Key words internal limiting membrane - rhegmatogenous retinal detachment - vitrectomy - macular
hole
Schlüsselwörter Vitrektomie - rhegmatogene Netzhautablösung - innere Grenzmembran - Makulaforamen
Introduction
A macular hole (MH) is an anatomical opening in the central fovea. It is a treatable
cause of central vision loss, more common in older adults, and may occur secondary
to myopia and trauma [1 ] – [5 ].
MH accompanying rhegmatogenous retinal detachment (MHRD) is a challenging condition,
with a prevalence varying from 2 to 8% [6 ], [7 ]. Even though the pathogenesis of MH in MHRD is different from other common causes
of MH such as pathological myopia and trauma, the formation mechanism of MH has not
been fully elucidated in these cases. MHRD may result from posterior vitreous detachment,
leading to peripheral tears. Another proposed hypothesis is related to tangential
retraction of the macula, which occurs in conditions such as vitreoretinal interface
abnormalities or proliferative vitreoretinopathy [6 ], [7 ], [8 ], [9 ].
Pars plana vitrectomy (PPV) is one of the standard treatments for MHRD. Tamponade
is necessary to reduce the fluid flow rate from open retinal tears that will cause
recurrent rhegmatogenous retinal detachment (RRD). The main buffering agents currently
available are various gases and silicone oils. Gases include air, sulfur hexafluoride
(SF6 ), hexafluoroethane (C2 F6 ), and perfluoropropane (C3 F8 ). The most significant advantage of gas tamponade is that the gas usually dissipates
spontaneously within a few weeks. Especially in eyes with proliferative vitreoretinopathy,
the permanent tamponade effect of silicone is a disadvantage for use [10 ].
However, in addition to the complexity of the formation mechanism of MHRD, surgical
management is also a challenging process. Trials and debates are still ongoing regarding
whether to perform internal limiting membrane (ILM) peeling, combining scleral buckling
with PPV, and using an exogenous extraocular tissue such as the amniotic membrane
lens capsular flap to close the hole [11 ], [12 ].
Although there are many different studies on this subject in the literature, the effect
of tamponade has not been evaluated. The aim of this study was to report the surgical
outcomes and observations of how intraocular tamponade affects the anatomic and functional
results of these complex cases.
Materials and Methods
This retrospective, cross-sectional, two-center case study included 29 eyes of 29
patients with MHRD who underwent 23-gauge PPV in the eye clinics of two tertiary-level
university hospitals between 2016 and 2021. The patients included were those with
an MH that was noted preoperatively, or which was detected during PPV to repair RRD.
Some patients had prolapsed RRD or media issues that obstructed the preoperative view
of the macula. Patients with at least one tear in the peripheral retina in addition
to the MH were included. The study exclusion criteria were defined as patients with
high myopic MHs with associated retinal detachment without peripheral retinal breakage,
diabetic retinopathy, trauma, or underlying hereditary or systemic diseases. An example
case is shown in [Fig. 1 ]. High myopia is defined as near-sightedness of ≥ − 6.00 diopters or axial length
> 26.5 mm.
Fig. 1 Preoperative OCT image of a patient with retinal detachment and macular hole (a ). OCT image of the same patient after silicone oil removal (b ).
Patients diagnosed with RRD underwent a detailed examination. If MH was detected preoperatively,
it was noted. Relevant clinical and surgical history information was collected. Best-corrected
visual acuity (BCVA), measured on the Snellen eye chart, was recorded before surgery
and at the final follow-up visit and these values were converted to logarithms of
minimum angle resolution (logMAR) acuities. All patients in the study underwent a
comprehensive ophthalmological examination, including slit lamp biomicroscopy, dilated
fundus examination, and spectral-domain optical coherence tomography (OCT) (Heidelberg
Spectralis, Heidelberg Engineering, Dossenheim, Germany and OCT-SLO, Optos, Dunfermline,
UK). The full thickness MH was defined using the OCT criteria in the International
Vitreomacular Traction Study [13 ]. The study was approved by the Haydarpasa Numune Training and Research Hospital,
Clinical Research Ethics Committee (2021/216 – 3405), and all
procedures complied with the principles of the Declaration of Helsinki. Informed consent
was waived due to the retrospective nature of this study.
