The surgical strategy of vitrectomy for refractory macular hole_Chinese Journal of Ocular Fundus Diseases

Authors：

 Zhao Peiquan , Lyu Jiao

Department of Ophthalmology, Xinhua Hospital, Affiliated Shanghai Jiaotong University School of Medicine, Shanghai 200025, China;

Corresponding author：

Zhao Peiquan, Email: zhaopeiquan@xinhuamed.com.cn

Keywords：

Retinal perforations/surgery; Vitreoretinal surgery; Editorial

DOI：

10.3760/cma.j.cn511434-20200622-00301

Video：

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Abstract Full text Figures/Tables Video References Cited by

Refractory macular holes typically represent macular holes larger than 400 μm, macular holes in pathological myopic eyes or complicated with myopic schisis, chronic holes longer than 6 months, persistent macular holes after surgeries, and some subtypes of secondary macular holes. A routine pars plana vitrectomy combined with internal limiting membrane peeling yielded a lower closure rate and unsatisfying visual rehabilitation in patients with refractory macular holes, which raised concerns among vitreoretinal surgeons. This editorial reviewed the new upcoming surgical techniques which were reportedly to improve the anatomical and visual prognosis of major subtypes of refractory macular holes. Although with a great variability, these surgical techniques are based the following surgical strategies: firstly, to sufficiently unravel the epi-macular tractional force; secondly, to bridge the defect of neurosensory retina by tissue insertion or implantation and stimulate wound healing process; thirdly, proper tamponade of gas or silicone oil so that the surface tension can stabilize the inserted or implanted tissue and encourage closure of the holes. In conclusion, surgical strategies for refractory macular holes should be made after a comprehensive consideration and a customized design.

Citation： Zhao Peiquan, Lyu Jiao. The surgical strategy of vitrectomy for refractory macular hole. Chinese Journal of Ocular Fundus Diseases, 2020, 36(7): 495-498. doi: 10.3760/cma.j.cn511434-20200622-00301 Copy

