Autologous Internal Limiting Membrane Fragment Transplantation for Large, Chronic, and Refractory Macular Holes

Abstract

Objective: To evaluate a technique of autologous internal limiting membrane (ILM) fragment transplantation for the treatment of large, chronic, and/or refractory macular holes (MH). Design: This was a 6-month prospective interventional case series. Method: Ten eyes of 10 patients with MH underwent pars plana vitretomy (PPV) and ILM peeling followed by transplantation of an autologous ILM fragment to the MH. Six patients had primary MH with an internal diameter greater than 500 µm and a duration of more than 18 months, including 1 patient with nonproliferative diabetic retinopathy previously treated with panretinal photocoagulation. Four eyes with MH had previously been submitted to PPV (i.e. 1 for retinal detachment and 3 to attempt to close large MH). One of the latter also displayed juxtapapillary choroidal neovascularization due to age-related macular degeneration. The primary and secondary outcomes were MH closure and improvement of the best corrected visual acuity (BCVA), respectively. Results: Complete MH closure was achieved in all cases. A statistically significant improvement in the average BCVA was observed after 6 months of follow-up (p = 0.018; paired t test). The BCVA improved in 8 eyes (80%), and in 6 of those eyes it improved by ≥15 letters. In 1 patient, the BCVA remained unchanged after the surgery, but the visual field reportedly improved. One patient experienced a slight worsening (0.16 logMAR). Two cases developed atrophy of the retinal pigment epithelium despite MH closure and BCVA improvement. Conclusion: Treatment with autologous ILM fragment transplantation seems to be an efficient alternative for large, chronic, and refractory MH.

Comparative analysis of large macular hole surgery using an internal limiting membrane insertion versus inverted flap technique

“…Direct, long-term contact between BBG-stained ILM and the RPE may induce chemical damage within the RPE. In a previous study, RPE atrophy was reported in 2 of 10 eyes (20%) that underwent the ILM insertion technique 17. In the present study, foveal discolouration was more common in the insertion group (86.7%) than in the inverted flap group (7.7%).…”

“…Subsequently, De Novelli et al 17 performed the ILM insertion technique as an initial surgery for eyes with large and chronic MHs. Whereas Morizane et al 15 placed viscoelastic material over the free flap for stabilisation, De Novelli et al 17 slowly removed the fluid to prevent dislodging of the ILM sheet from the hole. In the present study, we performed slow fluid-air exchange to retain the ILM sheet inside the hole.…”

Treatment of large, chronic and persistent macular hole with internal limiting membrane transposition and tuck technique

“…Three different prospective interventional case series have reported the use of viscoelastic to secure free ILM flaps into macular holes. The successful hole closure rate was reported to be between 90 and 92% [11][12][13][14][15]. The surgical techniques employed were similar in all 3 case series, 2 of them used viscoelastic to secure the free flap while 1 used the tuck technique.…”

“…More recently, the advent of autologous transplantation of free ILM flap has provided newfound optimism in improving visual and anatomical outcomes for persistent macular holes after primary surgery [7,8,14,15]. With this development, however, came a brand-new set of surgical challenges and direction for further research [9].…”

Internal limiting membrane insertion technique combined with nerve growth factor injection for large macular hole

“…Moreover, large MHs always tend to be V-or W-shaped, or flat-to-open (a flat MH lacking retinal pigment epithelium) after closure, and are usually associated with persistent photoreceptor loss, retinal pigment epithelium defects, and foveal tissue loss, leading to a poor visual recovery11,23 .Several treatment modifications have been tested, including an inverted ILM flap technique10 and autologous ILM transplantation24 . The inverted flap may not attach to the hole margin either during or after surgery, as the flap loss using OCT scan after the surgery could be observed.…”