MANAGEMENT OF LARGE IDIOPATHIC MACULAR HOLE WITH PARS PLANA VITRECTOMY AND MODIFIED MINIMAL ILM PEELING WITH SUPERIOR ILM FLAP

Main Article Content

Fatimah Syakirah Ramzi Amin Abdul Karim Ansyori

Abstract

Introduction: Idiopathic macular hole is an anatomic discontinuity of the neurosensory retina in the center of the macula or fovea resulted from tractional forces on the foveola at the vitreoretinal interface not associated with other causes. Diagnosis and management of this condition requires expertise, skills, and specialized examination to detect changes in the retina which is important for deciding the appropriate management.


Case Report: We report a case of 66-year-old man with idiopathic macular hole (IMH) in the right eye with initial best corrected visual acuity (BCVA) 20/1200. Fundus examination and optical coherence tomography (OCT) confirmed the presence of large full thickness macular hole with mean linear diameter 673 µm and posterior hyaloid still attached to the optic nerve. The patient was managed with pars plana vitrectomy (PPV) surgery using modified minimal internal limiting membrane (ILM) peeling with superior ILM flap and SF6 gas tamponade. Two weeks after surgery OCT showed closure of the macular hole. BCVA at two and four weeks after surgery improved to 20/240 and 20/200 respectively.


Discussion: PPV with ILM peeling is one of the standardized procedures in IMH surgery. Failure of the vitrectomy surgery to close the macular hole or late reopening of initially successfully closed holes may occur without removal of the ILM due to ILM role as a scaffold for cellular proliferation or attachment of contractile tissue that may cause persistent vitreomacular traction. Variations of ILM peeling such as inverted ILM peeling has been used to improve closure rate for large IMH and has showed favorable results both anatomically and functionally. Nowadays, to avoid or minimize the damage of retinal microstructure by ILM peeling, some surgeons introduced new techniques aiming to preserve the ILM for IMH. Minimal ILM peeling with superior ILM flap technique in this case was done to obtain MH closure with less microstructural retinal abnormalities and better visual outcomes.


Conclusion The management of large IMH with PPV and modified minimal ILM peeling with superior ILM flap in this case showed good results in terms of anatomic and functional outcomes.

Keywords

idiopathic macular hole, large, minimal ILM peeling, superior ILM flap

Article Details

How to Cite
SYAKIRAH, Fatimah; AMIN, Ramzi; ANSYORI, Abdul Karim. MANAGEMENT OF LARGE IDIOPATHIC MACULAR HOLE WITH PARS PLANA VITRECTOMY AND MODIFIED MINIMAL ILM PEELING WITH SUPERIOR ILM FLAP. International Journal of Retina, [S.l.], v. 5, n. 1, p. 72, feb. 2022. ISSN 2614-8536. Available at: <https://www.ijretina.com/index.php/ijretina/article/view/189>. Date accessed: 02 oct. 2022. doi: https://doi.org/10.35479/ijretina.2022.vol005.iss001.189.
Section
Case Report

