Elsevier

Ophthalmology

Volume 107, Issue 10, October 2000, Pages 1939-1948
Ophthalmology

Macular hole surgery with and without internal limiting membrane peeling

Presented in part at the Retina Society meeting, Washington, DC, September 1998, and at the annual meeting of the American Academy of Ophthalmology, Orlando, Florida, October 1999.
https://doi.org/10.1016/S0161-6420(00)00331-6Get rights and content

Abstract

Objective

To compare results of surgery for idiopathic macular hole with and without internal limiting membrane (ILM) peeling in a series of consecutive patients over a 5-year period.

Design

A retrospective, nonrandomized, comparative trial with concurrent control group.

Participants

Forty-four eyes with macular holes of less than or equal to 6 months duration without ILM peeling were compared to 116 eyes with ILM peeling and the same hole duration. A third group of 65 eyes with ILM peeling and duration greater than 6 months was also evaluated.

Intervention

All eyes underwent pars plana vitrectomy with or without ILM peeling, intravitreous gas, and positioning face down. No adjunctive therapies were used in any group.

Main outcome measures

Comparing the closure and/or reopening rate, prognosis, visual acuity, and complications for macular holes with and without ILM peeling.

Results

All patients had postsurgical follow-up of 18 months or greater. Primary closure was significantly improved with ILM peeling with 116 of 116 eyes (100%) showing no reopenings versus 36 of 44 holes (82%) primarily closed, 9 of which (25%) reopened without ILM peeling (P < 0.00001) in holes less than or equal to 6 months. The 27 eyes without ILM peeling that had successful surgery displayed a mean postoperative vision of 20/40, which is the same as the successful eyes with ILM peeling (P = 0.6). The 52 stage II eyes with ILM peeling had a mean postoperative vision of 20/30, and 48 of the 52 eyes (92%) were 20/40 or better. Stage III eyes (greater than 400-μm holes) without ILM peeling had a poor prognosis, with 6 of the 25 eyes (24%) having initial surgery fail and an additional 4 of 25 eyes (16%) reopening. Without ILM peeling, holes less than 300 μm had only one reopen, whereas holes greater than or equal to 300 μm had 16 of the 17 (94%) primary failures and/or reopenings (P < 0.001). All 12 holes that reopened and/or primarily failed were repaired with ILM peeling with excellent visual recovery. Macular holes with a duration greater than 6 months were treated with ILM peeling, and 63 of 65 holes (97%) were closed primarily and 65% had an increase in vision by two or more Snellen lines.

Conclusions

ILM peeling significantly improves visual and anatomic success in all stages of recent and chronic macular holes and reopened and failed holes, while eliminating reopening for holes greater than 300 μm.

Section snippets

Patients and methods

This study consists of a retrospective consecutive series of patients seen between October 1992 and October 1997 and operated on by one physician (HLB). A total of 231 eyes (217 patients) was identified. Six patients were excluded from this series: three patients did not attain minimal follow-up periods and three other patients had previous vitrectomy for macular hole and were excluded from the stage IV data.

The remaining 225 eyes (211 patients) with idiopathic macular holes were reviewed.

Surgical technique

Standard three-port vitrectomy was performed, followed by surgical separation of the posterior cortical vitreous from the optic nerve and posterior retina in both groups. Eyes without ILM peeling had no epiretinal tissue removed. ILM peeling was performed by making a small opening and flap tear in the ILM with a bent microvitrealretinal blade about 1.5 mm from the fovea (Fig 3). The ILM flap was then grasped with an end-gripping forceps and carefully started in a circular capsulorrhexis

Postoperative evaluation

On the first postoperative day, vision testing, applanation tonometry, and indirect ophthalmoscopy were performed. Postoperative face-prone positioning instructions were given, and patients typically maintained the position for 5 days to 2 weeks, about 18 to 20 hours per 24-hour day, with good compliance as manifested by a positioning spot on the cornea.13 During the last 2 years of the study, positioning was used for 5 days only. Postoperative visual acuity was measured with the Topcon

Statistical analysis

Data were obtained from charts of 211 patients (225) eyes with idiopathic macular holes. Conversion of Snellen acuity to logarithm of the minimum angle of resolution values was performed with 20/20 converting to logarithm of the minimum angle of resolution of zero and 20/200 to 1, and the values in between according to the standard equation.22 Chi square was used to compare preprocedure and postprocedure results with a significance level set at P < 0.05. We used Student’s t test to compare

Results

Medical records of 211 patients with idiopathic macular hole were reviewed. Fourteen patients had bilateral macular holes that were repaired, so a total of 225 eyes had surgery to repair idiopathic full-thickness macular holes. Table 1 (no ILM peeling) and Table 2 (ILM peeling) summarize the results of each stage hole with duration of 6 months or less. Holes with duration greater than 6 months all had ILM peeling (Table 4). At the time of the final examination, 98% were pseudophakic. Cataract

Discussion

The impetus for this study came in early 1991 when I successfully treated two impending macular holes with complete posterior vitrectomy, only to have full-thickness macular holes develop in them 8 to 10 months later. I was puzzled how a full-thickness macular hole could develop much later on without persistent vitreous traction. Both patients were repaired with ILM peeling but excluded from this study because of the prior vitrectomy. In 1992, a report of vitrectomy and pathosis of an

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