1.	Tam ALC, Yan P, Gan NY, et al. The current surgical management of large, recurrent, or persistent macular holes[J]. Retina, 2018, 38(7): 1263-1275. DOI: 10.1097/IAE.0000000000002020.
2.	Duker JS, Kaiser PK, Binder S, et al. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole[J]. Ophthalmology, 2013, 120(12): 2611-2619. DOI: 10.1016/j.ophtha.2013.07.042.
3.	Gandorfer A, Scheler R, Haritoglou C, et al. Pathology of the macular hole rim in flat-mounted internal limiting membrane specimens[J]. Retina, 2009, 29(8): 1097-1105. DOI: 10.1097/IAE.0b013e3181aa8fb1.
4.	Al Sabti K, Kumar N, Azad RV. Extended internal limiting membrane peeling in the management of unusually large macular holes[J]. Ophthalmic Surg Lasers Imaging, 2009, 40(2): 185-187. DOI: 10.3928/15428877-20090301-03.
5.	Akahori T, Iwase T, Yamamoto K, et al. Macular displacement after vitrectomy in eyes with idiopathic macular hole determined by optical coherence tomography angiography[J]. Am J Ophthalmol, 2018, 189: 111-121. DOI: 10.1016/j.ajo.2018.02.021.
6.	Ishida M, Ichikawa Y, Higashida R, et al. Retinal displacement toward optic disc after internal limiting membrane peeling for idiopathic macular hole[J]. Am J Ophthalmol, 2014, 157(5): 971-977. DOI: 10.1016/j.ajo.2014.01.026.
7.	Alpatov S, Shchuko A, Malyshev V. A new method of treating macular holes[J]. Eur J Ophthalmol, 2007, 17(2): 246-252. DOI: 10.1177/112067210701700215.
8.	Charles S, Randolph JC, Neekhra A, et al. Arcuate retinotomy for the repair of large macular holes[J]. Ophthalmic Surg Lasers Imaging Retina, 2013, 44(1): 69-72. DOI: 10.3928/23258160-20121221-15.
9.	Felfeli T, Mandelcorn ED. Macular hole hydrodissection: surgical technique for the treatment of persistent, chronic, and large macular holes[J]. Retina, 2019, 39(4): 743-752. DOI: 10.1097/IAE.0000000000002013.
10.	Haritoglou C, Wolf A, Wachtlin J. Surgery of large and persistent macular holes[J]. Ophthalmologe, 2019, 116(11): 1011-1019. DOI: 10.1007/s00347-019-00949-x.
11.	Peng J, Zhang LH, Chen CL, et al. Internal limiting membrane dragging and peeling: a modified technique for macular holes closure surgery[J]. Int J Ophthalmol, 2020, 13(5): 755-760. DOI: 10.18240/ijo.2020.05.09.
12.	Michalewska Z, Michalewski J, Adelman RA, et al. Inverted internal limiting membrane flap technique for large macular holes[J]. Ophthalmology, 2010, 117(10): 2018-2025. DOI: 10.1016/j.ophtha.2010.02.011.
13.	Rizzo S, Tartaro R, Barca F, et al. Internal limiting membrane peeling versus inverted flap technique for treatment of full-thickness macular holes: a comparative study in a large series of patients[J]. Retina, 2018, 38(Suppl 1): S73-78. DOI: 10.1097/IAE.0000000000001985.
14.	Michalewska Z, Michalewski J, Dulczewska-Cichecka K, et al. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study[J]. Retina, 2015, 35(9): 1844-1850. DOI: 10.1097/IAE.0000000000000555.
15.	Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies[J]. Retina, 2016, 36(1): 163-170. DOI: 10.1097/IAE.0000000000000674.
16.	Peng J, Chen C, Jin H, et al. Autologous lens capsular flap transplantation combined with autologous blood application in the management of refractory macular hole[J]. Retina, 2018, 38(11): 2177-2183. DOI: 10.1097/IAE.0000000000001830.
