OSLI Retina

June 2016

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Practical Retina June 2016 · Vol. 47, No. 6 513 This involves harvesting an autologous neurosen- sory retinal free flap and positioning it over the re- fractory MH to provide a scaffold and plug for hole closure. Endolaser barricade was applied in a circular manner around a 2-disc diameter area of neurosenso- ry retina harvest site superior to the superotemporal arcade, followed by endodiathermy to blood vessels at the site edges. Using a bimanual approach under chandelier illumination, the edge of the graft was held using forceps and cut using vertical scissors. A retinal free flap was obtained and gently moved to- ward the MH. PFC was instilled over the retinal flap. Flap edges were gently flattened and it was stretched to lay flat and cover the entirety of the hole. Direct PFC-silicone oil exchange was performed followed by 1 week of face-down position. The patient, a –15-diopter myope, had undergone a PPV with ILM peel for MH 6 months prior that was complicated by a refractory MH and retinal detachment (RD) postoper- atively. She subsequently underwent a scleral buckle and PPV for RD repair with silicone oil endotampon- ade with a persistent 1,100 µm MH following oil re- moval. Following the autologous retinal flap, the MH closed, and vision improved from 1 logMAR to 0.6 logMAR, with reduction in the scotoma size and im- provement in microperimetry. CONCLUSION Newer surgical techniques summarized in this re- view greatly expand the surgeon's armamentarium in tackling challenging cases of myopic, recurrent, and large chronic MH that have traditionally had poor surgical anatomical and visual outcomes. Despite our lack of full understanding of the histological changes with these procedures, the greatly improved anatomi- cal and functional outcomes with all the techniques described are very promising. Advances in vitreoreti- nal surgical techniques will continue to permit fur- ther refinement of these techniques, reduce some of the technical challenges, and help shorten the learn- ing curve. REFERENCES 1. Brooks HL Jr. Macular hole surgery with and without internal lim- iting membrane peeling. Ophthalmology. 2000;107(10):1939-1948; discussion 1948-1939. 2. Shin MK, Park KH, Park SW, Byon IS, Lee JE. Perfluoro-n-octane- assisted single-layered inverted internal limiting membrane flap tech- nique for macular hole surgery. Retina. 2014;34(9):1905-1910. 3. Grewal DS, Reddy V, Mahmoud TH. Assessment of foveal micro- structure and foveal lucencies using optical coherence tomogra- phy radial scans following macular hole surgery. Am J Ophthalmol. 2015;160(5):990-999.e1. 4. Schneider EW, Todorich B, Kelly MP, Mahmoud TH. Effect of opti- cal coherence tomography scan pattern and density on the detection of full-thickness macular holes. Am J Ophthalmol. 2014;157(5):978- 984. 5. Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology. 2010;117(10):2018-2025. 6. Michalewska Z, Michalewski J, Dulczewska-Cichecka K, Adelman RA, Nawrocki J. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: A comparative study. Retina. 2015;35(9):1844-1850. 7. Andrew N, Chan WO, Tan M, Ebneter A, Gilhotra JS. Modifica- tion of the inverted internal limiting membrane flap technique for the treatment of chronic and large macular holes. Retina. 2016;36(4):834- 837. 8. Michalewska Z, Michalewski J, Dulczewska-Cichecka K, Nawrocki J. Inverted internal limiting membrane flap technique for surgical repair of myopic macular holes. Retina. 2014;34(4):664-669. 9. Kuriyama S, Hayashi H, Jingami Y, Kuramoto N, Akita J, Matsumo- to M. Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia. Am J Ophthalmol. 2013;156(1):125-131.e1. 10. Lai CC, Chen YP, Wang NK, et al. Vitrectomy with internal lim- iting membrane repositioning and autologous blood for macu- lar hole retinal detachment in highly myopic eyes. Ophthalmology. 2015;122(9):1889-1898. 11. Morizane Y, Shiraga F, Kimura S, et al. Autologous transplantation of the internal limiting membrane for refractory macular holes. Am J Ophthalmol. 2014;157(4):861-869.e1. 12. De Novelli FJ, Preti RC, Ribeiro Monteiro ML, Pelayes DE, Jun- queira Nobrega M, Takahashi WY. Autologous internal limiting membrane fragment transplantation for large, chronic, and refractory macular holes. Ophthalmic Res. 2015;55(1):45-52. 13. Chen SN, Yang CM. Lens capsular flap transplantation in the man- agement of refractory macular hole from multiple etiologies. Retina. 2016;36(1):163-170. 14. Grewal DS, Mahmoud TH. Autologous neurosensory retinal free flap for closure of refractory myopic macular holes. JAMA Ophthalmol. 2016;134(2):229-230. Dilraj S. Grewal, MD, can be reached at Duke Eye Center, 2351 Erwin Rd, Box 3802, Durham, NC 27710; email: dilraj@gmail.com. Howard F. Fine, MD, MHSc, can be reached at NJ Retina, 10 Plum Street, Suite 600, New Brunswick, NJ 08901; email: hffine@gmail.com. Tamer H. Mahmoud, MD, can be reached at Duke Eye Center, 2351 Erwin Rd, Box 3802, Durham, NC 27710; email: tamer.mahmoud@dm.duke.edu. Disclosures: Dr. Grewal has received funding from Heed Ophthalmic Foundation (San Francisco, CA) and Ronald G. Michels Fellowship Founda- tion (Riderwood, MD). Dr. Fine is a consultant for Allergan, Genentech, and Regeneron and has patent and equity interest in Auris Surgical Robotics. Dr. Mahmoud is on the advisory board for Alcon, Alimera, Allergan, and DORC.

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