Author: Li Yen Goh (United Kingdom)
Co-authors: Lorenzo Motta, Riddhi Bhatt, Dominic McHugh
Purpose
Overall the incidence of full thickness macular holes (FTMH) has been estimated at 0.1 - 0.8% in individuals aged over 40 years old. The current primary gold standard treatment is pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peel and gas tamponade. Several adjuncts have been described in current literature to address refractory FTMHs to varying levels of anatomical and visual success. Here we described the results of six patients who have undergone PPV +/- ILM peel alongside phacoemulsification and intraocular lens (IOL) implantation with autologous anterior capsule flap transplantation and serum application to the FTMH as both a primary treatment for idiopathic FTMHs or a secondary procedure for refractory idiopathic FTMHs. Main outcome measure: Closure rate of FTMHs and change in best-corrected visual acuity (BCVA)
Setting/Venue
King’s College Hospital NHS Trust, a tertiary hospital in South-East London
Methods
A retrospective case series review was undertaken of six patients who received this procedure between August 2019 and July 2020. Each case alongside relevant spectral domain optical coherence tomography (SD-OCT) images were analysed in depth; we describe demographics, BCVA in early treatment diabetic retinopathy study (ETDRS) letters, presenting macular hole characteristics and International Vitreomacular Traction Study Group grading, surgical treatment, complications, and status of macular hole following treatment.
Results
Presenting median FTMH diameter was 478um interquartile range(IQR) 432. Final median FTMH hole diameter was 0.00um, IQR 239.25. Mean FTMH size decrease was -355.17 standard deviation(SD) 515.80 (p=0.173, Wilcoxon Signed-rank test). 66.67% had large holes, 16.665% medium and 16.665% small. Median presenting BCVA was 42.50 letters IQR 35.00. Median final BCVA 57.50 letters IQR 53.74. Mean BCVA improvement was 9.16 SD 11.14 (p=0.068, Wilcoxon Signed-rank test). This was the primary procedure for four of the six cases. 75% (three patients) achieved FTMH closure within six weeks and the fourth patient in eight weeks with additional serum application. Visual improvement was experienced in 50% (two patients) and BCVA was maintained in the remainder. Two patients underwent this combination procedure following failure with standard PPV, ILM peel and octafluoropropane(C3F8) tamponade. Closure rate was 50%; one patient underwent this procedure six weeks following initial surgery for a large FTMH and three weeks later closure was achieved with BCVA improvement. The second case underwent this intervention four weeks after the primary procedure for a medium FTMH. The FTMH failed to close after two weeks and a further PPV with C3F8 was carried out. Unfortunately, improvement was subsequently limited by a rhegmatogenous retinal detachment (RD).
Conlusions
Previously this autologous capsule transplantation had been reported largely in East Asian, mainly myopic populations with large refractory holes. Here we describe PPV with ILM peel alongside phacoemulsification and intraocular lens (IOL) implantation with autologous anterior capsule flap transplantation and serum injection as a viable treatment option for both primary and refractory FTMHs of various sizes; hole closure was achieved in all except one case which was limited by a subsequent RD. Further work on a larger scale should be undertaken with longer follow-up periods to see if there are any long-term transplantation implications. Furthermore, this method should be trialled in different populations, in FTMHs of different sizes and presentations to further validate its use. Additionally, more research should be employed to investigate an optimum adjunct for capsule incorporation to FTMHs. We used autologous serum obtained from perioperative centrifugation effectively for its fibrocellular adhesive and proliferative properties but success has also been reported without serum or with whole blood instead.
Financial Disclosure
All authors have none to declare
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