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 Table of Contents  
Year : 2016  |  Volume : 28  |  Issue : 3  |  Page : 176-179

Persistent macular hole: When to intervene

Department of Vitreo-Retinal Surgery, Giridhar Eye Institute, Kochi, Kerala, India

Date of Web Publication2-May-2017

Correspondence Address:
Dr. Rutul Patel
Department of Vitreo-Retinal Surgery, Giridhar Eye Institute, Kadavanthra, Kochi - 682 020, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_8_17

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Purpose: To evaluate the efficacy and optimum timing for resurgery in case of persistent macular hole (MH).
Materials and Methods: Nineteen eyes of 19 patients who underwent fluid air exchange with intravitreal C3F8 for persistent MH after vitrectomy + internal limiting membrane peeling + SF6 were included in the study. Best corrected visual acuity (BCVA), optical coherence tomography (OCT) features including base diameter and configuration of MH, and time duration between two surgeries were noted.
Results: Patients who underwent resurgery within 3 months of the first surgery had better anatomical closure rate compared to those who underwent resurgery after 3 months (P < 0.05).Significant improvement was seen in BCVA in eyes with closed MH. Eyes having MH with irregular edges on OCT had better anatomical closure rates compared to round edges.
Conclusion: Patients undergoing repeat gas injection within 3 months of primary surgery for persistent MH have better anatomical closure rates compared to late intervention (>3 months).

Keywords: C3F8, persistent macular hole (MH), SF6

How to cite this article:
Patel R, Giridhar A, Gopalkrishnan M. Persistent macular hole: When to intervene. Kerala J Ophthalmol 2016;28:176-9

How to cite this URL:
Patel R, Giridhar A, Gopalkrishnan M. Persistent macular hole: When to intervene. Kerala J Ophthalmol [serial online] 2016 [cited 2022 Dec 3];28:176-9. Available from: http://www.kjophthal.com/text.asp?2016/28/3/176/205434

  Introduction Top

Idiopathic macular hole (MH) is one of the major retinal condition responsible for reduced central vision in elderly. Gass has described the basic pathogenesis of MH to be due to tangential traction by cortical vitreous on fovea.[1],[2] Kelly and Wendel first reported successfully treatment of macular holes using pars plana vitrectomy in 1991.[3] They achieved an anatomical closure rate of 73% and improvement in visual acuity of 2 lines or more in 55% of the cases. Various surgical modalities of treatments have been tried for macular hole surgeries.[4] Internal limiting membrane (ILM) peeling [5] has increased the surgical success rate, resulting in MH closure in 90–95% of the patients.

Persistent MH is the most common complication of MH surgery even with ILM peeling and gas tamponade, with an incidence of 10–12%. Resurgery in the form of repeat vitrectomy with enlargement of ILM rhexis and additional gas tamponade with or without autologous platelet concentrate has been documented in many studies for persistent and reopened MH.[6],[7],[8]

These studies have documented poor anatomical closure rates and final best corrected visual acuity (BCVA) in cases of persistent MH compared to reopened MH after repeated surgery. Presence of “cuff of fluid” around MH has been documented to be associated with better success rates after second surgery.[7] However, none of the studies has documented the duration between two surgeries and their effect on the surgical outcome of resurgery for persistent MH.

It is very important to know when to intervene in case of persistent MH after the first surgery to gain maximum visual acuity and anatomical closure. Hence, the main purpose of this study is to find the correlation between duration between second surgery and the success rate of resurgery.

  Materials and Methods Top

In this retrospective study, we evaluated patients who had undergone resurgery for persistent idiopathic MH. Persistent MH was defined as nonclosure of MH after 1 month of primary surgery. Parameters recorded were demographic details, BCVA, slit-lamp biomicroscopy, and spectral domain-optical coherence tomography (SD-OCT) features of MH [Figure 1].
Figure 1: Sequential SD OCT pictures of cases , Case 1 – resurgery was done 1 month after primary surgery - .Case 2 – resurgery was done after 7 months of primary surgery

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BCVA was recorded at the baseline, 1 month after the first surgery, and 2 months after the second surgery. OCT features of macular hole were observed at the baseline, 1 month after the first surgery, and 1 month after the second surgery. OCT features observed were diameter of MH, intraretinal cystoids edema around MH, edges of MH, and presence of vitreomacular traction (VMT). MH index such as hole forming factor (HFF) was also calculated at the baseline.

