Human Amniotic Membrane to Treat Macular Holes That Failed to Close, Sulfur Hexafluoride Endotamponade Versus Air Endotamponade

Abstract

Background/Purpose: To determinate the efficacy of the human amniotic membrane plugs with sulfur hexafluoride versus human amniotic membrane plug with air as endotamponade to treat macular holes that failed to close after vitrectomy plus internal limiting membrane peeling. Multimodal imaging was focused to evaluate preoperative features and postoperative changes.Methods: Prospective interventional comparative study. Twenty eyes of 20 patients affected with macular hole that failed to close were divided into 2 groups: 10 eyes received an amniotic membrane plug with 20% sulfur hexafluoride tamponade and 10 eyes received an amniotic membrane plug with air tamponade. All eyes were studied using multimodal advanced diagnostic tools, such as spectral-domain optical coherence tomography, optical coherence tomography angiography, microperimetry, and adaptive optics to investigate the postoperative results.Results: In both groups, all macular holes were found successfully closed after 12 months. Mean preoperative best-corrected visual acuity was 20/400 in the SF 6 group and 20/250 in air group. Final mean best-corrected visual acuity was 20/63 in both groups. The superficial capillary plexus, studied using optical coherence tomography angiography, showed a statistically significant difference between the treated and the fellow eyes. Adaptive optics images revealed the presence of a photoreceptor cell mosaic in the area of the amniotic membrane plug. Conclusion:The human amniotic membrane combined with air endotamponade demonstrated its effectiveness to seal macular holes that failed to close after vitrectomy plus internal limiting membrane peeling. Advanced multimodal diagnostic imaging helped us to better understand the modifications associated with the use of the amniotic membrane in these cases.RETINA 41:735-743, 2021M acular holes (MHs) that failed to close after pars plana vitrectomy (PPV) plus internal limiting membrane (ILM) peeling are still a challenge to vitreoretinal surgeons. The incidence varies from 0% to 39%, 1,2 without ILM peeling and from 0% to 8.6% in eyes in which the ILM has been peeled. 3 Many modern surgical options to treat this condi-tion have been proposed such as the introduction of autologous anterior crystalline lens capsule fragments, autologous neuroretina, autologous ILM plugs into the MH, or creating a subretinal bleb to mobilize the HM margins. [4][5][6][7][8][9] These techniques aim to generate a sealing of the hole with variable visual acuity recovery.

Inverted internal limiting membrane flap technique for retinal detachment due to macular holes in high myopia with axial length ≥ 30 mm

“…Currently, some alternative techniques have been reported for refractory macular holes, such as autologous ILM flap transplantation, ANRT, human amniotic membrane (hAM) plug, and so on. Several studies that use the hAM plug have been proven to be effective in repairing large 35 or failed macular holes 36 , 37 and high-myopic macular holes associated with retinal detachment 38 , with a 93.8% closure rate after one surgical intervention 35 . However, we have not yet carried out these technologies for legal reasons.…”

Surgical Management of Recurrent and Persistent Macular Holes: A Practical Approach

“…In a recent prospective case series of 13 eyes with refractory MHs (mean minimum diameter 964.38 ± 709.77 lm, mean base diameter 1615.38 ± 689.19 lm), closure rate after 12 months was 76.9% with this technique but there was no statistically significant improvement in vision [71]. [73]. Both groups maintained face down positioning for 3 days and there was no statistically significant difference in MH size or postoperative visual acuity between the two groups.…”

“…It is believed that the hAM induces retinal pigment epithelium (RPE) cell proliferation and secretion of growth factors that facilitate retinal growth, as optical coherence tomography (OCT) scans obtained during the postoperative period demonstrated a fully stratified retinal layer over the patch of hAM. In a comparative study of 10 eyes with a hAM plug and 20% SF6 gas endotamponade versus 10 eyes with hAM plug and air endotamponade, all MHs were found to be closed after 12 months [ 73 ]. Both groups maintained face down positioning for 3 days and there was no statistically significant difference in MH size or postoperative visual acuity between the two groups.…”

Surgical Techniques for Refractory Macular Holes

“…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. [67][68][69][70][71][72] In 2019, Rizzo et al 69 introduced the technique of AMG implantation into the subretinal space in refractory and myopic MHs. In this technique, chandelier light was used to allow bimanual manipulation of the AMG which was inserted under the MH in the subretinal space using PFO for AMG stabilization.…”

“…No adverse events were reported over 1 year of follow up, and visual acuity continued to improve up to 6 months postoperatively. In consecutive studies by Caporossi and colleagues, the authors studied different aspects and uses of applying AMG in refractory MHs 68,70,71,73. In a study that included 36 eyes with persistent MH after prior PPV and ILM peel, Caporossi et al70 utilized the AMG to plug the MH, which resulted in a successful closure rate of 100%.…”