Borgomanero

How to Avoid Failures in Macula Hole

Surgery

Vincenzo Ferrara, MD SS. Trinità Hospital

Borgomanero - ITALY

Primary failures 2% to 15%

• Olsen TW et al. Retina 1998

• Park DW et al. Ophthalmology 1999

• Mester V, Kuhn F. Am J Ophthalmol 2000

• Haritoglou C et al. Am J Ophthalmol 2002 and Retina 2006

• Da Mata AP, et al. Ophthalmology 2004

• Schumann RG et al. Am J Ophthalmol 2006

• Hillenkamp J et al Br J Ophthalmol 2007

It is not possible to determine the anatomic success rate of MH surgery in this study, but 4.2% of eyes underwent further MH surgery.

… not all patients with failed surgery will elect to undergo reoperation, and this proportion is likely to be greater than the approximately 6%

Ophthalmology 2013;120:629–634

It is not possible to determine the anatomic success rate of MH surgery in this study, but 4.2% of eyes underwent further MH surgery.

… not all patients with failed surgery will elect to undergo reoperation, and this proportion is likely to be greater than the approximately 6%

Ophthalmology 2013;120:629–634

How can it happen that we still

have so many failures?

c + d Hole Form Factor (HFF) = a Anatomy of the Hole

≥ 800 μ = Lower success rate

Anatomic Reasons for failure in Macular Hole

c + d Hole Form Factor (HFF) = a

Better postoperative

success and VA

HFF > 0,5

Anatomy of the Hole

≥ 800 μ = Lower success rate

Anatomic Reasons for failure in Macular Hole

c + d Hole Form Factor (HFF) = a

Worse postoperative

success and VA

HFF < 0,5

Anatomy of the Hole

≥ 800 μ = Lower success rate

Anatomic Reasons for failure in Macular Hole

Hole Form Factor (HFF) Anatomy of the Hole

Duration of Symptoms

Holes with cystic degeneration

older than 2 years

less chances of success !

≥ 800 μ = Lower success rate

Anatomic Reasons for failure in Macular Hole

Surgical Reasons for failure in Macular Hole

Relieve of Tractions

Tamponade

Drop of vitreous

Surgical Reasons for failure in Macular Hole

Failed Relieve of Tractions

Failed Relieve of Tractions

Surgical Reasons for failure in Macular Hole

PERSISTANCE OF THE ILM 1 Failed Relieve of Tractions

Surgical Reasons for failure in Macular Hole

1st op 2nd op

PERSISTANCE OF AN INNER RING OF ILM Failed Relieve of Tractions

Surgical Reasons for failure in Macular Hole

The ILM is a thin basement membrane in the

pit of the fovea which gradually becomes a

thick basement membrane in the parafovea.

Topographic Variations in the Rabbit and Primate Internal Limiting Membrane Brian

Marsumoro, Janer C. Blanks, and Stephen J. Ryan Invest Ophthalmol Vis Sci 25:71-82,

1984.

Traction during the peeling could induce the

ILM to tear off at the transitional site between

areas of different thickness leaving a rigid ring

Surgical Reasons for failure in Macular Hole

PERSISTANCE OF AN INNER RING OF ILM Failed Relieve of Tractions

Surgical Reasons for failure in Macular Hole

Tamponade We need a tamponade …

Surgical Reasons for failure in Macular Hole

Tamponade

bubbles keep

dry the edges

of the hole

provides a compartment and

smooth surface for the glial

proliferation which will seal it

Dhawahir-Scala FE, et al.

To posture or not to posture after macular hole

surgery. Retina 2008

Surgical Reasons for failure in Macular Hole

Failed Tamponade Holes can be closed in 93% after two

days of face-down positioning

Hasler PW, Prünte C. Early foveal

recovery after macular hole surgery.

Br J Ophthalmol 2008; 92:645– 649

Surgical Reasons for failure in Macular Hole

Failed Tamponade Watertight tamponade mandatory

during the first 48 hours

Kasuga Y, Arai J, Akimoto M, et al. Optical

coherence tomograghy to confirm early closure of

macular holes. Am J Ophthalmol 2000;130:675–6

Surgical Reasons for failure in Macular Hole

VITREOUS GEL ?

Ferrara V. Belloli V.

The Surgery Of Macular Holes:

Why We Still Cannot Close All Of Them ?

Retinal Physician, April 2010

Failed Tamponade

Failed Release of Tractions X X

Surgical Reasons for failure in Macular Hole

Drop of vitreous

Vitreous body is not uniform and compact

but contains lacunae and cisterns

Surgical Reasons for failure in Macular Hole

During vitrectomy we remove all the visible or the

stained cortical vitreous (collagen)

Surgical Reasons for failure in Macular Hole

… but there is an invisible liquid component

(hyaluronic acid - HA) which is delivered from the

lacunae and collects at the posterior pole

Surgical Reasons for failure in Macular Hole

At the end of fluid\air exchange

HA appears at the posterior pole

Surgical Reasons for failure in Macular Hole

and collects into the macular hole

Surgical Reasons for failure in Macular Hole

Surgical Reasons for failure in Macular Hole

This drop of gel left could become an obstacle to

glial migration and closure of the hole Schubert HD et al . Macular holes: migratory gaps and vitreous as obstacles to glial closure

Graefes Arch Clin Exp Ophthalmol 1997;235: 523–529

Hyaluronic Acid (HA) has inhibitory

effect and realizes with a

viscoseparation an obstacle for the

migration of glial cells

DROP OF VITREOUS

DROP OF VITREOUS

But HA dissolves in water …

it disappears!

if we search it one week later …

Avoiding Failures

Tips to avoid failures in Macular Holes

Avoid inner macular rexis Ring of ILM

Spreading the force along an arc

Tips to avoid failures in Macular Holes

Gently grasp the borders Ring of ILM

Yooh HS, Brooks HL Jr, Capone A Jr , L’Hernault NL, Grossniklaus HE:

Ultrastructural features of tissue removed du ring idiopathic macular hole

surgery. Am J Ophthalmol 1996;122:67 – 75.

Stimulating gliosis by activation of myofibroblasts at foveal ILM

Tips to avoid failures in Macular Holes

Radially cutting the borders Ring of ILM

Tips to avoid failures in Macular Holes

Gentle suction of the borders Ring of ILM

Approximating the borders of the hole

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

31 Gauges

SILICON OIL SILICON OIL

III EAKO Ekaterinburg 26-29 April 2003

V. Ferrara - ITALY

"SILICONE OIL IN MACULAR HOLE SURGERY "

Pre-op 1 day Post-op

31 Gauges

Macular Hole and Silicone Oil

Tips to avoid failures in Macular Holes

Avoid exchange over the hole or drain Drop of HA

Tips to avoid failures in Macular Holes

Inverted ILM flap Large Holes

Ophthalmology 2010;117:2018–2025

Tips to avoid failures in Macular Holes

Inverted ILM flap Large Holes

Ophthalmology 2010;117:2018–2025

Inverted ILM flap technique may

induce glial cell proliferation,

resulting in the macular hole

filling with proliferating cells

that enhance closure.

Tips to avoid failures in Macular Holes

Inverted ILM flap Large Holes

Inverted ILM flap technique may

induce glial cell proliferation,

resulting in the macular hole

filling with proliferating cells

that enhance closure.

Tips to avoid failures in Macular Holes

Inverted ILM flap

Tips to avoid failures in Macular Holes

Inverted ILM flap

TAKE HOME MESSAGE

Don’t touch Don’t harm Respect