17.	Grewal DS, Mahmoud TH. Autologous neurosensory retinal free flap for closure of refractory myopic macular holes[J]. JAMA Ophthalmol, 2016, 134(2): 229-230. DOI: 10.1001/jamaophthalmol.2015.5237.
18.	Chang YC, Liu PK, Kao TE, et al. Management of refractory large macular hole with autologous neurosensory retinal free flap transplantation[J/OL]. Retina, 2019, 2019: E1[2019-12-23]. https://doi.org/10.1097/IAE.0000000000002734. DOI: 10.1097/IAE.0000000000002734. [published online ahead of print].
19.	Ortisi E, Avitabile T, Bonfiglio V. Surgical management of retinal detachment because of macular hole in highly myopic eyes[J]. Retina, 2012, 32(9): 1704-1718. DOI: 10.1097/IAE.0b013e31826b671c.
20.	Wei Y, Wang N, Zu Z, et al. Efficacy of vitrectomy with triamcinolone assistance versus internal limiting membrane peeling for highly myopic macular hole retinal detachment[J]. Retina, 2013, 33(6): 1151-1157. DOI: 10.1097/IAE.0b013e31827b6422.
21.	Lai CC, Chen YP, Wang NK, et al. Vitrectomy with internal limiting membrane repositioning and autologous blood for macular hole retinal detachment in highly myopic eyes[J]. Ophthalmology, 2015, 122(9): 1889-1898. DOI: 10.1016/j.ophtha.2015.05.040.
22.	Lai CC. ILM peeling in macular hole retinal detachment: insert or not?[J]. Graefe's Arch Clin Exp Ophthalmol, 2018, 256(8): 1385-1386. DOI: 10.1007/s00417-018-4049-y.
23.	Shin MK, Park KH, Park SW, et al. Perfluoro-N-octane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery[J]. Retina, 2014, 34(9): 1905-1910. DOI: 10.1097/IAE.0000000000000339.
24.	Faria MY, Proenca H, Ferreira NG, et al. Inverted internal limiting membrane flap techniques and outer retinal layer structures[J]. Retina, 2020, 40(7): 1299-1305. DOI: 10.1097/IAE.0000000000002607.
25.	Hu Z, Gu X, Qian H, et al. Perfluorocarbon liquid-assisted inverted limiting membrane flap technique combined with subretinal fluid drainage for macular hole retinal detachment in highly myopic eyes[J/OL]. Retina, 2019, 2019: E1[2019-7-01]. https://doi.org/10.1097/IAE.0000000000002600. DOI: 10.1097/IAE.0000000000002600. [published online ahead of print].
26.	Nishimura A, Kimura M, Saito Y, et al. Efficacy of primary silicone oil tamponade for the treatment of retinal detachment caused by macular hole in high myopia[J]. Am J Ophthalmol, 2011, 151(1): 148-155. DOI: 10.1016/j.ajo.2010.07.023.
27.	Patel R, Gopalakrishnan M, Giridhar A. Timing and outcome of surgery for persistent macular hole[J]. Retina, 2019, 39(2): 314-318. DOI: 10.1097/IAE.0000000000001939.
28.	Rahimy E, McCannel CA. Impact of internal limiting membrane peeling on macular hole reopening: a systematic review and meta-analysis[J]. Retina, 2016, 36(4): 679-687. DOI: 10.1097/IAE.0000000000000782.
29.	Lee SH, Park KH, Kim JH, et al. Secondary macular hole formation after vitrectomy[J]. Retina, 2010, 30(7): 1072-1077. DOI: 10.1097/IAE.0b013e3181cd4819.
30.	Karth PA, Raja SC, Brown DM, et al. Outcomes of macular hole surgeries for macular telangiectasia type 2[J]. Retina, 2014, 34(5): 907-915. DOI: 10.1097/IAE.0000000000000009.

