OSLI Retina

June 2019

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June 2019 ยท Vol. 50, No. 6 401 The Cutting Edge Edited by Yoshihiro Yonekawa, MD, and Peter H. Tang, MD, PhD In this article, the authors present a beautiful video showing a modified technique for autolo- gous inner limiting membrane (ILM) transposi- tion to close a persistent macular hole (MH) us- ing a double layer of viscoelastic material. When performing autologous ILM transposi- tion, the process of securing the ILM free flap (as opposed to an ILM hinged flap) to the MH can be chal- lenging. The free flap can of- ten destabilize and float away. Although several techniques utilizing viscoelastics or per- fluorocarbon liquids have been reported, these typically require the ILM free flap to be embedded within the MH for stability. This often induces gliosis, which can hinder the recovery of the outer retinal layers and be detri- mental to recovery of visual acuity. Therefore, it would be preferable to "cover" the MH, similar to how a hinged ILM flap would sit above the MH, as opposed to "stuffing" it with ILM like previous techniques. This video presents just such a technique, and subfoveal gliosis of the MH was not observed on the postoperative opti- cal coherence tomography. Furthermore, the use of a dispersive, rather than cohesive, viscoelastic material is key to the success of this technique. Dispersive visco- elastics have low molecular weights and short- chained sodium hyaluronate, allowing it to even- ly and flatly distribute along the surface of the retina when applied. This property allows it to maintain and spread the free flap evenly over the MH. Covering the free flap with a second layer of viscoelastic material minimizes the chances for it to dislocate during the fluid-air exchange. Further studies are needed to determine the success rate of this procedure and the visual prognosis over a longer follow-up period. Yuki Morizane, MD, PhD Associate Professor of Ophthalmology Okayama University Yuki Morizane, MD, PhD Internal Limiting Membrane Transposition for Persistent Macular Holes Using Double Layers of Viscoelastic Mohamed Kamel Soliman, MD; Alexander J. Lingley, MSc; Raman Tuli, MD, FRCS(c) ABSTRACT: Internal limiting membrane (ILM) graft- ing provides a useful option for repair of large and refractory macular holes that fail to close follow- ing prior ILM removal. However, current ILM graft techniques are associated with several challenges that may result in failure, most notably the difficulty in maintaining the graft in situ. In this video, the authors describe their modified technique for ILM grafting using a double layer of viscoelastic for sta- bilization in situ during the procedure. Four of five eyes managed with this technique demonstrated type 1 closure, and all eyes demonstrated improve- ment in visual acuity. Closure of macular holes (MHs) that persist follow- ing unsuccessful pars plana vitrectomy (PPV) with in- ternal limiting membrane (ILM) peeling represents a therapeutic challenge. Several factors may contribute to failure of primary repair, including the tendency of refractory holes to be large and long-standing, as well as the persistence of postoperative tangential surface traction by residual ILM or epiretinal membranes (ERMs) around the margin of the hole. 1,2 Recently, several approaches have been proposed to overcome the challenge of persistent MHs, includ- ing grafting autologous ILM. Once translocated, ILM grafts act as a physical barrier that prevents fluid en-

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