Foveal-Sparing ILM Peeling with ILM Flap Transposition over the Macular Hole for Repair of Full-Thickness Macular Holes

Abstract

Background Full-thickness macular holes, defined as full-thickness defects of the fovea, lead to central scotoma and deterioration of vision. Apart from peeling of the internal limiting membrane (ILM), ILM flap techniques have been reported to have potential in improving results in macular hole surgery. In addition, foveal-sparing ILM peeling gives a high macular hole closure rate and improvement in postoperative visual acuity. The aim of this study was to examine outcomes in a cohort of patients with full-thickness macular holes that underwent vitrectomy with foveal-sparing ILM peeling and transposition of an ILM flap over the macular hole.

Methods This retrospective study included patients scheduled for pars plana vitrectomy with foveal-sparing ILM peeling, combined with ILM flap transposition over the macular hole, for macular hole repair. All patients received a gas tamponade with 20% sulphur hexafluoride and were encouraged to undergo postoperative face-down positioning for 48 hours after surgery. Optical coherence tomography (OCT) imaging of the macula and distance-corrected visual acuity (DCVA) were performed before and 3 months after surgery.

Results In total, 42 eyes of 42 patients were included in this study. Leaving a broad area of residual ILM at the foveal rim led to a high risk of failure in macular hole closure, while leaving a narrow zone of residual ILM at the foveal rim resulted in high macular hole closure rates (97% type 1 closure and 3% type 2 closure), with a median improvement of DCVA of 4 lines [interquartile range (IQR): 3 to 6] among pseudophakic and 3.5 lines (IQR: 2 to 5) among phakic patients.

Conclusions A combination of foveal-sparing ILM peeling with ILM flap techniques was shown to be a safe and effective surgical option for patients with full-thickness macular holes, resulting in a high macular hole closure rate and improvement in visual acuity in the majority of patients.

Zusammenfassung

Hintergrund Makulaforamina werden definiert als alle retinalen Schichten betreffende Defekte der Fovea, und führen zu zentralen Skotomen und Visusverschlechterung. Abgesehen vom Peeling der “internal limiting membrane” (ILM) und “ILM flap” Techniken, die Potenzial zur Verbesserung der Resultate in der Chirurgie von Makulaforamina haben, zeigte das foveaaussparende Peeling der ILM eine hohe Verschlussrate von Makulaforamina und Verbesserung des Visus. Das Ziel dieser Studie war es, die Resultate in eine Patientenkohorte nach Vitrektomie mit foveaaussparendem ILM-Peeling mit Transposition eines ILM-Lappens über das Makulaforamen zu untersuchen.

Patienten/Material und Methoden Diese retrospektive Studie inkludierte Patient*innen, die zur Pars Plana Vitrektomie mit foveaaussparendem ILM-Peeling mit ILM-flap-Transposition über das Makulaforamen geplant waren. Alle Patient*innen erhielten eine Gastamponade mit Sulfur Hexafluorid 20% und wurden zur postoperativen “face down” Positionierung motiviert. Aufnahmen mit der optischen Kohärenztomographie (OCT) und Testung des bestkorrigierten Fernvisus (DCVA) erfolgten vor und 3 Monate nach der Operation.

Ergebnisse Es konnten 42 Augen von 42 Patient*innen in diese Studie inkludiert werden. Das Belassen einer breiten residualen ILM-Zone um das Makulaforamen führte zu einem hohen Risiko eines Versagens in Bezug auf den Makulaforamenverschluß, während beim Belassen einer schmalen ILM-Zone um das Makulaforamen eine hohe Verschlußrate der Makulaforamina erfolgte (97% Typ 1 und 3% Typ 2 Verschluß). Die mediane Verbesserung des DCVA betrug 4 Zeilen (Interquartilrange (IQR): 3 bis 6) bei pseudophaken Patient*innen und 3.5 Zeilen (IQR: 2 bis 5) bei phaken Patient*innen.

Schlussfolgerung Die Kombination eines foveaaussparenden ILM-Peelings mit ILM-flap Techniken erwies sich als sichere und effektive chirurgische Option für Patient*innen mit Makulaforamina und resultierte in einer hohen Makulaforamenverschlussrate und einer Verbesserung des Visus bei einer Mehrzahl der Patient*innen.

Conclusion Box

Already known:

Foveal-sparing ILM peeling has resulted in a high macular hole closure rate and better postoperative visual acuity among patients with full-thickness macular holes compared to patients that underwent standard ILM peeling [9], [10].

Newly described:

The combination of foveal-sparing ILM peeling with a narrow residual ILM zone combined with ILM flap techniques has been shown to be a safe and effective surgical option for patients with full-thickness macular holes, resulting in a high macular hole closure rate with a low rate of occurrence of postsurgical central atrophy of the EZ, and improvement of visual acuity in the majority of patients.