After surgery, the patients were divided into two groups according to the type of
tamponade used. Patients using silicone oil were classified as Group 1, and patients
using C3 F8 gas as Group 2. Retinal attachment was defined as complete absorption of the subretinal
fluid and complete attachment of the neurosensory retina to the retinal pigment epithelium.
Successful MH closure was defined as the absence of neurosensory defects over the
fovea on OCT images (type 1 closure).
Data collected included preoperative BCVA, MH closure, intraocular tamponade, and
postoperative BCVA. The anatomic condition of both the peripheral retina and the macula
was documented postoperatively.
Surgery was performed using a standard 3-port, 23-gauge PPV by two surgeons (Y.O,
M. N. B.). Combined phaco-PPV was performed in the presence of a cataract. The primary
intent in all patients was to repair the RRD, but an attempt was also made to repair
the MH. Trocar cannulas of 23 g were placed 3.5 mm behind the limbus. All patients
underwent PPV and ILM peeling surgery. Intraoperatively, posterior hyaloid was completely
separated from the retina after core vitrectomy. Liquid perfluorocarbon was injected
to facilitate subretinal fluid drainage and safer peeling of the ILM. Brilliant blue
injection was applied to visualize the ILM in the macular region, and it was then
peeled off. PVR (proliferative vitreoretinopathy) membranes were also peeled if present.
Vitreous base cleanup was carefully completed. Fluid-air exchange was performed, and
then following retinal reattachment, endolaser was performed around the peripheral
tears. The air in the vitreous cavity was replaced with
16% C3 F8 or 1000 centistokes silicone oil. Patients were advised to stay prone for 1 week
after the surgery. The decision of postoperative tamponade was made according to the
clinical presentation of retinal detachment (RD). Silicone was preferred in patients
with RD or a break in the inferior quadrants, or RD due to a giant retinal tear, and
PVR gas was preferred if the break or RD area was localized superiorly, or the detachment
was shallow.
The study data were analyzed using SPSS, version 22.0, software (SPSS, Inc., Chicago,
IL, USA). Data distribution was analyzed with the Shapiro-Wilk test. Demographic variables
are expressed as count and percentage, whereas continuous variables are expressed
as a median value. In the comparisons of median values, the Mann–Whitney U test was
used. Changes in values from baseline to final follow-up were analyzed using the Wilcoxon
signed-rank test. Differences between the groups were compared with Fisherʼs exact
test. A value of p < 0.05 was considered statistically significant.
Results
Evaluation was made of 29 eyes of 29 patients with a median age of 61.6 years (range
33 – 80 years), in a male/female ratio of 18 : 11. The average follow-up was 9 months
(range: 3 – 17 months). Silicone oil was used as a tamponade in 17 (58.6%) patients,
and C3 F8 was used in 12 (41.4%; [Table 1 ]). RRD surgery was successful in 26 (89.7%) eyes and unsuccessful in 3 (10.3%) eyes
([Table 2 ]). The MH was closed in 22 (75.9%) eyes and not closed in 7 (24.1%) eyes. In the
assessments of the groups, retinal attachment showed a success rate of 15/17 (89.3%)
in Group 1, and 11/12 (91.7%) in Group 2 (p = 0.64). The MH closure rate was 12/17
(71.6%) in Group 1, and 10/12 (78.1%) in Group 2. The postoperative median BCVA increased
from 3 to 1 logMAR in Group 1 and from 3 to 0.76 logMAR in Group 2 (p < 0.001, p = 0.08,
respectively). Intraocular pressure (IOP) before and after surgery was similar in
both
groups (p = 0.41, p = 0.82, respectively; [Table 3 ]).
Table 1 Patient demographics and characteristics.
Variable
Data
Gender (M/F)
18 (62.1%)/11 (37.9%)
Age (median)
61.6
Hole closure (yes/no)
22 (75.9%)/7 (24.1%)
Retinal attachment (yes/no)
26 (89.7%)/3 (10.3%)
Tamponade (silicone oil/C3 F8 )
17 (58.6%)/12 (41.4%)
Table 2 Surgical success in patient groups.
Group 1
Group 2
P*
Fisherʼs exact test, *p < 0.05
Retinal attachment
Yes
15 (89.3%)
11 (91.7%)
0.64
No
2 (11.7%)
1 (8.3%)
Macular hole closure
Yes
12 (71.6%)
10 (78.1%)
0.52
No
5 (29.4%)
2 (16.6%)
Table 3 Comparison of median BCVA and IOP values before and after surgery within the groups.
