OSLI Retina

July 2019

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450 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ T E C H N I Q U E ■ A Technique for Closing Challenging Macular Holes Robert A. Sisk, MD, FACS BACKGROUND AND OBJECTIVE: To describe a new technique for closing challenging macular holes (MHs). PATIENTS AND METHODS: The technique involves vitrectomy with internal limiting membrane (ILM) peeling, isolating the macula under perfluorocar- bon liquid, alternating scraping of the retina toward the MH, aspirating fluid from the MH until closure is achieved intraoperatively, and sealing the MH with an inverted ILM flap or autologous ILM free flap. Gas or oil tamponade is used to prevent rehy- dration of the MH. RESULTS: Covering the MH with ILM scaffolding by the inverted flap technique or autologous ILM free flap promoted closure of large MHs by photoreceptor layer migration rather than gliosis. Iatrogenic macu- lar trauma from manipulation produced funduscopic and optical coherence tomography changes but did not preclude significant vision improvement. CONCLUSIONS: ILM scaffolding over the surgically reduced MH enhanced surgical closure by photo- receptor migration. Although anatomic success resulted in improvement in visual acuity, further study is required regarding long-term outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:450-452.] INTRODUCTION Despite generally high surgical success rates, a minority of full-thickness macular holes (MHs) remain challenging to close. Recent analysis sup- ports the covering or filling of larger MHs with in- ternal limiting membrane (ILM) scaffolding to fa- cilitate closure and improve visual and anatomic outcomes. 1 In one recent series, drainage of fluid from the MH by subretinal cannula produced supe- rior vision outcomes compared to the inverted flap technique. 2 In this modified technique, we utilize the advantages of both techniques. This technique is not recommended as the primary procedure for small or medium-sized idiopathic macular holes. TECHNIQUE After pars plana vitrectomy (PPV), the ILM is stained with indocyanine green (ICG) diluted in 20 mL 5% dextrose solution for 15 seconds to pro- vide an intense green stain. The ILM is peeled with temporal sparing, and then perfluorocarbon liquid (PFCL) tamponade isolates the aqueous phase with- in the MH. A membrane scraper centripetally mi- grates subretinal fluid (SRF) and retinal tissue from the peripheral macula gradually toward the MH, taking advantage of retinal elasticity. 3 Scraping is avoided over the papillomacular bundle. Fluid is drained from the MH under PFCL with a subreti- nal cannula (38-gauge outer diameter polyimide tip) to produce a progressively more elliptical and, ultimately, slit-like configuration of the MH. The From the Cincinnati Eye Institute, Cincinnati; the Department of Ophthalmology, University of Cincinnati, Cincinnati; and the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, Cincinnati. Originally submitted August 6, 2018. Revision received November 9, 2018. Accepted for publication January 17, 2019. This technique was presented at the 6th Annual Vit-Buckle Society Meeting in Miami on March 23, 2018. Dr. Sisk reports no relevant financial disclosures. Address correspondence to Robert A. Sisk, MD, Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242; email: rsisk@cincinnatieye.com. doi: 10.3928/23258160-20190703-07

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