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Advances in Macular Hole Surgery

Jamin Brown, MD Retina Vitreous Surgeons of CNY December 6th, 2014

Outline

Ø Classification of Macular Holes Ø Importance of the ILM Ø Does Positioning matter?

Ø OCT guided positioning

Etiology o Disease of cortical vitreous

o Abnormal vitreous separation o MHs result from abnormal perifoveal

posterior vitreous detachment

o Anterior/posterior traction o Tangential traction

Macular Hole Stages o!Gass Classificaiton

o!Biomicroscopic classification o!1a – Yellow dot, no hole

o!Foveal detachment

o!1b – Yellow circle, no hole o!2 – Small hole

o!! 400 "m

o!3 – Larger hole o!# 400 "m

o!4 – Hole, complete PVD

1

2

3

4

OCT Stages

o!OCT - gold standard o!Stage 0

o!VMA o!Stage 1 o!Stage 2 o!Stage 3 o!Stage 4

0

1a

1b

2

3

4

Surgical Repair o!Described in 1991 o!Steps

o!Debulk vitreous o!Create PVD (if not present) o!ILM removal? o!Inject gas

http://www.retinalphysician.com/articleviewer.aspx?articleID=104014

Ongoing Controversies o!ILM removal

o!When Is it necessary? o!Stain or no Stain?

o!Face Down positioning o!Is it necessary? o!How long?

ILM removal o Rational

o ILM = scaffold for proliferation of cellular components

o ILM thickens with age o leads to tangential traction o ILM peeling

o Removes tangential tractional o Guarantees complete separation of the

posterior hyaloid o Vitreoschesis

ILM Peel using BBG

ILM Peel using Kenalog

ILM Removal: Risk/Benefit o Risk

o More Traumatic o Staining Toxicity o Light Toxicity

o Benefit o Increase rate of closure o Improved vision?

ILM Removal: Anatomic Success

o!30+ studies reviewing ILM removal o!ILM removal " higher closure rate

o!Closure rates: 80-100% with ILM peel o!Closure rates: 40-70% without peel

o!Meta-Analysis Cochrane 2013 (4 RCT’s) o! ILM removal " higher closure rates, less likely to need

additional surgery o!No increase in complications with ILM removal o!Cost effective

Vitrectomy with internal limiting membrane (ILM) peeling versus vitrectomy with no peeling for idiopathic full-thickness macular hole (FTMH). Spiteri Cornish K, et al. Cochrane Database Syst Rev. 2013 Jun 5;6

ILM Removal o!Decreased rates of MH reopening1

o!Review of 877 MH closures o!0.4% reopening in ILM peel o!7% reopening without

Visual Success o!ILM peeling

o!Vision improvement in many studies o!Other studies have equivalent results o!No studies show negative impact on vision in

ILM peeled group 1 Kumagai K, Furukawa M, Ogino N, Larson E. Incidence and factors related to macular hole reopening. Am J Ophthalmol 2010;149:127–132.

Positioning?

o!Gas tamponade: Rational o!Facilitate re-apposition of edges o!provide a scaffold for the migration of

glial cells o!promote and maintain hole closure

o!Face-Down Position: Rational o!May optimize the effect of gas o!Unproven o!Current practice varies

Macular Hole - Positioning o!Non-compliance

o!compliance with face-down positioning averages only 38% of the prescribed time1

o!RCT’s (Cochrane 2011) suggests: o! benefit in holes > 400 o! no benefit in smaller holes

1 Verma D, Jalabi MW, Watts WG, Naylor G. Evaluation of posturing in macular hole surgery. Eye 2002;16(6):701-4.

OCT driven decision making o!FD-OCT can image MH through gas o!If hole is closed:

o!stop face down positioning

Masuyama K, Yamakiri K, Arimura N, Sonoda Y, Doi N, Sakamoto T. Posturing time after macular hole surgery modified by optical coherence tomography images: a pilot study. Am J Ophthalmol. 2009 Mar;147(3):481-488.

Study Image Obtained Hole Closed

Masuyama 09 81% (13/16) 77% (10/13)

Sano 11 92% (24/26) 95% (23/24)

Yamakiri 12 76% (31/40) 94% (29/30)

Goto 12 88% (22/25) 82% (18/22)

PRE-OP

Post-Op Day 1

3 Months

PRE-OP

Post-Op Day 1

3 Months

Conclusions

o ILM peeling increasing success o OCT-Driven Decision making

o Limits Face Down Positioning