Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

Abstract

Background The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making. Methods We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups. Results Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases. Conclusions The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400–550 µm) and X-Large (550–800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

The Evolution and Visual Prognosis of Glial Proliferation with Different Grades after Macular Hole Surgery: An Optical Coherence Tomography-Based Study

“…In this research, the ROC curve analysis indicated that MLD was a robust predictive factor for the presence of A-type glial proliferation at 1 month, with a cut-off >547.5 μm, which suggested that patients with a MH >547.5 μm are quite possible to have a poor anatomical and visual prognosis after surgery. This result was similar to the previous studies suggesting a MLD of around 550 μm as a threshold of successful MH closure [19, 20]. Hypothetically, in large MHs (>547.5 μm), it is challenging for outer retinal layers to reapproximate so that a large amount of glial cells are required to fill the foveal defect.…”

Outcomes of 25-Gauge Pars Plana Vitrectomy in the Treatment of Idiopathic Macular Hole

“…Data from the "CLOSE" study group presents a practically 100% success rate of PPV with the use of ILM peeling and/or the creation of an ILM flap in the case of type S and M macular holes, while in the case of type L holes the success rate is reduced to 97%, for type XL holes 86% and for type XXL holes to 80% [4]. In our co- hort the total success rate of primary closure of macular hole was 93%, in which in the case of holes with preoperative MLD of ≤ 550 we achieved a 100% success rate.…”

“…In our cohort the success rate for type XL holes was only 46.7%, which raises the question as to whether it would be more advantageous to choose the technique of an ILM flap as the method of first choice for such holes. Although the authors of the "CLOSE" study group in 2023 demonstrated that there is a higher success rate of closure upon the use of a flap from the ILM for holes of types L, XL and XXL, the gains of BCVA are lower in comparison with gains of BCVA upon the use of ILM peeling only [4,11]. The lower gains of BCVA are probably due to the fact that manipulation of the flap from the ILM presents a higher risk of mechanical damage to the RPE, while the flap itself may lead to an excessive glial reaction and hyperproliferation of the Müller cells, which subsequently prevents the adequate reconstruction of the outer layers of the retina [17].…”

“…The authors of this study are of the opinion that type L, XL and XXL holes can be treated surgically with the aid of ILM peeling and/or the creation of an ILM flap. Alternative surgical techniques (i.e., perifoveal hydrodissection, amniotic membrane graft and autologous retinal transplant) should be applied exclusively for such MHs which ILM peeling or an ILM flap failed to close, or in the case of an MLD of > 800 μm [4].…”

Predictive factors of surgical success with the Inverted ILM Flap Technique

“…In contrast to ILM peeling, no correlation was observed between the macular hole size and failure rate. 33,34 Further studies are required to determine whether the ERM should be completely removed or inverted together with the ILM flap.…”