What Do You Think About the New Advances in Macular Hole Surgery?

July 31, 2009

At the recent meeting of the Asia-Pacific Academy of Ophthalmology and American Academy of Ophthalmology in Indonesia, the results of macular hole surgery have improved thanks to improvements in technology.

Macular hole surgery was first introduced in the late 1980’s/early 1990’s and was somewhat controversial for several years. At it’s introduction, macular hole surgery consisted of vitrectomy combined with fluid/gas exchange. Most surgeons elected to use a mixture of C3F8 and required 2-3 weeks of face down positioning.

Current macular hole surgery is now accepted standard of care, but there have been a few advances allowing increased success compared to it’s introduction. Macular hole surgery is now indicated for Stage II, III and IV macular holes with highest visual success seen in stage II and III repairs.

ILM peeling is now performed by most surgeons although the best ILM stain has yet to be determined as there are some concerns with toxicity using ICG dye.  Concerns over strength and duration of exposure may cause retina toxicity.  It is this surgeon’s view that good ILM peeling has enhanced macular hole closure.

OCT has allowed more accurate evaluation of the macular hole during the post-operative period.  Closure of macular holes usually occurs within hours of the operation with most closing within 24 hours of the operation.  This has clear implications to the usual “face-down” positioning for several weeks.  Anatomic, post-operative positioning may not be as crucial as once thought.

What does this mean? As a retinal surgeon, I have long been suspicious about the time it takes to close a macular hole.  As the hole slides closed, due to surface tension, I have seen in a few instances (somehow I could see the macula in perfect detail, despite intravitreal gas) that holes seem closed within days.  Regardless of my observations, this is good news for several reasons;  patients may no longer have to endure the “torture” of face down positioning as it may be obsolete, and, (another observation by yours truly) the rate of post-operative retinal detachment may decrease as a longlasting “bubble” may no longer be wise.  Surgeons may elect to use quicker absorbing gas (for instance air, I use SF6 for exactly this reason) as the longer lasting bubble may cause retinal tears as it bounces around and gets caught in the vitreous skirt (the anterior vitreous that is adjacent to the pars plana).

Read more on these developments in the following article on the OSN website.

Randall V. Wong, M.D.
Retina Specialist




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One Response to “What Do You Think About the New Advances in Macular Hole Surgery?”

  • With SF6 tampon the anatomic success rate was 64% whilst in the C3F8 cohort a complete closure was achieved in 88%. This significantly higher success rate using C3FB tamponade was made without positioning, compared to SF6 gas tamponade with positioning. This would appear to suggest that even in supine position C3F8 attains a continuous tamponade enforcinga sufficient glial wound healing without any positioning. Can anyone provide further case control studies to support this?