Advanced techniques can close ‘difficult’ macular holes
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An inverted internal limiting membrane flap technique and autologous retinal transplantation can be used to successfully close certain full-thickness macular holes, according to a speaker at the virtual OSN New York Retina meeting.
“I want to emphasize that the success rate with a traditional PPV and ILM peeling for most macular holes exceeds 90%,” Christina Y. Weng, MD, MBA, told Healio/OSN. “However, certain types of holes, such as large, chronic or myopic, are intrinsically more difficult to fix, and for those, I will consider a technique such as an inverted ILM flap or autologous retinal transplant.”
A modified inverted internal limiting membrane (ILM) flap technique, in which only the temporal ILM is peeled, hinged along the temporal aspect of the macular hole edge and inverted to cover the hole, was found in a comparative study to have a 93% closure rate and similar visual acuity improvements to a traditional ILM flap technique. However, the modified technique results in less dissociated optic nerve fiber layer appearance, Weng said.
The modified technique should be considered for myopic macular holes, chronic full-thickness macular holes and large full-thickness macular holes. However, the ILM must be present to consider the technique, Weng said.
“With the inverted ILM flap, one theory is that it provides a scaffold for, and perhaps induces, glial cell proliferation that enhances closure,” Weng said.
For refractory macular holes that have already undergone pars plana vitrectomy and ILM peel, autologous retinal transplant can be considered. The procedure is also appropriate for refractory, large and chronic full-thickness macular holes, she said.
The retinal graft should be slightly larger than the full-thickness macular hole, and surgeons should ensure full-thickness cuts along the inner of the diathermy marks, Weng said.
The graft should be grasped at its edge, transplanted under perfluorocarbon heavy liquid and gently seated over the hole, she said.
“The proposed mechanism of autologous retinal transplantation extends beyond the graft acting as a mechanical ‘plug.’ Rather, the graft may stimulate regenerative processes and facilitate ectopic synaptogenesis where photoreceptors in the graft retina are able to rebuild connections with other neural cells in the host retina,” Weng said.
While none of the described advanced surgical techniques for macular hole repair are fully understood in terms of their mechanism of action, they do result in increased anatomic closure rates, and there is evidence they can lead to visual acuity improvement in affected patients, she said.
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Weng CY. Retinal surgery. Presented at: OSN New York and OSN New York Retina; Oct. 17-18, 2020 (virtual meeting).
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