As the most common technique to close a macular hole is vitrectomy with Internal Limiting Membrane (ILM ) peeling, gas tamponade and face down position, a refractory macular hole is defined by the absence ILM of all around the hole. Several techniques have been proposed to close this kind of hole: the most responded are free ILM flap, retina graft or amniotic membrane MA patch.
Objective
To evaluate the anatomical and functional results of surgery for refractory macular hole by free ILM flap vs retina graft vs amniotic membrane patch.
Multicentric and retrospective study concerning 19 vitreoretinal surgeons (authors 1 to 11 plus Koen Van Overdam, Matteo Forlini, Olivier Rebollo, Joel Uzzan, Paolo Mora, Vincent Soler, Franck Meyer, Eric Denion et Emilio Rapizzi) from 19 different institutes from 4 different countries (France, Italie, Pays Bas and San Marino Republique).
All refractory macular holes were treated with pars plana vitrectomy followed either by a free ILM flap , or a retina auto graft, or an amniotic membrane patch, tamponade by air, gas or silicon oil, and positioned face down for a period between 1 and 3 days . SD-OCT HD images, retinal fundus photography , fundus autofluorescence and best corrected visual acuity (BCVA) were analysed to evaluate both anatomical and functional outcomes during a total of 12 months follow-up.
Seventy-one eyes of 71 patients presented a refractory macular hole. Physiopathology was the result of a macular hole surgery with ILM peeling, a foveal rupture for macular edema after ILM removal, retinal detachment in an eye where ILM has been remove and other mechanism. Fifty eyes undergone to free ILM flap technique, 8 to retina graft and 13 to amniotic membrane patch. Anatomic success, with complete closure of the hole was seen in 43/50 (86%) of the free ILM flap ,7/8 87% of the retina graft and 100% of the amniotic membrane .
To the best of our knowledge this is the first multicentric study, with the large series on refractory macular hole comparing these 3 kind of techniques.
Refractory macular hole is a rare pathology and the most of surgeons has only a few cases, for that reason is so important to share them.
ILM free flap technique has been described in 2014 whereas retina autograft in 2017 and amniotic membrane in 2018. This can partly explain the difference between the number of eyes in the different groups . Very often eyes presenting refractory macular hole also show other macular disease like myopic maculopathy, pigment epithelial and neurosensory dystrophy following retinal detachment or chronic macular oedema, so the functional potential is often not very high. Nevertheless some cases show an unexpected functional improvement.
All the three techniques are safe and effective surgical option to close refractory macular hole. Free ILM flap seem to get better results for small-medium holes, wheras amniotic membrane patch and retina graft can close heaven huge macular hole.
