Internal Limiting Membrane Peeling and Gas Tamponade For Full-Thickness Macular Holes of Different Etiology - Is It Still Relevant?

Abstract

Background: Despite the abundance of novel surgical approaches proposed for full thickness macular hole (FTMH) treatment, the choice of the optimal technique remains debatable Vitrectomy with «classic» internal limiting membrane peeling and gas tamponade remains the standard of FTMH surgery in many cases, but there are still very limited recent publications on the outcomes of such surgery.

Purpose: To investigate the anatomical and functional result and to analyze the significance of outcome-related risk factors of the classic 25-gauge pars plana vitrectomy (PPV) with ILM peeling and gas tamponade (GT) for treatment of FTMH of different etiology.

Patients and methods: Thirty-eight eyes of thirty-seven patients with FTMH who underwent 25-gauge PPV, ILM peeling and GT were recruited for this retrospective, consecutive, interventional study. Four eyes with persistent holes underwent a re-operation. Outcome-related factors were discussed.

Results: The primary closure rate was 89.5% (34/38). All eyes that underwent the repeated surgery (4 cases) obtained final closure. A hole size of >500 μm has a statistically significant effect on the primary macular hole closure (F = 0.048; φ = 0.38; p ˂ 0.05). In the general group (N = 38), the duration of symptoms directly correlated with age (ρ = 0.34; p = 0.04), size of the hole (ρ = 0.66; p ˂ 0.001) and BCVA before surgery (ρ = 0.59; p ˂ 0.001), after 1 month (ρ = 0.36; p = 0.03), and after 3 months (ρ = 0.35; p = 0.03). Preoperative BCVA was better in initially closed cases (Group 1) (U = 26.0; p = 0.05). In the Group 2 with primary unclosed holes, 75% of the eyes (3/4) had an axial length (AL) >26 mm, while in Group 1 such eyes were 12.5 times less (2/34) 5.9% (F = 0.004; φ = 0.63; р ˂ 0.01). The ELM recovery rate at 3 months was 92% (35/38 eyes) and the restoration of EZ at 3 months was 47% (18/38 eyes). Best-corrected visual acuity of all individuals improved significantly from 0.72 ± 0.35 (logMAR) (Me = 0.7; IQR: 0.5-0.8) to 0.25±0.14 (logMAR) (Me = 0.2; IQR: 0.2 - 0.3) at 1 month and 0.17 ± 0.13 (logMAR) (Me = 0.2; IQR: 0.1 - 0.2) at 3 months after surgery (P = 0.0001).

Conclusion: 25G PPV with ILM and GT for FTMH of different etiology provide satisfactory morphologic and functional outcomes. Elongated AL, large diameter of MH and long duration of symptoms are the risk factors for initial closure. Proper second surgery can obtain satisfactory outcomes for persistent holes.

Keywords: full-thickness macular hole; gas tamponade; internal limiting membrane peeling; macular hole closure; pars plana vitrectomy; restoration of ELM/EZ.

Figure 1

Case: 3 (A) 56-year-old woman with idiopathic large MH was treated with conventional PPV and ILM peeling. Her preoperative minimum MH diameter was 633 μm, the axial length was 22.4 mm and the BCVA was 0.3 decimal (A). One day after surgery, the edges of the macular hole were not in contact with each other (red arrow), therefore a face down position was recommended for two more days (B). On the third day closure of the MH was confirmed with OCT (green arrow), but the ELM line and the EZ line were still noticeably interrupted (C). Face down position was discontinued. One month after surgery, the BCVA was 0.4 decimal, the ELM line was partially restored and the EZ line was disrupted (long distance between two white arrows). Multiple intraretinal hyperreflective areas were seen on OCT as well (yellow arrow) (D). Three months postoperatively, the BCVA improved to 0.6 decimal. The ELM line was completely restored but the EZ line was still disrupted although the size of the defect has significantly decreased (between two white arrows) (E). Six months after the surgery both the ELM and the EZ lines were completely restored. The BCVA was 0.9 decimal (F). Microperimetry (SLO) has shown that there was no scotoma within fovel area (G).

Figure 2

Case 4: (A) 60-year-old woman with idiopathic large MH was treated with conventional PPV and ILM peeling. Her preoperative minimum MH diameter was 461 μm, the axial length was 23.6 mm and the BCVA was 0.1 decimal (A). Two weeks after the surgery, the MH was closed and the BCVA increased to 0.3 decimal. The ELM line was restored, but the EZ line was noticeably interrupted (yellow arrow) (B). One month after the surgery, the BCVA was 0.5 decimal and the EZ line was almost completely restored (C). Three months postoperatively, the decimal BCVA improved to 0.9 decimal. The ELM line and the EZ line were completely restored (D). Microperimetry (SLO) was performed at 3 months period and showed neither paracentral scotoma nor reduced central retinal sensitivity after ILM peeling in foveal area (E).

Figure 3

Case 5: (A) 58-year-old woman with idiopathic large MH was treated with conventional ILM peeling. Her preoperative minimum MH diameter was 404 μm, the axial length was 23.1 mm and the BCVA was 0.2 decimal (A). One day after surgery, the MH was closed, but the ELM line and the EZ line was noticeably interrupted (yellow arrow) (B). One month after surgery, the BCVA was 0.6 decimal, the ELM line and the EZ line were completely restored (C). Three months postoperatively, the decimal BCVA improved to 0.9 decimal (D).