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      Delayed Macular Hole Closure

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          Abstract

          Purpose: The presented case raises questions regarding the favorable scheduling of planned postoperative care and the ideal observation interval to decide for reoperations in macular hole surgery. Furthermore a discussion about the use of short- and long-acting gas tamponades in macular hole surgery is encouraged. Methods: We present an interventional case report and a short review of the pertinent literature. Results: We report a case of spontaneous delayed macular hole closure after vitreoretinal surgery had been performed initially without the expected success. A 73-year-old male Caucasian patient presented at our clinic with a stage 2 macular hole in his left eye. He underwent 23-gauge pars plana vitrectomy and internal limiting membrane peeling with a 20% C<sub>2</sub>F<sub>6</sub>-gas tamponade. Sixteen days after the procedure, an OCT scan revealed a persistent stage 2 macular hole, and the patient was scheduled for reoperation. Surprisingly, at the date of planned surgery, which was another 11 days later, the macular hole had resolved spontaneously without any further intervention. Conclusions: So far no common opinion exists regarding the use of short- or long-acting gas in macular hole surgery. Our case of delayed macular hole closure after complete resorption of the gas tamponade raises questions about the need and duration of strict prone positioning after surgery. Furthermore short-acting gas might be as efficient as long-acting gas. We suggest to wait with a second intervention at least 4 weeks after the initial surgery, since a delayed macular hole closure is possible.

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          Most cited references 6

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          Vitreous surgery for idiopathic macular holes. Results of a pilot study.

          Idiopathic macular holes are generally considered an untreatable condition. We used modern vitrectomy techniques to evaluate two questions: (1) Is it possible to reattach the retina around the macular hole? (2) If it is reattached, will the patient's central vision improve? In 30 (58%) of 52 patients, we were able to reattach successfully the detached macula with our surgical procedure. In 22 (73%) of the 30 patients in whom the macula was successfully reattached, there was an improvement in visual acuity of two lines or better. In the 22 patients in whom reattachment of the macular hole was not obtained, there was no significant improvement in visual acuity. Thus, the overall success rate for improved vision postoperatively was 42% (22/52). Complications related to surgery were observed in eight patients (15%) early in our experience with this procedure and included increase in the size of the macular hole, mottling of the retinal pigmented epithelium, and a vascular occlusion. Our clinical observations indicate that the treatment of macular holes by vitrectomy may offer some promise for this otherwise untreatable condition. In patients in whom reattachment was successful, the technique used appeared to allow for clinically significant improvements in visual acuity. However, additional work on increasing surgical success and minimizing surgical complications, as well as a further understanding of the mechanism of retinal reattachment, is required before widespread use of this procedure for treating macular holes.
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            Vitreous Surgery for Idiopathic Macular Holes

             Neil E. Kelly (1991)
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              Re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel

              Background/aims A retrospective consecutive case series to evaluate the efficacy of re-operation in patients with persistent or recurrent idiopathic full-thickness macular hole after initial surgery with internal limiting membrane peel (ILM). Methods 491 patients underwent surgery for full-thickness macular hole from January 2004 to November 2007. Fifty-five patients either did not close or reopened during the follow-up period. Thirty patients with initial ILM peel underwent repeat surgery involving vitrectomy, enlargement of ILM rhexis and gas tamponade. Results Anatomical closure rate was 88.8% for primary surgery and 46.7% (14/30) for re-operation. There was a statistically significant improvement in overall best corrected visual acuity (BCVA) from re-operation baseline BCVA (p=0.02) within 1 year. For holes that did not close after the second surgery, visual acuity did not worsen. Conclusion Re-operation has a reduced success rate of anatomical closure. However, BCVA is statistically significantly improved from re-operation baseline, so even though we cannot return vision to pre-pathological baseline, re-operation can improve on this new baseline.
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                Author and article information

                Journal
                COP
                COP
                10.1159/issn.1663-2699
                Case Reports in Ophthalmology
                S. Karger AG
                1663-2699
                2014
                January – April 2014
                10 April 2014
                : 5
                : 1
                : 121-124
                Affiliations
                Herzog Carl Theodor Eye Clinic, Munich, Germany
                Author notes
                *Peter Distelmaier, MD, Herzog Carl Theodor Eye Clinic, Nymphenburger Strasse 43, DE-80335 Munich (Germany), E-Mail distelmaier_peter@web.de
                Article
                362401 PMC4025162 Case Rep Ophthalmol 2014;5:121-124
                10.1159/000362401
                PMC4025162
                24847257
                © 2014 S. Karger AG, Basel

                Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) ( http://www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Pages: 4
                Categories
                Published: April 2014

                Vision sciences, Ophthalmology & Optometry, Pathology

                Macular hole, Vitrectomy, Gas tamponade

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