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Novel technique successful in closure of large macular holes
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Tapping of macular hole edges results in an intraoperative increase in macular hole index, contributing to successful closure with surgery, even in large macular holes with preoperative low macular hole index, according to a study.
“Conventionally, macular holes with MHI less than 0.5 are considered to have a poor outcome,” co-author Sana Ilyas Tinwala, MD, said in an email interview with Ocular Surgery News. “However, with our modified technique, holes with MHI between 0.25 and 0.5 are also seen to close with good functional and anatomic outcomes postoperatively.”
Macular hole index (MHI) represents both horizontal and vertical dimensions of the macular hole, thus reflecting macular deformation, Tinwala and colleagues said in their study published in the Asia-Pacific Journal of Ophthalmology.
Intraoperative tapping of macular hole edges from the inner side is a newly incorporated adjuvant surgical method, the study authors said.
By tapping all quadrants with a 23-gauge GreenTip soft cannula (Iridex), height of the macular hole is increased, thus increasing ratio of height to base and consequently increasing MHI.
“This maneuver translates into increased MHI and thus can contribute to macular hole closure even in cases of large holes,” Tinwala and colleagues said in the study.
Patients with MHI of 0.25 or more can significantly improve with surgery and should not be left for observation alone, Tinwala said.
“With a good surgical technique, anatomic and functional results can be optimized even in eyes with low MHI,” she said.
Study method
All 28 patients in the prospective, interventional study had large idiopathic macular holes with MHI less than 0.5, with a mean of 0.32. They underwent intraoperative tapping of all macular hole edges with a 23-gauge GreenTip soft cannula tip during vitrectomy.
Macular holes closed in 25 patients (89.3%).
“The three cases in our series wherein the macular hole failed to close, the MHI was less than 0.25,” Tinwala said.
LogMAR corrected distance visual acuity significantly improved from 0.86 at baseline to 0.43 postoperatively, (P < .0001).
Twenty of the 25 eyes (80%) had no interruption in the continuity of foveal tissue above the retinal pigment epithelial layer after surgery for macular hole, while five eyes (20%) had an interruption in the continual foveal tissue after surgery, resulting in an exposed retinal pigment epithelial level.
“In our experience, results of tapping have been found to be far superior to observation alone, especially for large macular holes with MHI greater than 0.25,” Tinwala said.
Compared with previous studies that attribute macular hole closure to glial cell proliferation, which may take up to 6 months to completely fill the tissue, in this novel technique, significant improvement in visual acuity with hole closure can be seen as early as day 1, she said.
Positioning
Face-down positioning for 14 to 16 hours daily for 5 days was advised in all cases, the study authors said.
“Our regimen includes 2 hours face-down positioning with 1 hour of rest in between,” Tinwala said.
Patients can maintain a face-down position while seated rather than lying down in the prone position, which is less cumbersome and is well-accepted by most patients.
“The aim of positioning is to maximize the vector forces directed against the macular hole, and this can be successfully achieved with either prone or sitting posture, minimizing patient discomfort and increasing patient compliance,” Tinwala said.
A prospective, randomized control trial is under way to compare the results of observation vs. surgery in patients with large macular holes and low MHI, she said.
“We also intend to procure intraoperative OCT, which will help us in objective documentation of our findings and will further enable us to consolidate our hypothesis of intraoperative increase in MHI by our technique,” Tinwala said. – by Christi Fox