Complex Macular Hole Surgery [Part I]: Overview of Techniques

Macular hole surgery is considered “bread and butter” for us vitreoretinal surgeons. The vast majority of macular holes will close with vitrectomy, usually with ILM peeling, and gas tamponade. A few weeks ago on RETINA Roundup we also discussed an interesting technique where the authors “re-draped” the peeled ILM back onto the macula, to prevent inner retinal dimpling that you see after ILM removal.

But what about macular holes with high-risk characteristics: chronic, very large, highly myopic, traumatic, pediatric, recurrent, etc? Many will start with standard surgery as above. But what if that fails? Or can you start with a different approach?

MH 2

Surgeons have proposed various creative approaches for high-risk macular holes in recent years. In general, they can be categorized into:

(A) Inverted ILM Flap
This technique has become the most widely used technique (mostly outside the U.S.) with many papers describing its outcomes. The ILM is hinged at the edge of the macular hole, and flapped over to cover the hole. This technique is often used as the initial surgery, as it requires ILM to be present surrounding the hole. Unlike free ILM flaps that are “stuffed” into the hole, the hinged ILM allows a smoother foveal contour without the gliotic plug. Here is a recent RETINA paper from Taiwan suggesting its benefits for myopic macular holes: Wu et al. 2017. I personally prefer this approach as the primary surgery for high-risk macular holes.

ILM Flap
Creating an ILM flap for a highly myopic eye with MH

(B) Covering the macular hole with autologous tissue
There are successful reports using autologous ILM, lens capsule, neurosensory retina, platelet rich plasma, etc. Here is a paper from Italy demonstrating how to use autologous ILM free flaps to plug paravascular or juxtapapillary retinal breaks over areas of chorioretinal atrophy in high myopia: Rizzo et al. 2017.

(C) Relaxing the rim of the macular hole
Chronic macular holes often have a stiff annular rim, and it may help to relax that ring. We recently reported creating radial “maculotomies” by snipping the macular hole rim along the horizontal raffe, in complex pediatric macular holes: Shah et al. 2016. Other methods include “massaging” the macular hole with scrappers or nudging it with forceps. I use this technique quite often for macular holes with stiff rims and limited visual potential. This tends to be in chronic retinal detachments associated with macular holes. You can use vertical scissors or an MVR blade.

(D) Creating a macular detachment
I find this technique intriguing, and it’s on my to-do list when I identify an appropriate patient. BSS is injected in the subretinal space to lift and stretch the macula. Several recent RETINA papers have described various iterations and indications: (Wong 2013, Szigiato et al. 2016, Wong et al. 2017, Claes 2017).

In Part II of this post, we interview Mark Walsh, M.D., Ph.D. from Retina Associates in Tucson, AZ, for pearls about the macular detachment technique that he and his co-authors published in RETINA recently.

Yoshihiro Yonekawa, M.D.