Author: Rocío Eguilior Alvarez (Spain)
Co-authors: Muxima Acebes García, Marta Belmonte Grau, Miguel Viso Garrote, Cynthia Leon Niz
Purpose
To show the clinical evolution and the follow-up by optical coherence tomography (OCT) of a full thickness macular hole (FTMH) over an aneurysmal type 1 neovascularization (AT1) after treatment with aflibercept (Eylea®) in a patient who required a vitrectomy with inverted internal limiting membrane (ILM) flap technique.
Setting/Venue
Urban tertiary hospital. Spain.
Methods
Clinical and OCT follow-up of a 79-year-old male patient who had a best corrected visual acuity (BCVA) of 0.32 in his right eye (RE) and his funduscopy showed signs that suggested a choroidal neovascular membrane: small hemorrhages and macular exudates. The presence of the following tomographic signs: fibrovascular retinal pigment epithelium detachment (PED) with subretinal fluid, elevated PED, notch in the PED, double layer sign and a rounded lesion on the posterior face of the PED with moderate reflectivity inside, alluded to the diagnosis of AT1. The loading dose with 3 monthly injections of aflibercept was underway. Few months later, a new neurosensory retinal detachment appeared, so a fixed monthly interval was maintained during the COVID-19 pandemic, according to the recommendations of scientific societies. The patient returned for a check-up after three months without any follow-up, suffering a decrease in BCVA in his RE of 0.16 and a medium-size FTMH of 300 µm with posterior vitreous detachment (FTMH grade IV) in OCT, one month after the last injection. A 23 gauge pars plana vitrectomy (PPV) was performed, with the peeling of the ILM using the superior inverted flap technique and 20% SF6 gas at the final stage of the surgery.
Results
Complete closure of the macular hole (MH) was observed in OCT ten days after surgery with an improvement in BCVA of 0.32 in the RE two months later, without requiring new antiangiogenic treatment.
Conlusions
MH is a complication associated with antiangiogenic treatment, especially in patients with pre-existing vitreomacular traction or elevated PED. In some cases, observation until spontaneous closure could be an option, but most patients will require surgical intervention, being PPV with peeling of the ILM the preferred technique. We are unaware of the existence of any previous case using the inverted flap technique of ILM for the treatment of a MH associated with choroidal neovascular membrane (CNV) under antiangiogenic treatment. We consider that superior inverted ILM flap technique would get a better closure rate and visual acuity in secondary MHs associated with neovascular membranes, given the fact that it facilitates tissue proliferation and photoreceptor repositioning next to the CNV area.
Financial Disclosure
Urban tertiary hospital. No financial interest.
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