Persistent Macular Holes after Vitrectomy Combined With Routine Peeling of the Internal Limiting Membrane (ILM)

Lochan S Bellamkonda, 1 Kamal Kishore1,2 1 2

Illinois Retina Institute, Peoria, IL; Department of Surgery-Ophthalmology, UI College of Med-Peoria Campus, Peoria, IL;
312-B0290

Purpose Results Conclusion

Modern vitrectomy surgery with routine peeling of ILM is
highly successful in the management of idiopathic macular
holes. While smaller (<400 microns) holes of <6 months
duration have higher closure rate,1 successful closure has
been obtained in very large2 and chronic holes.3 The purpose
of our study is to analyze preoperative and intraoperative
factors that might predict failure, and to report outcomes of
repeat surgery for holes that failed to close after initial surgery.
Methods
A retrospective chart review of 152 eyes of 143
consecutive patients undergoing vitrectomy with ILM peel
surgery for idiopathic full-thickness macular holes between
April, 2003 and June, 2013 by a single surgeon was
conducted. Intraocular tamponade consisted of 25% SF6 or
18% C3F8 at surgeons discretion. Six eyes failed to close
after initial surgery. Patients' age, hole size, duration of
symptoms, lens status, gas tamponade, preop visual acuity
(VA) were analyzed to investigate predictive factors for
persistence. Minimum diameter of the hole on a raster scan
through the center of fovea (Figure 1) was used as diameter
of the hole.4 Diameter of the hole was measured on color
fundus photographs with OIS software for patients where
OCT was not available. Face-down (FD), or eye-down (ED)
positioning for one (SF6) to two (C3F8) wks was utilized
during initial surgery. Repeat surgery, after a mean of 6
(range 3-10) wks, consisted of ILM peeling over a wide area,
almost to the arcade, and 18% C3F8 tamponade followed by
Table 1: Comparison of Two Groups 1. Very high success rate of initial surgery
2. Unable to predict preoperative factors for failure
3. Intraoperative factors (gas tamponade, area of ILM peel)
were not controlled, but were not significant.
4. Repeat surgery was successful in closing all holes.
5. Patients with initially successful surgery tended to have better
final postoperative VA (p=0.07)
Case 3: The hole is essentially unchanged after first surgery (left). Successful
closure after repeat surgery (right) 6. Perhaps, FD position immediately after surgery encourages
hole closure. Success of repeat surgery might be due to
improved compliance with FD or ED positioning.
Table 2 Bibliography
1. Tognetto D, Grandin R, Sanguinetti G, et al. Macular Hole Surgery Study
Summary of Failed MH Surgery Patients Group. Internal limiting membrane removal during macular hole surgery:
Results of A Multicenter Retrospective Study. Ophthalmology
2006;113:1401-10
2. Wu DM, Fawzi AA, Recasens MA, et al. Good visual outcome after repair
of a very large macular hole with neurosensory retinal operculum. Retinal
Cases and Brief Reports 2014; 8:138-40
3. Stec LA, Ross RD, Williams GA, et al. Vitrectomy for chronic macular
holes. Retina. 2004; 24:341-7.
4. Ruiz-Moreno JM, Staicu C, Piero DP, et al. Optical coherence
Case 4: Large macular hole. Preop fundus photo (left) and OCT (right)
tomography predictive factors for macular hole surgery outcome. Br J
Ophthalmol. 2008;92:640-4
5. 18441174.
6. Schulze-Bonsel K, Feltgen N, Burau H, et al. Visual acuities "hand motion"
Scatter Plot of Preop
and Final Postop VA
and "counting fingers" can be quantified with the Freiburg visual acuity
test. Invest Ophthalmol Vis Sci 2006;47:1236-1240
2

2 wks of FD or ED positioning. For ED positioning, patients

Final Postop VA (LogMAR)

1.5

were advised to read or perform fine visual task such as 1

watching a movie gazing at a book or electronic device 0.5

placed horizontally at or below their chest level. They were

0
also advised to take 10 minutes break every hr. Diluted (1:10) 0 0.5 1 1.5
Preop VA (LogMAR)
2

triamcinolone acetonide was used to help visualize ILM Financial Disclosures: None
during repeat surgery in 5/6 eyes, and in most cases during Contact Information: kishorekvn@comcast.net
primary surgery. Snellen VA was converted into LogMAR for
statistical analysis. VA of CF was assigned LogMAR value of Case 4: Persistent MH 9 weeks after surgery. fundus photo (left) and OCT (right)
1.6.5Two-sample t-test and Fisher Exact test were used for
statistical analysis. All eyes had >3 months follow up.

Figure 1: Hole diameter is minimum distance between hole edges on raster scan Case 3: Small MH (282 microns). Preop Fundus photo left and OCT right
through center of fovea
Case 4: Closed MH 15 months after repeat surgery. fundus photo (L) and OCT (R)