Key words

foveal-sparing ILM peeling - ILM flap transposition - full-thickness macular hole

Schlüsselwörter

foveaaussparendes ILM-Peeling - ILM-Flap-Transposition - Makulaforamen

Publikationsverlauf

Eingereicht: 13. September 2023

Angenommen: 16. November 2023

Artikel online veröffentlicht:
19. Januar 2024

• References

• 1 Steel DH, Lotery AJ. Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment. Eye (Lond) 2013; 27 (Suppl. 01) S1-21
• 2 Sebag J, Gupta P, Rosen RR. et al. Macular holes and macular pucker: the role of vitreoschisis as imaged by optical coherence tomography/scanning laser ophthalmoscopy. Trans Am Ophthalmol Soc 2007; 105: 121-129
• 3 Duker JS, Kaiser PK, Binder S. et al. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology 2013; 120: 2611-2619
• 4 Meuer SM, Myers CE, Klein BE. et al. The epidemiology of vitreoretinal interface abnormalities as detected by spectral-domain optical coherence tomography: the beaver dam eye study. Ophthalmology 2015; 122: 787-795
• 5 McCannel CA, Ensminger JL, Diehl NN. et al. Population-based incidence of macular holes. Ophthalmology 2009; 116: 1366-1369
• 6 Ho TC, Chen MS, Huang JS. et al. Foveola nonpeeling technique in internal limiting membrane peeling for myopic foveoschisis surgery. Retina 2012; 32: 631-634
• 7 Shimada N, Sugamoto Y, Ogawa M. et al. Fovea-sparing internal limiting membrane peeling for myopic traction maculopathy. Am J Ophthalmol 2012; 154: 693-701
• 8 Itoh Y, Inoue M, Koto T. et al. Alterations of Foveal Architecture During Vitrectomy for Myopic Retinoschisis Identified by Intraoperative Optical Coherence Tomography. Ophthalmologica 2019; 242: 87-97
• 9 Ho TC, Yang CM, Huang JS. et al. Foveola nonpeeling internal limiting membrane surgery to prevent inner retinal damages in early stage 2 idiopathic macula hole. Graefes Arch Clin Exp Ophthalmol 2014; 252: 1553-1560
• 10 Murphy DC, Fostier W, Rees J. et al. Foveal sparing internal limiting membrane peeling for idiopathic macular holes: effects on anatomical restoration of the fovea and visual function. Retina 2020; 40: 2127-2133
• 11 Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991; 109: 654-659
• 12 Eckardt C, Eckardt U, Groos S. et al. Removal of the internal limiting membrane in macular holes. Clinical and morphological findings. Ophthalmologe 1997; 94: 545-551
• 13 Park DW, Sipperley JO, Sneed SR. et al. Macular hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology 1999; 106: 1392-1397
• 14 Brooks jr. HL. Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology 2000; 107: 1939-1948
• 15 Michalewska Z, Michalewski J, Adelman RA. et al. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology 2010; 117: 2018-2025
• 16 Michalewska Z, Michalewski J, Dulczewska-Cichecka K. et al. Temporal inverted internal limiting membrane flap Technique versus Classic Inverted Internal Limiting Membrane Flap Technique: A Comparative Study. Retina 2015; 35: 1844-1850
• 17 Shiode Y, Morizane Y, Matoba R. et al. The Role of Inverted Internal Limiting Membrane Flap in Macular Hole Closure. Invest Ophthalmol Vis Sci 2017; 58: 4847-4855
• 18 Morawski K, Kocemba-Pilarczyk K, Zarzycka M. et al. In vitro culture Muller cell model to study the role of inverted internal limiting membrane flap technique in macular hole closure. J Physiol Pharmacol 2021; 72
• 19 Vogt D, Haritoglou C, Mautone L. et al. Premacular Cells as Source of Neurotrophic Factors in Idiopathic Macular Holes. Curr Eye Res 2020; 45: 1395-1402
• 20 Leisser C, Findl O. Foveal-sparing ILM peeling with ILM flap transposition in a case with idiopathic full-thickness macular hole. Spektrum Augenheilkd 2023; 37: 124-126
• 21 Jin H, Zhang Q, Zhao P. Fovea sparing internal limiting membrane peeling using multiple parafoveal curvilinear peels for myopic foveoschisis: technique and outcome. BMC Ophthalmol 2016; 16: 180
• 22 Kang SW, Ahn K, Ham DI. Types of macular hole closure and their clinical implications. Br J Ophthalmol 2003; 87: 1015-1019
• 23 Leisser C, Findl O. Predictive value of macular hole indices for vitrectomy with ILM peeling combined with ILM flap transposition over the macular hole on macular hole closure. Spektrum Augenheilkd 2023; 37: 15-21