Variable
Preoperative BCVA (logMAR; median [min-max])
Postoperative BCVA (logMAR; median [min-max])
P value
Wilcoxon signed-rank test, *p < 0.05, BCVA = best-corrected visual acuity, IOP = intraocular
pressure
Group 1
3 (0.7 – 3)
1 (0.2 – 3)
< 0.01*
Group 2
3 (2 – 3)
0.76 (0.3 – 3)
0.008*
Preoperative IOP (mmHg; median [min-max])
Postoperative IOP (mmHg; median [min-max])
Group 1
13 (10 – 19)
15 (12 – 16)
0.41
Group 2
15 (10 – 17)
14 (9 – 18)
0.82
No significant difference was determined between the groups in respect to preoperative
and postoperative BCVA, preoperative and postoperative IOP, and BCVA improvement (p = 0.77,
p = 0.16, p = 0.63, p = 0.54, p = 0.21, respectively; [Table 4 ]).
Table 4 The median values of the groups were analyzed using the Mann-Whitney U test.
Variable
Group 1 (n = 17) (logMAR; median [min-max])
Group 2 (n = 12) (logMAR; median [min-max])
P value
Mann-Whitney U test, *p < 0.05, BCVA = best-corrected visual acuity, IOP = intraocular
pressure
Preoperative BCVA
3 (0.7 – 3)
3 (2 – 3)
0.77
Postoperative BCVA
1 (0.2 – 3)
0.76 (0.3 – 3)
0.16
BCVA increment
1.14 (0.18 – 2.48)
2 (0.4 – 2.7)
0.21
Preoperative IOP (mmHg)
13 (10 – 19)
15 (12 – 16)
0.63
Postoperative IOP (mmHg)
15 (10 – 17)
14 (9 – 18)
0.54
Discussion
The complex process of the formation of MHRD and the two criteria (retinal attachment
and MH closure) on which success is based create various difficulties in applying
the optimal intervention and obtaining the intended anatomic and functional outcome
in this patient group when faced with the problem of MH. The results of this study
represent the surgical outcomes and the effects of two crucial postsurgical internal
tamponades, silicone oil and C3 F8 gas, on the visual and anatomic results. Surgery in patients with MHRD has two purposes.
The first goal is to restore the retinal attachment, and the second is to close the
MH. If only retinal attachment is achieved, postoperative vision will not improve
to the desired level. Therefore, successful MH closure must be ensured to improve
the subsequent visual acuity. In this series, retinal attachment was achieved in 89%
of Group 1 and 91% of Group 2, and MH closure in 71% of Group 1 and 78% of Group 2.
ILM peeling is a cornerstone for MH closure by completely removing all contractile
cells from the edge of the MH. Although the ILM does not have natural contractile
properties, it serves as a scaffold for the contractile tissue to exert tangential
traction on the umbo. The completeness of elimination of the overlying contractile
tissue when the ILM is peeled provides greater surgical success and higher contrast
sensitivity than in eyes without membrane peeling [14 ], [15 ]. In contrast, it was reported in a study by Shukla et al. that ILM peeling did not
result in higher closure rates of MH than in cases without ILM peeling, which have
better BCVA [16 ]. In that series, unlike the current study, Shukla et al. used silicon oil in 26
cases and C3 F8 gas in 5 cases. In addition, a 100% retinal attachment rate was reported, and all
patients underwent encircling scleral buckle,
unlike the current series. This minor difference in terms of the two series may be
related to the possible effect of the scleral buckle. Moreover, the authors advocated
type 2 closure as a successful closure in that study, and 8 (57%) of the 14 closed
holes in patients with ILM peeling had type 2 closure, whereas in patients without
ILM peeling, 3 (23.1%) of 13 closed holes had type 2 closure. The current study classified
only type 1 closure as an accurate and successful closure and achieved these rates.
Chen et al. [17 ] achieved 100% success in both retinal attachment and closure of the MH with a free
retinal flap assisted by liquid perfluorocarbon in their case series of 7 patients.
