Current management strategies for atypical macular holes

Abstract

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Revision Surgery for Idiopathic Macular Hole after Failed Primary Vitrectomy

“…Macular graft has recently been described for large and refractory MHs. According to Mahmoud and Marlow [ 21 ], the macular graft should be considered for refractory MHs or large MHs (≥700 μ m). Wu et al [ 22 ] observed a closure rate at revision surgery of 67% (4/6 eyes) in eyes with a mean MH size of 979 ± 441 μ m at baseline, and BCVA was 31 ± 59 letters at 12 months of follow-up.…”

Surgical Techniques for Refractory Macular Holes

“…Flap displacement or accidental extrusion during fluid-air exchange might occur. 18 Viscoelastic-assisted or PFC-assisted free ILM flap technique has been utilized to improve the stabilization and secure the flap over the MH. 59,62 Harvesting a free ILM flap and tucking it inside the MH has also been proposed to minimize the risk of flap displacement.…”

“…51,64 However, this technique has not been widely adopted as the ILM strip and the flap hinge are small and prone to displacement and retraction with reopening of the MH. 18,65 Superior Wide-Base ILM flap Transposition (SWIFT) technique A wide-based ILM flap is fashioned from the ILM over the superior macula. The flap is then inverted to cover the MH.…”

“…One advantage of the technique is preserving more ILM to use for potential future surgeries in these complicated myopic MH cases. 18,66,67 (B) Alternative scaffold tissues Amniotic Membrane Graft (AMG) The human amniotic membrane graft (AMG) can be used as scaffold in refractory MH cases. It can facilitate MH closure through acting as a scaffold supporting tissue growth as well as its potential ability to release growth factors that can help with tissue regeneration.…”

“…15 Early surgical repair of MH is recommended to achieve the best anatomical and visual outcomes. 18 High Myopia High myopia (myopia of −6 Diopters or more) is a well-recognized risk factor for failure of MH repair with poorer visual outcomes. 19 Multiple studies suggested that the long axial length (AL) and posterior staphyloma induce traction over the edges of the MH, which impairs its anatomical closure.…”