The treatment of macular holes has evolved greatly since the initial surgical management proposed by Wendell and colleagues. Now routinely surgeons can achieve between a 80-95% closure rate routinely with pars plana vitrectomy and internal limiting membrane (ILM) peeling with gas tamponade. In particular, large macular holes (defined as greater than 600-650 microns), myopic macular holes and retinal detachments associated with macular holes were all associated with poorer visual outcome and lower macular hole closure rates. This has led to modification of conventional macular hole surgery, such as inverted ILM flap technique, autologous retinal transplantation, and the use of amniotic membrane for hole closure.
There are two types of macular hole closure. In type 1 closure, the macular hole is closed without a neurosensory defect. In type 2 closure, the macular hole is open with the neurosensory defect. The type of closure has a direct relationship with visual acuity improvements following surgical repair. In this initial study by Kang and colleagues in 2002, they demonstrated this correlation.
A more recent innovation in addressing chronic or recurrent holes is the transplantation of autologous retinal tissue to cover the neurosensory defect in essence inducing a type 1 closure. A recent publication in the journal of Ophthalmology of 130 cases with 33 surgeons found 89% of macular holes closed with a 95% closure rate in MH-RRD. Visual acuity improved by at least 3 lines in 43% of eyes and at least 5 lines in 29%.
When considering this procedure for the first time, there were many diverging opinions on how the surgery should be performed. Should we place PFO for tamponade and remove it two weeks later or perform a direct PFO to oil exchange? Should we peel ILM? Where and how large should the graft site be? How best to harvest the graft? Watch my video below to see how this case turned out. We also used intraoperative OCT to confirm the location of the graft after placement.