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Free flap de membrane limitante interne pour traiter les trous maculaires réfractaires: résultats anatomiques et fonctionnels

The gold standard surgery for macular holes (MHs) is based on a pars plana vitrectomy (PPV), internal limiting membrane (ILM) peeling (with or without a flap technique), and a gas tamponade. A refractory MH is characterised by the absence of ILM around the hole, as it has already been peeled off in a primary surgery. There is no clear consensus concerning the surgical approach for refractory MHs. Our purpose is to o evaluate anatomical and functional outcomes after performing a free ILM flap insertion in a refractory MH.

This is a multicentric, retrospective study concerning 16 surgeons from 16 different institutes. A total of 48 eyes/patients were included in this study.  All patients were treated with a PPV, Perfluoro-n-octane (PFCL) or Viscoelastic assisted free flap technique and gas tamponade, followed by a face-down positioning. SD-OCT HD images, retinal fundus photography and best-corrected visual acuity (BCVA) were analysed and compared to evaluate both anatomical and functional results during a total of 12 months postoperative follow-up. 

All patients presenting refractory MHs underwent surgery between January 2016 and January 2019. The mean age at surgery was 64, 19 were male while 29 were female. A complete anatomical MH closure was achieved in 43/48 eyes (90%), with no recurrence observed in the 12 months follow up period. The SD-OCT’s demonstrated a partial microstructural reconstruction of both external limiting membrane (ELM) and the ellipsoid zone (EZ) in most of the eyes were MH closure was achieved. The mean BCVA was 0.15 at study baseline and 0.31 at final follow-up (p=0.0049).In terms of functional outcomes, almost 60% of patients showed an improvement in BCVA, varying between 0.5 and 2 lines at month 12. 

The first study using ILM free flaps in MHs was published by Morizane et al. (2014), showing positive anatomical and visual results. Since then, it has been applied as a valid surgical option for refractory MHs. Fei-Yan Ma et al (2019) recently demonstrated, for the first time, positive microstructural changes using a free ILM flap, being the study with the largest number of cases so far (42 eyes). To the best of our knowledge, this study includes the largest number of cases (48 eyes) evaluating the efficacy of free ILM flaps in refractory MHs.

There are some very important factors that have to be considered before result interpretation, such as the MH size (minimum diameter varying between 120-992 Microns), the presence or absence of macular detachment (6% of cases), pigmented epithelium atrophy and the number of previous surgeries. 

A free ILM flap technique seems to be a safe and effective surgical option for small to medium refractory MHs, showing positive anatomical and functional results especially in MHs under 800 Microns.