Paracentral retinotomy facilitates closure of large, resistant macular hole

Most macular hole surgeries end successful with achievement of hole closure.  However, there is a small percentage, ranging from 3% to 10%, of large macular holes that will not close despite peeling of the internal limiting membrane (ILM) and instructing the patients to maintain a face-down position with injection of a long-acting gas, such as perfluoropropane (C₃F₈). 

Recognition of this problem resulted in an innovative approach for closing persistent macular holes after the primary surgery has failed by creating a separate paracentral retinotomy in the nasal macula. Michael S. Tsipursky, MD, described the rationale for trying this treatment approach. 

“This technique is similar to a relaxing incision,” said Dr. Tsipursky, who is in private practice in Effingham, IL.

He described six patients (6 eyes) who had large macular holes exceeding 400 μm. The patients all had undergone at least one surgery to close the holes. The rationale in creating a separate paracentral hole to address these large macular holes is that the amount of tissue in the nasal macula might be increased with the creation of a round retinotomy. 

Dr. Tsipursky creates the hole using endocautery and aspiration with a soft-tipped cannula. In these eyes, the ILM had been peeled and vitrectomies had been performed in the previous surgeries. C₃F₈ gas was injected into the eyes. 

Patients were instructed to remain face down for 1 week after the surgery.

Of the 6 patients who underwent the procedure, closure of the central hole was achieved in 5 patients, for a closure rate of 83.3%. Visual acuity improved in 3 of those patients, and remained the same in 2 patients. In the 6th patient, the hole was 1,550 μm, which likely was responsible for the inability to achieve closure. This hole decreased in size after creation of the paracentral hole and remained smaller for several months but later enlarged again. The visual acuity remained counting fingers.  

He recounted the case of a 49-year-old man with a macular hole that remained open despite undergoing two previous surgeries. One year after the endocautery burn was performed to create the paracentral hole, the patient’s visual acuity increased from counting fingers to 20/70 and the retinal nerve fiber layer was intact. The patient had a residual central scotoma and a small paracentral temporal scotoma.

However, upon questioning he did not report a visual defect, according to Dr. Tsipursky

In another case that involved a 90-year-old woman, the macular hole remained open after one surgical attempt to close it.  Following creation of the paracentral retinotomy, her visual acuity improved from 20/100 to 20/80, he noted.

The benefits of this surgery are that the paracentral scotomas were well tolerated, a high percentage of patients achieved closure of the macular holes, the visual acuity increased significantly in three of the five holes that closed, the visual acuity did not decrease in any cases, and there was no optic neuropathy or loss of the retinal nerve fiber layer, Dr. Tsipursky said.

“This procedure is designed to treat resistant cases and serves as a viable option for macular hole closure,” Dr. Tsipursky concluded. “In most cases, there was robust evidence that the retinal nerve fiber layer was not damaged and patients had subjective improvement in the visual acuity and no complaints about a paracentral scotoma. There were no decreases in visual acuity. The creation of a paracentral hole between the nasal macula and optic disc can be done safely during vitrectomy to close resistant macular holes.”

Dr. Tsipursky has no financial interest in any aspect of this report.  He described his findings at the 2017 meeting of the American Society of Retina Specialists in Boston.