Primary surgical technique

Standard 23 or 25-gauge three-port pars plana vitrectomy was done along with PVD induction with or without use of diluted triamcinolone. ILM peeling was done in all the cases after staining with brilliant blue dye. Internal tamponade was given with nonexpansile 20% sulfur hexafluoride (SF6) gas followed by face down position.

Resurgery technique

Resurgery procedure included revitrectomy with fluid air exchange followed by internal tamponade with nonexpansile 12% perfluoropropane (C3F8) gas followed by face down position.

  Results Top

Nineteen eyes of 19 patients were included in the study. Mean age was 65.06 ± 6.5 years. Out of the total 19 patients, 14 were females (73.7%) and 5 were males (26.3%). Four patients were pseudophakic and 15 phakic. Out of 19 eyes, 12 eyes (63%) had complete closure of MH after 1 month of resurgery, and 7 eyes (37%) remained open [Table 1]. Based on SD-OCT, 7 eyes were having stage-3 and 12 eyes were having stage-4 FTMH. Mean base diameter of MH was 817 ± 227 μ measured on SD-OCT [Table 2.2]. HHF (a + c/d) was calculated for all cases. Seven eyes (37%) had HFF <0.8 and 12 eyes (63%) had HFF >0.8. Nine eyes (75%) with HFF >0.8 had closure of MH after resurgery compared to 3 eyes (25%) with HFF <0.8 who had closure of MH after resurgery. Another SD-OCT feature which was studied was irregular or rounded edge of MH at the baseline. Out of 15 eyes with irregular edges, 10 (67%) had closure of MH after resurgery compared to 4 patients with rounded edge, out of which only 1 eye (25%) had closure after resurgery [Table 2.3].
Table 1: Frequency of final outcome in the study population

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Mean BCVA at the baseline, after 1 month of the first surgery, and after 2 months of resurgery were 0.96 ± 0.36, 1.02 ± 0.26, and 0.86 ± 0.32 logMAR, respectively. There was significant improvement in BCVA after resurgery compared to the baseline, though it was not statistically significant (P = 0.09) [Table 3].

Time interval between the two surgeries were calculated in all patients. Mean interval was 4.5 ± 4.84 months. Out of 19 eyes, 10 had interval of <3 months and 9 eyes had interval of >3 months. Nine out of 10 eyes (90%) with interval of <3 months had closure of MH after resurgery. In contrast, only 3 out of 9 eyes (33%) had closure of MH after resurgery. This difference was statistically significant with P = 0.02 [Table 2.1].
Table 2.1: Time in months vs final outcome

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Table 2.2: Base diameter vs final outcome

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Table 2.3: Edges vs final outcome

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Table 3: Assessment of BCVA - Baseline and 2nd post procedure

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  Discussion Top

The failure of the primary surgery and persistent MH is the most common complication of MH surgery. Vitrectomy with ILM peeling and gas tamponade has increased the success rate of primary surgery to 85-95%.[9],[10] Possible reasons for persistence of MH in remaining patients can be persistent vitreomacular traction, insufficient tamponade, or noncompliance to face down position.

In this study, out of 18 cases of persistent MH, 12 cases (67%) had complete closure of MH after the second surgery.[6],[7],[8] These results are similar to those found in other studies of persistent MH. Jost Hillenkamp et al.[7] and D'Souza et al.[6] have documented 68% and 52% closure rate, respectively, after surgery for persistent MH. Valldeperas et al.[8] documented 76% and 100% closure rates after second surgery in cases of persistent and reopened MH, respectively, suggesting better prognosis for reopened MH compared to persistent MH.

Many studies have documented prognostic factors for success rate of resurgery for persistent MH such as duration of symptoms, surrounding cuff of fluid, and baseline diameter of MH.[7],[8],[11] However, none of the studies have emphasized on the optimum duration for resurgery and its relation with anatomical closure rate after resurgery. In this study, we have noted that patients who underwent resurgery within 3 months of the first surgery had significantly better anatomical closure rate compared to eyes who underwent resurgery after 3 months (P = 0.04).