1. Tam ALC, Yan P, Gan NY, et al. The current surgical management of large, recurrent, or persistent macular holes[J]. Retina, 2018, 38(7): 1263-1275. DOI: 10.1097/IAE.0000000000002020.
2. Duker JS, Kaiser PK, Binder S, et al. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole[J]. Ophthalmology, 2013, 120(12): 2611-2619. DOI: 10.1016/j.ophtha.2013.07.042.
3. Gandorfer A, Scheler R, Haritoglou C, et al. Pathology of the macular hole rim in flat-mounted internal limiting membrane specimens[J]. Retina, 2009, 29(8): 1097-1105. DOI: 10.1097/IAE.0b013e3181aa8fb1.
4. Al Sabti K, Kumar N, Azad RV. Extended internal limiting membrane peeling in the management of unusually large macular holes[J]. Ophthalmic Surg Lasers Imaging, 2009, 40(2): 185-187. DOI: 10.3928/15428877-20090301-03.
5. Akahori T, Iwase T, Yamamoto K, et al. Macular displacement after vitrectomy in eyes with idiopathic macular hole determined by optical coherence tomography angiography[J]. Am J Ophthalmol, 2018, 189: 111-121. DOI: 10.1016/j.ajo.2018.02.021.
6. Ishida M, Ichikawa Y, Higashida R, et al. Retinal displacement toward optic disc after internal limiting membrane peeling for idiopathic macular hole[J]. Am J Ophthalmol, 2014, 157(5): 971-977. DOI: 10.1016/j.ajo.2014.01.026.
7. Alpatov S, Shchuko A, Malyshev V. A new method of treating macular holes[J]. Eur J Ophthalmol, 2007, 17(2): 246-252. DOI: 10.1177/112067210701700215.
8. Charles S, Randolph JC, Neekhra A, et al. Arcuate retinotomy for the repair of large macular holes[J]. Ophthalmic Surg Lasers Imaging Retina, 2013, 44(1): 69-72. DOI: 10.3928/23258160-20121221-15.
9. Felfeli T, Mandelcorn ED. Macular hole hydrodissection: surgical technique for the treatment of persistent, chronic, and large macular holes[J]. Retina, 2019, 39(4): 743-752. DOI: 10.1097/IAE.0000000000002013.
10. Haritoglou C, Wolf A, Wachtlin J. Surgery of large and persistent macular holes[J]. Ophthalmologe, 2019, 116(11): 1011-1019. DOI: 10.1007/s00347-019-00949-x.
11. Peng J, Zhang LH, Chen CL, et al. Internal limiting membrane dragging and peeling: a modified technique for macular holes closure surgery[J]. Int J Ophthalmol, 2020, 13(5): 755-760. DOI: 10.18240/ijo.2020.05.09.
12. Michalewska Z, Michalewski J, Adelman RA, et al. Inverted internal limiting membrane flap technique for large macular holes[J]. Ophthalmology, 2010, 117(10): 2018-2025. DOI: 10.1016/j.ophtha.2010.02.011.
13. Rizzo S, Tartaro R, Barca F, et al. Internal limiting membrane peeling versus inverted flap technique for treatment of full-thickness macular holes: a comparative study in a large series of patients[J]. Retina, 2018, 38(Suppl 1): S73-78. DOI: 10.1097/IAE.0000000000001985.
14. Michalewska Z, Michalewski J, Dulczewska-Cichecka K, et al. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study[J]. Retina, 2015, 35(9): 1844-1850. DOI: 10.1097/IAE.0000000000000555.
15. Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies[J]. Retina, 2016, 36(1): 163-170. DOI: 10.1097/IAE.0000000000000674.
16. Peng J, Chen C, Jin H, et al. Autologous lens capsular flap transplantation combined with autologous blood application in the management of refractory macular hole[J]. Retina, 2018, 38(11): 2177-2183. DOI: 10.1097/IAE.0000000000001830.
17. Grewal DS, Mahmoud TH. Autologous neurosensory retinal free flap for closure of refractory myopic macular holes[J]. JAMA Ophthalmol, 2016, 134(2): 229-230. DOI: 10.1001/jamaophthalmol.2015.5237.
18. Chang YC, Liu PK, Kao TE, et al. Management of refractory large macular hole with autologous neurosensory retinal free flap transplantation[J/OL]. Retina, 2019, 2019: E1[2019-12-23]. https://doi.org/10.1097/IAE.0000000000002734. DOI: 10.1097/IAE.0000000000002734. [published online ahead of print].
19. Ortisi E, Avitabile T, Bonfiglio V. Surgical management of retinal detachment because of macular hole in highly myopic eyes[J]. Retina, 2012, 32(9): 1704-1718. DOI: 10.1097/IAE.0b013e31826b671c.
20. Wei Y, Wang N, Zu Z, et al. Efficacy of vitrectomy with triamcinolone assistance versus internal limiting membrane peeling for highly myopic macular hole retinal detachment[J]. Retina, 2013, 33(6): 1151-1157. DOI: 10.1097/IAE.0b013e31827b6422.
21. Lai CC, Chen YP, Wang NK, et al. Vitrectomy with internal limiting membrane repositioning and autologous blood for macular hole retinal detachment in highly myopic eyes[J]. Ophthalmology, 2015, 122(9): 1889-1898. DOI: 10.1016/j.ophtha.2015.05.040.
22. Lai CC. ILM peeling in macular hole retinal detachment: insert or not?[J]. Graefe's Arch Clin Exp Ophthalmol, 2018, 256(8): 1385-1386. DOI: 10.1007/s00417-018-4049-y.
23. Shin MK, Park KH, Park SW, et al. Perfluoro-N-octane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery[J]. Retina, 2014, 34(9): 1905-1910. DOI: 10.1097/IAE.0000000000000339.
24. Faria MY, Proenca H, Ferreira NG, et al. Inverted internal limiting membrane flap techniques and outer retinal layer structures[J]. Retina, 2020, 40(7): 1299-1305. DOI: 10.1097/IAE.0000000000002607.
25. Hu Z, Gu X, Qian H, et al. Perfluorocarbon liquid-assisted inverted limiting membrane flap technique combined with subretinal fluid drainage for macular hole retinal detachment in highly myopic eyes[J/OL]. Retina, 2019, 2019: E1[2019-7-01]. https://doi.org/10.1097/IAE.0000000000002600. DOI: 10.1097/IAE.0000000000002600. [published online ahead of print].
26. Nishimura A, Kimura M, Saito Y, et al. Efficacy of primary silicone oil tamponade for the treatment of retinal detachment caused by macular hole in high myopia[J]. Am J Ophthalmol, 2011, 151(1): 148-155. DOI: 10.1016/j.ajo.2010.07.023.
27. Patel R, Gopalakrishnan M, Giridhar A. Timing and outcome of surgery for persistent macular hole[J]. Retina, 2019, 39(2): 314-318. DOI: 10.1097/IAE.0000000000001939.
28. Rahimy E, McCannel CA. Impact of internal limiting membrane peeling on macular hole reopening: a systematic review and meta-analysis[J]. Retina, 2016, 36(4): 679-687. DOI: 10.1097/IAE.0000000000000782.
29. Lee SH, Park KH, Kim JH, et al. Secondary macular hole formation after vitrectomy[J]. Retina, 2010, 30(7): 1072-1077. DOI: 10.1097/IAE.0b013e3181cd4819.
30. Karth PA, Raja SC, Brown DM, et al. Outcomes of macular hole surgeries for macular telangiectasia type 2[J]. Retina, 2014, 34(5): 907-915. DOI: 10.1097/IAE.0000000000000009.

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The surgical strategy of vitrectomy for refractory macular hole

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