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Short-term air tamponade safe, effective in idiopathic macular hole surgery
ICG-assisted surgery is preferable when using air tamponade, especially in eyes with macular holes of long duration.
MONTREUX, Switzerland – Short-term air tamponade in macular hole surgery has an anatomical success rate comparable to other methods. There are also indications that indocyanine green (ICG) staining is preferable when using air tamponade, especially in eyes with macular hole of long duration, according to a presentation at the Club Jules Gonin meeting here.
Jan-Olof Carlsson, MD, of Örebro University Hospital, Sweden, presented a retrospective study on 41 eyes of 38 patients with macular hole stage II, III or IV, operated with air tamponade from April 1999 to April 2002. Mean age of patients was 70 years (range 58 to 82 years). Preoperative duration of symptoms was between 2 months and 2 years (mean 6.7 months), with a duration time of 6 months or more in 61% of the cases.
“We included patients who had been able to comply with the postoperative posturing regime and had had successful internal limiting membrane peeling without complications. Patients with retinal breaks detected perioperatively were excluded,” Dr. Carlsson said.
High anatomical success rate
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Patients were divided into two subgroups. In group A, 16 eyes were included, and macular hole surgery was performed without ICG staining for ILM peeling. In the 25 eyes of group B, surgery was performed with ICG staining.
“We induced posterior vitreous detachment by using an illuminated pick and an active soft extrusion needle. In the cases where the ICG was used, we sprayed it inside the cavity before fluid–air exchange. The ICG was then immediately aspirated and membrane peeling was carried out, nearly up to the vascular arcades,” Dr. Carlsson said.
A high rate of anatomical success was obtained at the first operation. In 80% of the eyes the macular hole was flat, with no visible edges, he said. The follow up ranged from 1 month to 2 years.
“Looking at the two groups, the use of ICG was associated with a higher rate of anatomical success,” he said. “In group A success rate was 62%, while in group B it was 92%. If we focus on the 25 eyes with long-duration macular holes (6 months or longer), the advantages of using ICG staining are even more evident, as the rate of anatomical success was 94% in group B compared to 44% in group A.”
Of the eight anatomical failures, seven had a second operation performed in a more conservative way, using platelets combined with C2F6 gas. The overall anatomical success rose to 98%, with 40 of 41 patients experiencing complete closure of the macular hole.
Visual results, complications
“In the 33 eyes where the macular hole was closed after the first operation, we found that 67% of these eyes had doubled their visual acuity. In this case the higher percentage was in group A, with 90% of the eyes doubling visual acuity against the 57% of group B. However, the mean follow-up of patients in the A group was much longer, reaching nearly 2 years, while in group B the mean follow-up was 6.7 months, with the majority of patients who have been followed for less than 6 months,” Dr. Carlsson said.
The rate of complications was relatively low in both groups. There was one case of small, localized retinal detachment and one case of hyphema that each resolved spontaneously, five cases of visual field defects and 12 cases of discrete pigmentary disturbances in the foveal area. Six patients had elevated IOP, and two of them are still under topical medications. Phaco with IOL implantation was performed after the macular hole surgery in 13 of 27 phakic patients.
“We had one case of retinal damage due to the ICG, which was caused by a mechanical error during the surgical procedure. The ICG was sprayed too powerfully, creating a jet stream that damaged the tissue between the fovea and the optic disc,” Dr. Carlsson said.
Encouraging conclusions
The results of this study, Dr. Carlsson concluded, support the hypothesis that a short-term air tamponade and brief immobilization may be sufficient in the treatment of idiopathic macular hole, and could replace the long-term tamponade with expanding gases, with much benefit to patients.
“They also demonstrate that ICG, when used correctly, can be of great help during surgery, and improve the outcomes without undesirable side effects,” he said.
For Your Information:
- Jan-Olof Carlsson, MD, can be reached at Ögonkliniken, Universitetssjukhuset Örebro, 70185 Örebro, Sweden (46) 19-60-21-43; fax: (46) 19-10-16-32; e-mail: jan-olof.carlsson@orebroll.se.