Surgical management of macular holes: techniques, outcomes, and treatment of special cases

ABSTRACT

Introduction

Full-thickness macular hole is a visually significant condition with a very high surgical anatomical closure rate.

Areas covered

A literature review was performed focusing on surgical techniques for macular holes. What is known about the underlying anatomy and pathophysiology of macular hole formation is applied to surgical techniques that address the mechanisms for hole closure.

Expert opinion

While anatomic and functional success can be achieved at high rates, much is yet to be learned about the molecular and microstructural changes resulting from surgical manipulation. These insights will help guide novel techniques for complex cases which still suffer from suboptimal surgical outcomes.

KEYWORDS:

• Autologous retinal graft
• human amniotic membrane graft
• ILM flap
• ILM peel
• macular hole
• pars plana vitrectomy

Article highlights

• For idiopathic macular holes (MH) less than 400 µm in diameter, vitrectomy plus gas tamponade with or without internal limiting membrane (ILM) peel/flap or face-down positioning (FDP) achieves high rates of anatomic closure and significant improvement in visual acuity.

• In holes larger than 400 µm, adding ILM peel or inverted ILM flap plus at least 5 days of FDP increased the chance of achieving >90% primary hole closure rates.

• For idiopathic MH, an inverted ILM flap is likely superior to an ILM peel.

• Traumatic MH is more likely than idiopathic MH to close spontaneously, particularly smaller holes in younger patients.

• Myopic MH has the highest operative failure rates and can be associated with concurrent foveoschisis and retinal detachment.

• Advanced techniques to induce hole closure can be helpful in complicated macular holes.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., NYC, NY, and Foley Research Fund, New York, NY.