INTERNAL LIMITING MEMBRANE PEELING AND AIR TAMPONADE FOR STAGE III AND STAGE IV IDIOPATHIC MACULAR HOLE

To compare results of surgery for idiopathic macular hole with and without internal limiting membrane (ILM) peeling in a series of consecutive patients over a 5-year period. A retrospective, nonrandomized, comparative trial with concurrent control group. Forty-four eyes with macular holes of less than or equal to 6 months duration without ILM peeling were compared to 116 eyes with ILM peeling and the same hole duration. A third group of 65 eyes with ILM peeling and duration greater than 6 months was also evaluated. All eyes underwent pars plana vitrectomy with or without ILM peeling, intravitreous gas, and positioning face down. No adjunctive therapies were used in any group. Comparing the closure and/or reopening rate, prognosis, visual acuity, and complications for macular holes with and without ILM peeling. All patients had postsurgical follow-up of 18 months or greater. Primary closure was significantly improved with ILM peeling with 116 of 116 eyes (100%) showing no reopenings versus 36 of 44 holes (82%) primarily closed, 9 of which (25%) reopened without ILM peeling (P: < 0.00001) in holes less than or equal to 6 months. The 27 eyes without ILM peeling that had successful surgery displayed a mean postoperative vision of 20/40, which is the same as the successful eyes with ILM peeling (P: = 0.6). The 52 stage II eyes with ILM peeling had a mean postoperative vision of 20/30, and 48 of the 52 eyes (92%) were 20/40 or better. Stage III eyes (greater than 400-microm holes) without ILM peeling had a poor prognosis, with 6 of the 25 eyes (24%) having initial surgery fail and an additional 4 of 25 eyes (16%) reopening. Without ILM peeling, holes less than 300 microm had only one reopen, whereas holes greater than or equal to 300 microm had 16 of the 17 (94%) primary failures and/or reopenings (P: < 0.001). All 12 holes that reopened and/or primarily failed were repaired with ILM peeling with excellent visual recovery. Macular holes with a duration greater than 6 months were treated with ILM peeling, and 63 of 65 holes (97%) were closed primarily and 65% had an increase in vision by two or more Snellen lines. ILM peeling significantly improves visual and anatomic success in all stages of recent and chronic macular holes and reopened and failed holes, while eliminating reopening for holes greater than 300 microm.

To evaluate the clinical significance of macular hole closure types assessed by optical coherence tomography (OCT). This study involved 34 eyes of 32 patients who had undergone anatomically successful idiopathic macular hole surgery. The closed macular holes were categorised into two patterns based on OCT; type 1 closure (closed without foveal neurosensory retinal defect) and type 2 closure (closed with foveal neurosensory retinal defect). Association between visual prognosis, type of hole closure, and possible prognostic factors were analysed. 19 eyes (61.3%) were classified into the type 1 closure and 12 eyes (38.7%) into the type 2 closure. The extent of postoperative visual improvement of type 1 closure group was larger than that of type 2 closure group (p=0.002). The preoperative macular hole size of type 2 closure group was significantly larger than that of type 1 closure group (p=0.006). The duration of symptoms was positively correlated with the preoperative macular hole size (p=0.01). Recurrence of macular hole occurred only in the type 2 closure group. The type of macular hole closure, which was influenced by the preoperative hole diameter, was associated with postoperative visual prognosis. Early detection and intervention in macular hole should be emphasised.

To examine the results of macular hole surgery using pars plana vitrectomy, internal-limiting membrane peeling, and intravitreous air in a series of consecutive patients. A retrospective, interventional, noncomparative case series. Fifty consecutive patients (58 eyes) with full-thickness macular holes. All eyes underwent a pars plana vitrectomy with internal-limiting membrane peeling and intravitreous air, and patients were asked to position face-down for only 4 days. Status of macular holes, visual acuity, and associated findings and complications. All patients had postsurgical follow-up of 6 months or greater. Eight eyes (14%) presented with stage-2 macular holes, 48 eyes (83%) with stage-3 macular holes, and 2 eyes (3%) with stage-4 macular holes. Only 26 eyes (45%) had a macular epiretinal membrane seen before surgery. Fifty-three (91 %) of the 58 macular holes were closed with 1 operation, and 55 (95%) had closure of the macular holes with subsequent operations. Five (9%) of 58 eyes had an initial visual acuity of 20/50 or better, and 31 eyes (53%) had a final visual acuity of 20/50 or better. Of the 45 eyes with symptoms of less than 6 months' duration, 44 (98%) had macular holes that were closed with 1 operation and 27 (60%) had a final visual acuity of 20/50 or better. Of the 13 eyes with symptoms of 6 months' duration or longer, 9 (69%) had macular holes that were closed with 1 operation and 4 (31 %) had a final visual acuity of 20/50 or better. Complications attributed to the operation included retinal tears, retinal detachments, postoperative macular puckers, and macular light toxicity. The anatomic and visual results in this series are good. The current technique is similar to that of conventional macular hole surgery except for the use of intravitreous air, internal-limiting membrane peeling in all eyes, and only 4 days of postoperative positioning. This study would suggest that peeling of the internal-limiting membrane is an important adjuvant for successful closure of macular holes.