OSLI Retina

July 2020

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July 2020 · Vol. 51, No. 7 375 Practical Retina Incorporating current trials and technology into clinical practice Approaches to Refractory or Large Macular Holes by Ajay E. Kuriyan, MD, MS; and Claire E. Fraser, MD, PhD There is no uncertainty that advances in vitreoretinal surgical techniques have allowed for high rates of sur- gical success after macular hole (MH) surgery. Therefore, a less-than-perfect outcome can be particularly dis- heartening for the surgeon. Less-than- perfect outcomes are more frequent- ly seen in patients who present with larger holes or those who have failed macular surgery in the past. I have asked Ajay E. Kuriyan, MD, MS, and Claire E. Fraser, MD, PhD, to discuss their thoughts and experi- ence regarding approaches to refrac- tory or large MHs. They will discuss risk factors for unsuccessful surgery and various techniques reported in the literature to address this situa- tion that many of us have faced who perform MH surgery. This clearly is an evolving landscape, and an added challenge is that no one technique has been proven to be superior to another. I am certain that their insights will be very valuable, as it will provide several options for surgeons dealing with MH patients at high risk for fail- ing traditional methods. Macular holes (MHs) can cause a sudden change in vision and central scotomas. 1 The prevalence of MHs range from 0.02% to 0.8%. 1-6 Surgical repair often includes a pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and gas tamponade. Overall, MH surgery is very successful, with reported closure rates of 90% or greater. 7,8 Risk factors for unsuccessful surgery include not peeling ILM, large size, chronicity, trauma, previous unsuccessful MH surgery (refractory MHs), concurrent retinal detachment, and myopic MHs. 7,9 Several techniques have been utilized to improve MH surgery success, especially in cases with the previously listed risk fac- tors. This review outlines some of these ap- proaches, including additional conventional surgical methods (broader ILM peeling and repeat fluid-gas exchange), MH scaffolds (inverted ILM, ILM free, posterior capsule flaps), increasing retinal tissue compliance (retinal incisions, macular detachment), use of growth factors/cytokines to aid healing (macular laser and placement of adjuvant agents into the MH), tissue replacement (autologous neurosensory retinal transplant), and pre- and subretinal amniotic membrane (AM) placement in the MH to act as both a scaffold and release growth factors/cytokines to promote healing. ADDITIONAL CONVENTIONAL SURGICAL METHODS For refractory MHs, simply widening the previous ILM peel may help further relieve the tangential traction on the MH and yield subsequent closure in 47% to 69% of cases (Figure 1). 10,11 Of note, one study found limited visual improvement even with anatomic improvement. 10 Repeat fluid-gas exchange performed in clinic for refractory or reopened MHs yielded a 74% to 89% closure rate and improved vision. 12,13 MH SCAFFOLDS Scaffolds for Müller cell and tissue proliferation within the MH have been proposed as a method to aid the closure of MHs. There are several approaches for this, including the in- verted ILM, ILM free, and lens capsule flap techniques. In ad- Claire E. Fraser Ajay E. Kuriyan doi: 10.3928/23258160-20200702-02 Seenu M. Hariprasad Practical Retina Co-Editor

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