean follow up was 29 months (range 1.5-78 months). Primary anatomical success (hole closure) was 95.7% (n = 67); however, six (8.5%) holes reopened at a mean of 12.7 months (range 3.6-36.3 months) after their initial surgery. Final surgical success was 98.5% (65/66) in those eyes of patients electing re-operation procedures. Seventy-seven per cent (n = 54) of patients obtained 2 or more lines of visual acuity improvement at final follow up with a mean improvement of 4 lines (range -3 to +12 lines). Forty per cent (n = 28) achieved final BCVA of 6/12 or better, which improved to 51% (n = 36) if best postoperative BCVA was considered. CONCLUSIONS: Adjunctive use of autologous platelets at the time of macular hole surgery yields good surgical and visual results, without significant complications, and should remain a considered option in the surgical management of macular holes. Improved macular hole closure with autologous platelets (compared with vitrectomy alone) has previously been demonstrated in a randomized controlled trial. Visual outcome benefit of platelets remains to be investigated by randomized controlled trial and any planned trials should include an autologous platelets intervention arm along with visual acuity as a primary outcome measure.     

The macular hole: report of an Australian surgical series and meta-analysis of the literature

Purpose : To report an Australian series of macular hole surgery by pars plana vitrectomy and fluid‐gas exchange, and to identify factors influencing the outcome of the surgery through meta‐analysis of the literature. Methods : Fifty‐six consecutive cases of macular hole were treated by pars plana vitrectomy, fluid‐gas exchange and face‐down positioning for at least 7 days, and prospectively followed for 3–12 months. Thirty‐six reports of macular hole surgery were reviewed. A meta‐analysis on the pre‐ and postoperative parameters was performed on 389 cases, in which case‐specific data‐points were available. Results : In the current series, anatomical closure was achieved in all (100%) of 16 stage 2, and in 35 (87.5%) of 40 stage 3 or 4 macular holes. At least 2 logMAR lines of improvement in visual acuity were seen in 10 (62.5%) stage 2 and 20 (50.0%) stage 3 or 4 holes. Postoperative visual acuity was 6/12 or better in 10 (62.5%) stage 2 and 17 (42.5%) stage 3 or 4 holes. In both the current series and the meta‐analysis, favourable surgical outcomes were associated with stage 2 macular holes, better preoperative visual acuity, and shorter preoperative duration. Adjuvant use was associated with a higher rate of anatomical closure but there was no clear benefit in terms of postoperative visual acuity. Conclusion : Our experience and the results of the meta‐analysis suggest that macular hole surgery should be offered as early as possible once full‐thickness neuroretinal defect occurs.     

特发性黄斑裂孔玻璃体切割手术后的视功能

目的：探讨特发性黄斑裂孔（IMH）玻璃体切割手术后的视功能状况，方法：复习并总结国内外相关文献资料，综合评述IMH玻璃体切割手术后视功能状况。结果：多数患者术后视力较术前提高2行或2行以上，并且主观感觉的视物变形和暗点，辨色力，双眼融合功能和立体视功能也有所改善，术后视野光敏度较术前有所提高；注视性质由术前的偏心注视多数恢复为主后的中心注视，然后部分患者视力的改善提高不显著甚至出现视力下降，部分患者黄斑裂孔虽然获得解剖愈合，但仍遗留某些视觉缺陷。影响术后视力和其他视功能恢复的因素是复杂的，通常与术前视力和视功能状况的好坏，病程长程，裂孔分期早期、手术方式，裂孔愈合状态以及手术合并症等诸多因素相关。结论：黄斑裂孔一旦发生，其裂孔愈合和视功能稳定的机会极少，因此多数学者主张若诊断明确应早手术封闭裂孔，评价玻璃体切割手术治疗IMH的疗效。应在解决形态愈合的基础上综合患者的视力，主观感觉及临床多项视功能进行全面评估。     

Vitrectomy for stage 1 macular holes identified by optical coherence tomography.

