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Chirurgie du trou maculaire par greffe de membrane amniotique : un cas clinique

We report a case of chronic large macular hole for which we performed a human amniotic membrane plug. We assess the effects of this surgery on macular morphology and visual outcome.

A 64-year-old woman asked for the treatment of a chronic large macular hole on her right eye. At her initial visit, best corrected visual acuity was 20/63 Parinaud 8. The macular hole was at least 8 months old. The basal maximum hole diameter was 1403 micrometres, the minimum diameter was 693 micrometres, measured by optical coherence tomography.

To treat her, we performed vitrectomy, peeling of inner limiting membrane, amniotic membrane plug and gas tamponade. One month after surgery, optical coherence tomography reveals closure of the macular hole. The amniotic membrane is visible on optical coherence tomography and seems to be included in the retina. The patient reports a subjective improvement in visual acuity. We observe no adverse event such as an increase of intraocular pressure, hypotony, endo-ocular inflammation, endophthalmitis, dissociated optic nerve fibre layer, and no rejection of the amniotic membrane.

We have chosen a patient with poor prognostic factors for a classic macular hole surgery:  big size and chronic macular hole, with atrophy of retinal pigment epithelium. This case report demonstrates that amniotic membrane plug is a new alternative for surgical treatment of large and chronic macular hole.

We obtained fully stratified retinal layers over the amniotic membrane patch. Those stratified layers may be enabled by the amniotic membrane. Indeed, amniotic membrane plug stimulates retinal ingrowth over it, being a suitable substrate for retinal cells and producing growth factor involved in retinal homeostasis.

On post-operative optical coherence tomography, amniotic membrane is identifiable and spread on retinal pigment epithelium. There is no hyperreflective point, no fluid under retina, retinal layers remain visible and regular. So, there is a good tolerance of the amniotic membrane with no evidence of inflammation.

Amniotic membrane stimulates tissue proliferation, providing migration support and growth factors. It seems to be assimilated, without leaving fibrous tissue.

In order to evaluate long-term visual acuity, we need a bigger prospective study with a longer follow-up. Possible complications such as risks of infection and graft rejection must be evaluated by new studies. In addition, investigations are needed to understand more precisely cellular interactions between retina and human amniotic membrane.

Human amniotic membrane provides a new alternative for treatment of large and chronic macular hole. Thanks to its cellular properties and growth factors, it might induce cellular ingrowth and serve as a support for retinal cells migration. Further studies are required to confirm efficiency and well tolerance of this technique, but amniotic membrane is opening new horizons for macular hole surgery.