References

1. McCannel CA. Section 12: Retina and Vitreous. In: McCannel CA, Leonard BC, Berrocal AM, Rosen RB, Holder GE, Spaide RF, et al., editors. 2020-2021 Basic and Clinical Science Course. San Fransisco: American Academy of Ophthalmology;
2. Flaxel CJ, Adelman RA, Bailey ST, Fawzi A, Lim JI, Vemulakonda GA, et al. Idiopathic Macular Hole Preferred Practice Pattern®. Ophthalmology [Internet]. 2019 Feb 1;127(2):P184–222. Available from: https://doi.org/10.1016/j.ophtha.2019.09.026
3. Lowe RJ, Gentile RC. Application of Optical Coherence Tomography and Macular Holes in Ophthalmology. In: Kawasaki M, editor. Optical Coherence Tomography [Internet]. InTechOpen; 2013. Available from: http://dx.doi.org/10.5772/53535
4. Iu LPL, Wong IYH. Macular Hole Surgery: Current Approaches and Trends. In: Chang A, Mieler WF, Ohji M, editors. Macular Surgery Current Practice and Trends [Internet]. Springer Nature Singapore Pte Ltd.; 2020. p. 241–7. Available from: https://doi.org/10.1007/978-981-15-7644-7_18
5. Altaweel M, Ip M. Macular hole: Improved understanding of pathogenesis, staging, and management based on optical coherence tomography. Seminars in Ophthalmology [Internet]. 2003 Jun;18(2):58–66. Available from: http://dx.doi.org/10.1076/soph.18.2.58.15858
6. Veith M, Vránová J, Němčanský J, Studnička J, Penčák M, Straňák Z, et al. Surgical treatment of idiopathic macular hole using different types of tamponades and different postoperative positioning regimens. Journal of Ophthalmology [Internet]. 2020;2020. Available from: https://doi.org/10.1155/2020/8858317
7. Bikbova G, Oshitari T, Baba T, Yamamoto S, Mori K. Pathogenesis and Management of Macular Hole: Review of Current Advances. Journal of Ophthalmology [Internet]. 2019;2019. Available from: https://doi.org/10.1155/2019/3467381
8. Hirneiß C, Neubauer AS, Gass CA, Reiniger IW, Priglinger SG, Kampik A, et al. Visual quality of life after macular hole surgery: Outcome and predictive factors. British Journal of Ophthalmology [Internet]. 2007 Apr;91(4):481–4. Available from: https://dx.doi.org/10.1136%2Fbjo.2006.102376
9. Hu Z, Qian H, Fransisca S, Gu X, Ji J, Wang J, et al. Minimal internal limiting membrane peeling with ILM flap technique for idiopathic macular holes: A preliminary study. BMC Ophthalmology [Internet]. 2020 Jun 15;20(228). Available from: https://doi.org/10.1186/s12886-020-01505-x
10. Chatziralli IP, Theodossiadis PG, Steel DHW. INTERNAL LIMITING MEMBRANE PEELING IN MACULAR HOLE SURGERY; WHY, WHEN, AND HOW? Retina [Internet]. 2018 May;38(5):870–82. Available from: https://doi.org/10.1097/iae.0000000000001959
11. Spaide RF. “DISSOCIATED OPTIC NERVE FIBER LAYER APPEARANCE” AFTER INTERNAL LIMITING MEMBRANE REMOVAL IS INNER RETINAL DIMPLING. RETINA [Internet]. 2012;32(9):1719–26. Available from: https://doi.org/10.1097/iae.0b013e3182671191
12. Hisatomi T, Tachibana T, Notomi S, Nakatake S, Fujiwara K, Murakami Y, et al. INCOMPLETE REPAIR OF RETINAL STRUCTURE AFTER VITRECTOMY WITH INTERNAL LIMITING MEMBRANE PEELING. RETINA [Internet]. 2017;37(8):1523–8. Available from: https://doi.org/10.1097/iae.0000000000001388
13. Ohta K, Sato A, Senda N, Fukui E. Comparisons of foveal thickness and slope after macular hole surgery with and without internal limiting membrane peeling. Clinical Ophthalmology [Internet]. 2018 Mar 16;12:503–10. Available from: https://doi.org/10.2147/opth.s154394
14. Hu Z, Ye X, Lv X, Liang K, Zhang W, Chen X, et al. Non-inverted pedicle internal limiting membrane transposition for large macular holes. Eye (Lond) [Internet]. 2018 Sep 1;32(9):1512–8. Available from: https://doi.org/10.1038/s41433-018-0107-2
15. Tian T, Chen C, Peng J, Jin H, Zhang L, Zhao P. Novel Surgical Technique of Peeled Internal Limiting Membrane Reposition for Idiopathic Macular Holes. Retina [Internet]. 2019 Jan;39(1):218–22. Available from: https://doi.org/10.1097/iae.0000000000001745
16. Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. American Academy of Ophthalmology [Internet]. 2010 Oct;117(10):2018–25. Available from: https://www.aaojournal.org/article/S0161-6420(10)00175-2/fulltext