Idiopathic full-thickness macular hole (FTMH) is a vitreomacular interface disorder with an incidence of 8.69 eyes per 100,000 people per year.1 Older age and female gender are known risk factors for its development.1,2 In 1991, Kelly and Wendel first reported that FTMHs could be repaired surgically, revolutionizing the prognosis for patients affected by this vision-threatening condition.3 Since then, continued advancements in surgical techniques and instrumentation have allowed surgical success rates to exceed 85%.4,5

Macular hole repair is a common operation for retinal surgeons but can be a bit daunting for those early in their career. This may be due to limited hands-on experience during fellowship or insecurity with internal limiting membrane (ILM) peeling, one of the more technically challenging maneuvers in vitreoretinal surgery. This article will briefly review some approaches to FTMH repair and practical tips on how to improve surgical performance and increase confidence with this type of surgery.

SURGICAL APPROACHES TO MACULAR HOLE REPAIR

Observation (for smaller holes <250 microns or pediatric traumatic macular holes), pneumatic vitreolysis (with gas or air), topical carbonic anhydrase inhibitors, and ocriplasmin (Jetrea, ThromboGenics) have all been used to treat FTMHs with variable rates of success.6-9 However, the following surgical options are also available.

• Pars plana vitrectomy (PPV) with ILM peeling: Perhaps the most common technique used today for primary FTMHs, this approach involves performing a complete PPV, elevating the hyaloid, and peeling the ILM off the macula. ILM peeling appears to improve FTMH closure rates by relieving tractional forces,10 and most surgeons feel this is a critical component of the surgery. The necessary extent of peeling is debated, but some have suggested that larger ILM peel areas correlate with higher closure rates.11
• PPV with ILM flap: Michalewska and colleagues first introduced the concept of an inverted ILM flap technique to improve closure rates in large (>400 microns) macular holes.12 This technique involves peeling the ILM but leaving it hinged at the edge of the hole and then inverting it upside down to cover the hole. The flap is thought to act as a scaffold for tissue proliferation and aid in hole closure. Multiple variations of this technique have also been tried with varied levels of success.13,14
• Adjuvant agents: Agents such as growth factor-beta 2, thrombin, and autologous blood components (whole blood, serum, platelet concentrate) used at the time of surgery have been found to improve anatomical closure of FTMHs.15-19 Although slight differences in application processes exist, in general, the procedure involves performing a PPV, elevating hyaloid, peeling ILM (not done in some studies), conducting an air-fluid exchange (AFX), “air drying” the retina, placing the adjuvant agent over the macula for 10 minutes, and then exchanging air for gas. In cases in which an autologous blood product is used, venous blood is typically drawn from the patient’s antecubital fossa under sterile conditions following AFX and spun down to separate the desired components.
• Autologous transplantation of a retinal free flap or lens capsular flap: In the transplantation of a retinal-free flap, a piece of neurosensory retina is harvested from outside of the arcades. The flap is then placed inside the FTMH under perfluoro-n-octane, followed by fluid-gas exchange.20 With the lens capsular flap technique, the surgeon harvests a flap of anterior or posterior capsule during concurrent cataract surgery, and inserts it into the hole.21 These approaches were studied in refractory FTMHs.
• Temporal macular arcuate retinotomy: Charles and colleagues described a technique in which 25-gauge curved retinal scissors were used to create a semicircular retinotomy temporal to the edge of the FTMH. This approach is theorized to relieve more traction than ILM peeling alone can achieve. Because of the risk for traumatic damage to the underlying retinal pigment epithelium (RPE), this technique should be reserved for very large FTMH or repeat operations.22
• Macular hole laser: For large macular holes, applying laser photocoagulation at the center of the FTMH may promote cytokine production that stimulates the formation of a glial plug, which closes the hole. No clinically significant changes in the visual field have been reported in association with this technique, although data is limited.23,24
• Macular hole detachment: With this approach, the macula is detached by injecting subretinal balanced salt solution, which separates the macular hole edges from the underlying RPE, thereby increasing retinal compliance and allowing the FTMH edges to reapproximate.25 This was studied in the setting of persistent or recurrent holes.
• Radial retinal incisions: In a study of seven eyes, five radial full-thickness retinal incisions were created 1 macular hole diameter outside of the FTMH and extending centripetally toward the hole, avoiding the papillomacular bundle (PMB). This technique is thought to relax the perifoveal tissue and stimulate retinal gliosis to aid in healing for persistent holes.26

SURGICAL PEARLS

These tips may help improve performance and increase confidence with macular hole repair.