The basic mechanism of closure of MH is thought to be due to release of vitreomacular traction and centripetal growth of glial tissue starting from the base of MH gradually closing the MH. ILM peeling is thought to facilitate macular hole closure by removing an element of traction or by stimulating gliosis.[12] Gas tamponade is thought to enhance MH closure process by removing tangential force via its flotation force at the macula, its surface tension which excludes vitreous fluid from the subretinal space, and also by its role as a template to direct inner retinal glial cell migration.[12],[13] Sufficient tamponade is required during this process in the form of SF6, C3F8 gas, or silicon oil. Gas tamponade is preferred than silicon oil due to short-term requirement of tamponade for MH.

Hence, eyes with large diameter of macular holes may need prolonged tamponade in some cases. As tamponade effect of SF6 weans off in 3 weeks, resurgery with additional long-term tamponade with C3F8 may lead to the closure of persistent MH. In our study also, eyes with persistent MH underwent resurgery with additional tamponade with C3F8 gas, which leads to closure of MH. However, rate of anatomical closure of MH and BCVA improvement significantly reduce with duration of MH which is documented in several studies.[11],[14],[15] The possible reason for this can be gradual degenerating changes in outer retinal layers with increase in the duration of MH. In our study also, eyes with persistent MH who were retreated after >3 months of the first surgery were having significantly less anatomical closure rate compared to those eyes who were treated within 3 months of the primary surgery.

  Conclusion Top

Anatomical closure rate of persistent MH after resurgery was 63%. Improvement in final BCVA was also observed in eyes with closed MH compared to the baseline, though it was not statistically significant. Resurgery with additional gas tamponade done within 3 months of the first surgery had significantly better closure rates compared to eyes with resurgery after 3 months. Hence, prompt intervention with tamponading agents can result in improved chances of closure and better final BCVA.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gass JDM. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629-39.  Back to cited text no. 1
Gass JDM. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752-9.  Back to cited text no. 2
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-9.  Back to cited text no. 3
Glaser BM, Michels RG, Kuppermann BD, Sjaarda RN, Pena RA. Transforming growth factor-beta 2 for the treatment of full-thickness macular holes. A prospective randomized study. Ophthalmology 1992;99:1162-73.  Back to cited text no. 4
Christensen UC. Value of internal limiting membrane peeling in surgery for idiopathic macular hole and the correlation between function and retinal morphology. Acta Ophthalmol 2009;87 Thesis 2:1-23.  Back to cited text no. 5
D'Souza MJ, Chaudhary V, Devenyi R, Kertes PJ, Lam WC. Re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel. Br J Ophthalmol 2011;95:1564-7.  Back to cited text no. 6
Hillenkamp J, Kraus J, Framme C, Jackson TL, Roider J, Gabel VP, et al. Retreatment of full-thickness macular hole: Predictive value of optical coherence tomography. Br J Ophthalmol 2007;91:1445-9.  Back to cited text no. 7
Valldeperas X, Wong D. Is It Worth Reoperating on Macular Holes? Ophthalmology 2008;115:158-63.  Back to cited text no. 8
Brooks J, Logan H. Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology 2000;107:1939-49.  Back to cited text no. 9
Sheidow TG, Blinder KJ, Holekamp N, Joseph D, Shah G, Grand MG, et al. Outcome results in macular hole surgery: An evaluation of internal limiting membrane peeling with and without indocyanine green. Ophthalmology 2003;110:1697-701.  Back to cited text no. 10
Kusuhara S, Negi A. Predicting Visual Outcome following Surgery for Idiopathic Macular Holes. Ophthalmologica 2014;231:125-32.  Back to cited text no. 11
Schubert HD, Kuang K, Kang F, Head MW, Fischbarg J. Macular holes: Migratory gaps and vitreous as obstacles to glial closure. Graefes Arch Clin Exp Ophthalmol 1997;235:523-9.  Back to cited text no. 12
Berger JW, Brucker AJ. The magnitude of the bubble buoyant pressure: Implications for macular hole surgery. Retina 1998;18:84-6.  Back to cited text no. 13
Willis AW, Jesus F. Garcia-Cosio - Comparison of Longstanding versus Recent Macular Holes Ophthalmology 1996;103:1811-4.  Back to cited text no. 14
Scott RA, Ezra E, West JF, Gregor ZJ. Visual and anatomical results of surgery for longstanding macular holes. Br J Ophthalmol 2000;84:150-3.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2.1], [Table 2.2], [Table 2.3], [Table 3]

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