This method can be used in failed MH closure, although not in the first surgery. A
recent study conducted by Lyu et al. [18 ] compared the ILM flap and ILM insertion techniques on MH closure in 49 MHRD cases,
and the ILM flap was shown to be superior to the ILM insertion technique to improve
the postoperative BCVA. In that series, MH closure was observed in 95% of the ILM
flap group and 73% of the ILM insertion group, although 40 (82%) patients were high
myopic. In the current series, high myopic patients were excluded from the evaluation.
MH closure was obtained in 75.9% of the patients in this series by performing only
ILM peeling.
Ryan et al. [11 ] showed that ILM peeling increased the success of MH closure in MHRD cases and reported
MH closure at the rate of 90.7% in these cases, and at a rate of 33.3% in cases where
the ILM was not peeled (average 83.7%). Perfluorooctane was not used in those cases
due to the concern of transmission to the subretinal region due to MH and possible
toxicity of the dye. In the current study, brilliant blue and perfluorocarbon were
used in all cases and no associated problems were encountered. In the previous study,
SF6 was shown to be superior to C3 F8 in terms of success, but SF6 was not used as a postoperative tamponade in any patient of the current series.
Although modern surgical techniques are very advanced, ILM peeling from the detached
retina is challenging. Using liquid perfluorocarbon and dyes such as brilliant blue
facilitates ILM peeling in these cases. Some authors have developed bimanual peeling
techniques because of the concern that there may be transition from the hole to the
back of the retina during the use of liquid perfluorocarbon. This technique risks
serious complications such as macular trauma and paramacular breaks. Peeling the ILM
under perfluorocarbon liquid eliminates the need for bimanual counterpressure and
reduces the risk of macular annealing. In the current study, liquid perfluorocarbon
and brilliant blue dye were used when peeling the ILM in all cases [19 ], [20 ], [21 ], [22 ], [23 ].
To the best of our knowledge, although there is much information about MHRD secondary
high myopia, there is no study in the literature as large as the current series that
has evaluated patients with MHRD without high myopia. The efficacy of these intraocular
tamponades on surgical success was investigated and the surgical results are presented.
However, limitations of this study included the retrospective nature, and that preoperative
OCT imaging could not be performed in all patients due to the nature of RRD. Furthermore,
the diagnosis of an MH was made mostly during the operation. As the study was conducted
in two centers, two different OCT devices were used, one of which did not have a segmentation
function, so retinal layers, including the ganglion cell complex, could not be examined
in detail. Thus, using two different OCT devices was a problem in terms of optimizing
the values.
Conclusion
The results of this study demonstrated that there was no significant difference between
silicone oil or C3 F8 gas as an intraocular tamponade after ILM peeling in patients with MHRD. Silicone
oil does not have a significant superiority over C3 F8 in cases with MHRD. Considering the potential problems that the use of silicone may
cause in the future, C3 F8 gas can be used in suitable cases as a postoperative tamponade in MHRD.
Conclusion Box
Already known:
Newly described:
PPV plus ILM peeling is a very safe and effective method in MH coexisting secondary
to retinal detachment without high myopia, which is quite complex and problematic.
There is no significant difference between silicone oil or C3 F8 gas as an intraocular tamponade after ILM peeling in patients with peripheral tear-induced
retinal detachment with coexisting MH without high myopia.
Silicone oil does not have a significant superiority over C3 F8 in cases with peripheral tear-induced retinal detachment with coexisting MH without
high myopia.
Funding
This study was funded by the authors and did not receive any grant from finance agencies
in the public or commercial sectors.
Data Availability Statement
Data Availability Statement
The data that support the findings of this study are available from the corresponding
author upon reasonable request.
Contributorsʼ Statement
Y. O. and M. N. B. performed the surgeries; A. Y. G. and M. T. were involved in drafting
the article; Y. O. designed the concept of the study, A. A. revised it critically
for important intellectual content, and all authors approved the final version to
be published. All authors had full access to all of the data in the study and take
responsibility for the integrity and the accuracy of the data.
This article was changed according to the Corrigendum on September 27, 2024.
Corrigendum
In the above-mentioned article, the infrared (IR) image on the left side of Figure
1a was mistakenly duplicated from Figure 1b. The correct IR image for Figure 1a, which
accurately depicts the preoperative IR and OCT images of a patient with retinal detachment
and a macular hole, has now replaced the incorrect one.
