Long-Term Outcomes of Macular Hole Repair with Triamcinolone Acetonide Visualization

Abstract

Purpose: To evaluate the long-term anatomic and visual outcomes of macular hole (MH) repair utilizing triamcinolone acetonide (TA) visualization of the internal limiting membrane (ILM) treated at a tertiary care retina practice.

Methods: Retrospective chart review of eyes undergoing MH repair with ILM peel utilizing TA visualization followed by gas tamponade and facedown positioning between 2014 and 2020. Pre- and post-operative visual acuity (VA), IOP, and anatomic closure based on optical coherence tomography were documented.

Results: Seventy-eight eyes were followed for 2.3±0.2 years after primary repair with anatomic closure in 73 (94%) eyes at their final visit and excluding eyes with pathologic myopia, 97%, and for stage 2 and small MHs, 100%. In all eyes, VA significantly improved from 0.97±0.04 (Snellen: 20/187) to 0.66±0.06 (20/91) logMAR (p < 0.0001). There were 16 eyes with 4 years of follow-up, 10 (63%) eyes achieving a VA ≥20/30 at that follow-up visit. Stage 2 and 3 MHs had significantly greater improvements in VA than Stage 4 MHs, -0.46 ± 0.06 versus -0.11 ± 0.11 logMAR (p = 0.021). Of the 13 (17%) eyes with recurrent MHs, 6 (46%) had pathologic myopia and 8 (61.5%) had associated cystoid macular edema. Cataract progression was reported in 52 (96%) phakic eyes and 2 eyes required Ahmed valve placement for management of pre-existing glaucoma.

Conclusion: Long-term results of MH repair with TA for ILM visualization demonstrate that it is safe and effective. Visual acuity continued to improve throughout the follow-up. Pre-existing glaucoma may progress and recurrence is associated with pathologic myopia and macular edema.

Keywords: internal limiting membrane; macular hole; triamcinolone acetonide.

Figure 1

Optical coherence tomography image of an eye with a macular hole associated with pathologic myopia demonstrating characteristic findings. (A) Pre-operative macular scan oriented vertically from inferior to superior arcade reveals outward bulge of macula associated with posterior staphyloma. This vertical orientation can more clearly demonstrate these findings. Mirror artifact (arrow) is another commonly associated imaging feature in eyes with pathologic myopia. (B) Pre-operative macular scan oriented horizontally (temporal to nasal) demonstrates less pronounced outward bulge and full-thickness macular hole. Post-operative images from (C) 3-months and (D) 2-years showing closed macular hole.

Figure 2

Change in best-corrected visual acuity (BCVA) compared to baseline over time. Negative values indicate a decrease in logMAR which represents improved BCVA. Number of eyes included at each follow-up visit noted next to each data point. Error bars demonstrate 95% confidence intervals.

Figure 3

The mean best-corrected visual acuity pre-operatively and at final visit for acute and chronic macular holes. Acute was defined as presenting within 6 months of symptom onset and chronic presented beyond 6 months of symptom onset. Error bars represent standard error of means and (*) indicates statistically significant data (p < 0.05).

Figure 4

The mean best-corrected visual acuity pre-operatively and at final visit based on stage of macular hole. Error bars represent standard error of means and (*) indicates statistically significant data (p < 0.05).

Figure 5

The mean best-corrected visual acuity pre-operatively and at final visit based on size of macular hole on optical coherence tomography (small <250 microns, medium 250 to 400 microns, large >400 microns). Error bars represent standard error of means and (*) indicates statistically significant data (p < 0.05).

Figure 6

In eyes without pathologic myopia, (A) single surgery closure rates and (B) final closure rates stratified by duration of symptoms, stage of macular hole and size of macular hole. The single surgery closure was defined as successful macular hole closure after one intervention while final closure was defined by macular hole closure at the final follow-up visit independent of number of interventions. (*) indicates statistically significant data (p < 0.05).