• Pre-operative planning: The key to good outcomes starts in the pre-operative phase. Patient counseling is important. Discuss surgical risks, review implications of gas tamponade, and set realistic expectations (especially when treating a refractory macular hole). Carefully plan your surgical approach. Note whether a complete posterior vitreous detachment (PVD) is present. If the patient is phakic, confirm that your view will be sufficient without concurrent cataract extraction. If you will be using adjunct agents, ensure that you have all necessary supplies. Because ILM peeling requires such steadiness, I defer any caffeine intake on the days I operate; however, this may actually have a negative impact on some, and should be an individual decision.
• PPV set-up: I generally choose 25-gauge instrumentation for my FTMH repairs, although any gauge is fine. I prefer to place superior cannulae at 10 o’clock and 2 o’clock; this prevents my hands from feeling restricted, which can occur if the cannulae are too far superior. It is especially important to avoid placing trocars too close to the horizontal meridian where the nose bridge can impede movement of the forceps. If operating on a patient with a particularly high nose bridge or deep orbit, rotating the entire globe (for a right-handed surgeon: clockwise for a left eye, counterclockwise for a right eye) can facilitate range of motion.
• PPV and hyaloid elevation: A thorough core and peripheral shave vitrectomy should be performed to allow for a complete gas fill. I recommend always using diluted (1:3) triamcinolone acetonide to confirm that the hyaloid is elevated, even when you think there is a complete PVD. When lifting hyaloid over the macular hole, pull slowly and keep your forces tangential to the retina to avoid unintentionally expanding the hole. Elevate the hyaloid as far peripherally as you safely can without creating an iatrogenic tear or detachment. After this step, I often double stain with triamcinolone to confirm that no residual hyaloid remains.
• ILM staining: It is very helpful to stain with dyes, such as indocyanine green (ICG) or brilliant blue G (BBG), to highlight ILM. I use ICG diluted 1:4 with saline solution or dextrose 5% in water (D5W); some feel that the latter adds “weight” to the dye and allows for a better stain in a shorter amount of time. Inject the dye slowly and direct it away from the hole so that it does not enter the subretinal space or injure the retina. I allow the stain to sit for approximately 1 minute while removing my light pipe to prevent possible photo-induced toxicity.27 If staining is suboptimal, this step is repeated. Alternatively, performing an AFX and then depositing the ICG directly over the macula can provide a dense stain. The drawback of this technique is that residual air bubbles can obscure the view once the vitreous cavity is refilled with fluid.
• ILM flap formation: After aspirating excess dye, switch from the widefield to a macular lens. Most often, I peel under the Resight (Carl Zeiss Meditec) non-contact macular lens, but I occasionally switch to a contact macular lens (Figure 1) if I have trouble with visualization or am working with the Oculus BIOM viewing system. To optimize the view, it is important to center the lens on the cornea and keep the globe as close to primary position as possible. If it seems impossible to get in focus, you may be in accommodative spasm (especially if you are anxious). If this occurs, remove your instruments and focus on a distant target across the operating room for a minute or so.
  Initiating the ILM flap is arguably the part that surgeons find the most challenging. I prefer the pinch-and-peel technique in which forceps are used to grab the ILM somewhere within the arcades but away from the foveal center and PMB. You should see a bit of tenting of the ILM and retina with the initial lift, but the retina should release when the flap is formed. Another common way of initiating an ILM flap is to utilize a Tano Diamond Dusted Membrane Scraper (Synergetics) or the Alcon Finesse Flex Loop (Figure 2). These instruments have an irregular surface, which creates a flap when they are gently swept across the retinal surface.
• ILM peeling: I prefer using ILM peeling forceps, although other types, such as end-grasping forceps, can be used. When peeling ILM, be aware of the surrounding retina to prevent unintentional trauma with another part of the instrument. Keep your forceps tangential to the retina, but with a slight anterior lift; this helps maintain a continuous flap. It is ideal to peel ILM over the hole itself in one sheet (Figure 3); peeling circumferentially can leave remnants that encircle the hole. It is important to peel at least 2 disc diameters outside the hole, but I try to peel as close to the arcades as safely possible.
• Closure: After reverting back to a widefield lens, perform an AFX and a scleral-depressed examination to ensure no iatrogenic breaks. For phakic eyes in particular, I wait 5 minutes and drain again, as there is a tendency for additional fluid to accumulate posteriorly. I drain over the optic nerve; aspirating directly over the FTMH is unnecessary in most cases. Finally, an air-gas exchange is performed. I generally prefer to use 20% sulfur hexafluoride (SF6) with smaller holes and 14% perfluoropropane (C3F8) for larger or refractory holes. To prevent a gas underfill, I always suture my sclerotomies with 7-0 Vicryl in these cases, although others have had good success without doing so.
• Post-operative positioning: I position my patients facedown for 7 days. The benefits of facedown positioning are highly debated and the subject of ongoing studies. A recent large meta-analysis found that facedown positioning improved the overall FTMH closure rate, especially for larger holes.28 Most retina surgeons ask patients to maintain a facedown position for 3 to 7 days.

CONCLUSION

Macular hole repair is an important skill for vitreoretinal surgeons to possess. The surgical techniques I have shared here are ones that I have personally found helpful during my career thus far. As with most surgeries, there are many different approaches which may be effective, and it is worthwhile to find what works best for you in this challenging — but often very rewarding — type of surgery. ■

Dr. Weng is an associate professor of ophthalmology and fellowship program director of vitreoretinal diseases & surgery at Baylor College of Medicine in Houston. She serves as the Early Career Section Co-Chair for the American Society of Retina Specialists. She reports personal consulting fees from Alcon, Allergan, and Alimera Sciences.

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