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

Abstract

Background: Large, chronic full thickness macular holes which failed previous treatments are difficult to manage and even left untreated due to poor prognosis. A retrospective review of consecutive cases with chronic (at least 1 year) full thickness macular holes and internal limiting membrane (ILM) free flap transposition with tuck technique, after previously failed vitrectomy. Methods: This was a retrospective and interventional study conducted in a single centre by a single surgeon. Patients with full thickness macular hole for at least 1 year and at least one previously failed vitrectomy with ILM peeling were recruited. A 25G vitrectomy with ILM free flap transposition was done without assistance of PFCL, viscoelastic or autologous blood. The free flap was manually tucked into the macular hole free space and gas fluid exchange was performed with 20% SF6 as tamponade. The patients were postured prone for 2 weeks postoperatively. Best corrected visual acuity, macular hole duration, previous surgeries, optical coherence tomography (OCT) appearance, hole size and closure rate were recorded. Results: 8 consecutive patients were included from May 2016 to Feb 2018. Transposition surgery was performed an average of 1481 days (SD 1096) after diagnosis of macular hole and average of 1226 days (SD 1242) after first vitrectomy. Macular hole mean size was 821 μm (SD 361.3), preoperative VA was logMAR 1.038 (SD 0.19), postoperative VA was logMAR 0.69 (SD 0.19) at 3 months. There were 1.13 lines gained and a significant improvement of logMAR 0.33 (p = 0.0084) at 6 months. Hole closure was seen in 7 out of 8 eyes (87.5%). The OCT with failed closure showed ILM flap within a flat hole, however no overlying neurosensory layers was seen. The duration from diagnosis to surgery was 2349 days in this case. Conclusion: Free flap ILM transposition tuck without the use of additional intraoperative tamponade is an effective technique in treating large chronic macular holes with previously failed primary macular hole surgeries.

Revision Surgery for Idiopathic Macular Hole after Failed Primary Vitrectomy

“…Despite the relatively high success rate following primary surgery, the persistence of MH remains a surgical challenge, affecting 8–44% of all operated MHs [ 6 ]. The optimal approach to failure-to-close cases, as well as the added value of reoperating, is still up for debate.…”

Internal Limiting Membrane Peeling and Flap Inverting under Air in Large Idiopathic Macular Hole Surgery

“…On the other hand, for special MHs, including large, persistent, and highly myopic, special techniques were developed such as perfluorocarbon liquid-assisted inverted limiting membrane flap technique [ 15 ], internal limiting membrane transposition and tuck technique [ 16 ], inverted ILM flap combined autologous blood clot technique [ 17 ], the neurosensory retinal flap [ 18 ], human amniotic membrane plug transplant [ 19 , 20 ], and lens capsular flap transplantation [ 21 ]. These techniques achieved a high success rate, but limitations such as retinal toxicity and risk of infection were also noticed ( Supplementary Table ).…”

Current management strategies for atypical macular holes

“…[ 86 93 94 ] Alternatively, the free ILM flap may be tucked into the edge of the hole to anchor it, though this carries risk of increased trauma to the underlying RPE and photoreceptors. [ 95 ] Ultimately, depending on the size of the initial ILM peel and the facility with which ILM is harvested, it can be difficult to obtain a single sheet of ILM adequate to cover the MH.…”