Strategies for macular hole recurrence after small-gauge vitrectomy

Findings from a retrospective review provide insights about the outcomes of surgery for recurrent macular holes in the era of small-gauge vitrectomy and possible strategies for reducing their occurrence, said Tarek S. Hassan, MD, at the inaugural Retina World Congress.

He presented data from a recently published analysis [Retina. 2016 Sep 13 Epub ahead of print] that included 392 eyes operated on by 8 surgeons using small-gauge techniques during the years 2001 to 2014.

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All eyes had an idiopathic macular hole measuring <750 μm that was successfully closed after initial vitrectomy with internal limiting membrane (ILM) peeling, said Dr. Hassan, professor of ophthalmology, Oakland University William Beaumont School of Medicine, Royal Oak, MI.

Recurrence, defined as re-opening >1 month after surgery, occurred in only 13 eyes (3.3%), and generally only many months after the primary procedure (mean 28 months).

Closure was achieved in all 13 recurrent cases through re-operation that included only small-gauge vitrectomy, additional tissue peeling, and fluid-gas exchange, and also in the 1 of 3 eyes with a second recurrence that underwent a third surgery. The other two patients chose not to have further surgery.

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Presence of an epiretinal membrane (ERM) appeared to be associated with macular hole recurrence as it was present in 11 (85%) of the 13 recurrent cases.

Other noteworthy features identified in eyes with recurrence included need for cataract surgery (38%) and development of cystoid macular edema (CME) after primary vitrectomy (15%).

Particularly interesting, the majority of patients with a macular hole recurrence (77%) had or later developed a full-thickness macular hole in the fellow eye, Dr. Hassan said.

“Prior to our series, all of the published studies about recurrent macular hole included cases operated on entirely or predominantly with 20-gauge vitrectomy,” he said. “By virtue of being less traumatic, small-gauge vitrectomy theoretically might reduce the risk for re-opening, although increased surgeon experience and advances in intraoperative visualization may also have contributed to the very low rate of recurrence in our series.

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“Therefore, the main messages that surgeons can take home from our study are as follows: Successful macular hole closure with vision improvement can be achieved for all patients that pursue all possible surgery, and a good outcome does not require ILM flaps and other more extensive techniques that have been advocated more recently,” Dr. Hassan added.

ILM peeling, ERMs

However, surgeons should be meticulous about ILM peeling and peel broadly throughout the macula, remove ERMs and even consider ERM removal after vitrectomy if a patient becomes symptomatic in the absence of a recurrent macular hole, he noted.

“Be aggressive about treating inflammation, including CME after vitrectomy and eyes with other pro-inflammatory insults, such as those with a history of uveitis or trauma, and consider cataract extraction before or combined with vitrectomy,” he said.

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Finally, monitor the fellow eye carefully and educate patients about using an Amsler grid and watching for any changes in their vision, he added.

Discussing the finding of a high incidence of bilateral macular holes in eyes with a recurrence, Dr. Hassan noted that Thompson et al. identified a similar rate (69%) in their series published in 2000 [Ophthalmology. 2000;107:1073-1077].

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The incidence of bilateral macular holes is generally reported to be in the range of 10% to 15%.

“The data showing that the rate is much higher in patients with a recurrent macular hole raises the idea that these individuals may have some intrinsic predisposition to macular traction, perhaps at the level of the ILM itself, that may then lead to the re-opening,” Dr. Hassan said. “This underscores the importance of vigilant follow-up and surveillance of the other eye in patients with recurrent macular holes.”

Dr. Hassan has no relevant financial interests to disclose.