The use of medical adjuvant therapy for macular holes during vitreous surgery seems to be decreasing in macular hole surgery, said Alain Gaudric, MD, of Lariboisière Hospital, Paris.

Biologic adjuvants, such as autologous serum, autologous platelets, and transforming growth factor beta, were not used on a large scale since they were difficult to prepare and the surgical success rates improved without their use, Dr. Gaudric said.

Peeling of the internal limiting membrane (ILM) facilitates hole closure but the mechanism by which this occurs is unclear, he said. Use of indocyanine green (ICG) to stain the ILM is problematic for visual acuity. ICG is toxic to the retinal pigment epithelium based on its concentration and the time that it is in contact with the tissue, and it does not improve the success rate of the surgery. It does improve the visualization of the membrane, however, and therefore the surgery is easier to perform, he said.

Trypan blue, which is used in Europe, was compared with ICG and was associated with high rates of macular hole closure. Triamcinolone acetonide (Kenalog, Bristol-Myers Squibb) is used as an alternative to dyes to avoid toxicity and to make it easier to identify the edge of the ILM.

"The real question in macular hole surgery is: Are adjuvants really needed for all macular holes? Closure seems to depend on the diameter of the macular hole. When the hole is 400 µm or less, there is a 92% closure rate; with holes of 400 µm or greater, the closure rate is 56%. With holes less than 400 µm no adjuvants are needed. With the larger holes, stimulants are needed to close the hole," Dr. Gaudric concluded.