BACKGROUND AND OBJECTIVE: To describe a series of patients with decreased vision secondary to stage 1 macular hole confirmed by optical coherence tomography (OCT) that failed to spontaneously resolve with observation. To determine whether current surgical techniques can prevent progression to a full-thickness macular hole and lead to improved visual acuity. PATIENTS AND METHODS: Retrospective, comparative case series presenting patient demographics, duration of symptoms, timing of surgery, preoperative and postoperative vision, and clinical outcome based on examination and OCT. RESULTS: Five eyes of five patients with stage 1 macular holes identified on OCT required surgical repair. All eyes showed anatomic closure and lack of progression to a full-thickness hole confirmed by OCT after one procedure. Mean preoperative visual acuity was 20/102 (range, 20/50 to 20/200) and mean postoperative visual acuity was 20/52 (range, 20/25 to 20/200). Average improvement for all five eyes was 3 Snellen lines, with four of the five (80%) improving 5 lines each. CONCLUSION: In symptomatic eyes with stage 1 macular holes that fail to spontaneously resolve with observation, vitrectomy with intraocular gas tamponade may prevent progression to a full-thickness hole and lead to improved visual acuity.     

Surgical management of macular holes: a report by the American Academy of Ophthalmology.

OBJECTIVE: The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique. METHODS: A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented. RESULTS: There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%). CONCLUSIONS: The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.     

Macular hole and myopic refraction

AIM: To study a correlation between age at the onset and myopic refraction and axial length in patients with idiopathic macular hole and to evaluate a correlation of the size and surgical outcome of macular hole with axial length. METHODS: In a prospective clinical study, 94 eyes of 91 patients with stage III and IV idiopathic macular hole were enrolled. A standardised surgical protocol was performed using vitrectomy and gas tamponade. This study evaluated the size of macular hole and the rate of anatomical and functional success of surgery. To assess dimensions of macular hole, confocal laser scanning tomography was employed. RESULTS: Age at the onset showed a significant increase in relation to myopic refraction and axial length (r = 0.689, p <0.0001; r = 0.723, p <0.0001). Mean age was 52.1 (SD 10.3) years in eyes with axial length of 26.0 mm and longer, 64.5 (8.5) years in eyes with 23.0 to 25.99 mm, and 69.8 (5.7) years in eyes with shorter than 23.0 mm. In stage III macular holes, mean area of macular hole was 0.291 (0.134) mm(2) in eyes with 26.0 mm and longer, 0.283 (0.170) mm(2) in eyes with 23.0 to 25.99 mm, and 0.296 (0.160) mm(2) in eyes with shorter than 23.0 mm. No significant difference was found in area, volume, and depth of macular hole, and area of cuff and retinal striae among the three groups. Overall anatomical success rate and logMAR visual improvement in stage III macular holes were 100% (19 of 19 eyes) and -0.575 (0.174) in eyes with 26.0 mm and longer, 100% (16 of 16 eyes) and -0.536 (0.174) in eyes with 23.0 to 25.99 mm, and 95% (40 of 42 eyes) and -0.599 (0.201) in eyes with shorter than 23.0 mm; there was no significant difference. CONCLUSIONS: Macular hole develops in eyes with the severer myopia at the younger age. Myopic refraction appears not to influence the size and surgical outcomes of macular holes. Further investigation on more cases is needed.     

Familial idiopathic macular hole

PURPOSE: To report macular hole formation among siblings within four families. DESIGN: Observational case series. METHODS: Four families were identified who had macular holes among siblings from within three multiphysician tertiary-care referral retina practices. RESULTS: In the first family, two sisters in their seventh decade developed Stage 2 macular holes requiring surgical intervention; two male siblings were unaffected. In a second family, three of four siblings were affected, including one brother with a Stage 4 macular hole, one sister with a Stage 3 macular hole, and a third sister with a lamellar macular hole. In a third family, two siblings (one man, one woman) developed macular holes within 1 year of each other. Three years later, the male sibling developed a macular hole in the fellow eye. In the last family, twin sisters developed macular holes (unilateral in one sister, bilateral in the other), and their deceased father may also have had bilateral macular holes. CONCLUSIONS: The occurrence of macular holes in these four sets of siblings suggests a possible genetic component in the formation of macular holes in these individuals.     

