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    Idiopathic macular holes: When to perform vitrectomy

     

    Vitrectomy for a macula hole is typically done with 23- to 25-gauge instrumentation. A core vitrectomy is first performed followed by detachment and removal of the posterior vitreous face from the retina followed by a gas tamponade. Surgeons debate whether the internal limiting membrane (ILM) should be peeled in every case, Dr. Folk said. Peeling of the ILM removes residual epiretinal membranes and cells that can be left behind after the vitreous is removed. This can result in a better initial closure rate and a decreased rate of later reopening of the macula hole.

    Most surgeons will use dyes such as indocyanine green or Brilliant Blue to visualize the ILM. Although Brilliant Blue is thought to be safer, most studies showed that the two dyes have been shown to have equivalent results after 6 to 12 months of follow-up,4 Dr. Folk said. Brilliant Blue is not available in the U.S. In addition, the closure rate of recent or smaller macular holes is very good, even without ILM peeling, he said.

    After surgery for a macular hole, patients were previously told they had to stay face down for 1 to 2 weeks, as that was thought to be important for sealing. “Now, we’ve become a little more relaxed with that face-down recommendation,” Dr. Folk said. Some surgeons will say patients are fine so long as they are not on their back, and others recommend positioning their head down for only 2 to 3 days.

    Virtually all phakic patients with a macular hole will go on to develop cataracts. Retinal detachment occurs in up to 1% to 5% of patients, and endophthalmitis occurs in 0.05% of patients.5-7

    “Visual recovery varies with the duration and size of the hole,” Dr. Folk said.

    The biggest decision an ophthalmologist must make is to decide if a macula hole is actually present, as well as other retinal disease.

    “If it is just vitreous traction without a hole, you should probably follow the patient, depending on the symptoms and acuity. If a hole is present, you should probably recommend surgery,” he said.

    References

    1. Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc. 2005;103:537-657.
    2. Haller JA, Stalmans P, Benz MS, et al. Efficacy of intravitreal ocriplasmin for treatment of vitreomacular adhesion: subgroup analyses from two randomized trials. Ophthalmology 2015;122:117-22.
    3. Kaiser PK, Kampik A, Kuppermann BD, et al. Safety profile of ocriplasmin for the pharmacologic treatment of symptomatic vitreomacular adhesion/traction. Retina. 2015 Jun;35(6):1111-27.
    4. AAO Retina/Vitreous Preferred Practice Pattern Panel. Idiopathic Macular Hole PPP-2014. American Academy of Ophthalmology. http://one.aao.org/preferred-practice-pattern/idiopathic-macular-hole-pp...
    5. Tarantola RM, Tsui JY, Graff JM, et al. Intraoperative sclerotomy-related retinal breaks during 23-gauge pars plana vitrectomy. Retina 2013;33:136-42.
    6. Grosso A, Panico C. Incidence of retinal detachment following 23-gauge vitrectomy in idiopathic epiretinal membrane surgery. Acta Ophthalmol 2011;89:e98.
    7. Le Rouic JF, Becquet F, Ducournau D. Does 23-gauge sutureless vitrectomy modify the risk of postoperative retinal detachment after macular surgery? A comparison with 20-gauge vitrectomy. Retina 2011;31:902-8.

     

     

    James C. Folk, MD

    E: james-folk@uiowa.edu

    This article is based on Dr. Folk’s presentation “How Does the Retina Specialist Manage Idiopathic Macular Hole?” at the annual meeting of the American Academy of Ophthalmology last year. He presented on behalf of the 2014 Retina/Vitreous Preferred Practice Pattern Panel.

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