Macular holes: Pathogenesis, natural history and surgical outcomes

Idiopathic full-thickness macular holes (FTMH) are a common cause of usually uniocular reduced visual acuity. The accepted pathogenesis has macular hole formation proceeding in stages from an impending hole to a FTMH, with visual acuity deteriorating to less than 6/60 in 85% of cases. Recent surgical advances in the treatment of FTMH, with excellent anatomic and visual results, have changed the surgical indications for both impending and established full-thickness macular holes.     

Spontaneous macular hole closure in bilateral macular holes

The natural course of full thickness macular hole is progression in size and stage. There have been reports of spontaneous closure of unilateral idiopathic full thickness macular holes, but we report the first case of spontaneous closure of a full thickness macular hole in one eye in a patient with bilateral idiopathic full thickness macular holes. After macular hole surgery in the left eye of the patient, spontaneous closure of the macular hole in the right eye was observed during the follow-up period.     

Macular hole following cataract extraction

Macular hole formation is a rare complication of cataract extraction. Although the exact etiology is unclear, macular holes can be classified into pre-existing holes that may not have been visible prior to cataract surgery, early stage macular holes that progressed to a more advanced stage, symptomatic holes following cataract extraction, and de novo symptomatic macular holes. Antero-posterior (A-P) tractional forces as well as macular edema are thought to play a role in the pathogenesis of these macular holes. In the traction hypothesis, A-P forces are thought to induce either an acute detachment of the posterior cortical gel or significant traction of the vitreous gel around the fovea, resulting in formation, or rapid progression of, macular holes. In late reopening of macular holes after cataract extraction, subclinical macular edema and epiretinal membrane formation have been suggested as possible causes. Current treatment options, including combining cataract extraction with macular hole repair, are reviewed.     

Macular hole following cataract extraction

Macular hole formation is a rare complication of cataract extraction. Although the exact etiology is unclear, macular holes can be classified into pre-existing holes that may not have been visible prior to cataract surgery, early stage macular holes that progressed to a more advanced stage, symptomatic holes following cataract extraction, and de novo symptomatic macular holes. Antero-posterior (A-P) tractional forces as well as macular edema are thought to play a role in the pathogenesis of these macular holes. In the traction hypothesis, A-P forces are thought to induce either an acute detachment of the posterior cortical gel or significant traction of the vitreous gel around the fovea, resulting in formation, or rapid progression of, macular holes. In late reopening of macular holes after cataract extraction, subclinical macular edema and epiretinal membrane formation have been suggested as possible causes. Current treatment options, including combining cataract extraction with macular hole repair, are reviewed.     

Spontaneous Macular Hole Closure in Bilateral Macular Holes

The natural course of full thickness macular hole is progression in size and stage. There have been reports of spontaneous closure of unilateral idiopathic full thickness macular holes, but we report the first case of spontaneous closure of a full thickness macular hole in one eye in a patient with bilateral idiopathic full thickness macular holes. After macular hole surgery in the left eye of the patient, spontaneous closure of the macular hole in the right eye was observed during the follow-up period.     

Optical coherence tomography of the vitreoretinal interface in macular hole formation

AIMS: To image the vitreoretinal interface and provide further information on the pathogenesis of idiopathic macular hole formation. METHODS: Prospective recruitment of 80 eyes of 41 consecutive patients referred with a diagnosis of idiopathic full thickness macular hole (FTMH) to a teaching hospital retinal clinic. Both eyes of each patient underwent optical coherence tomography (OCT) imaging with vertical and horizontal scans centred on the fovea. RESULTS: A total of 30 eyes had stage 2 or 3 FTMHs and, of these, 21 had persistent vitreofoveal attachment and associated prefoveal opacities. 18 prefoveal opacities were identified by Goldmann contact lens examination and confirmed on OCT examination. Three prefoveal opacities were identified only on OCT examination. 10 eyes had stage 4 FTMHs and four cases were identified in whom the OCT appearance was consistent with impending, aborted, or lamellar macular holes. CONCLUSIONS: The wide range in OCT appearance of macular holes and associated prefoveal opacities suggests that, in at least some cases, a significant amount of retinal tissue is torn from the foveal area during macular hole formation. OCT imaging provides additional information on macular hole pathogenesis and is valuable in the planning of surgical intervention.