Oct. 25, 2024
A retrospective study of 68 eyes (65 patients) indicates that macular hole surgery with broad internal limiting membrane (ILM) peeling, 20% sulfur hexafluoride (SF6) gas and no face-down positioning is highly effective in the surgical treatment of idiopathic macular holes. The method also eliminates the morbidity associated with postoperative face-down positioning.
Currently, most surgeons employ face-down positioning for variable periods following macular hole repair surgery. "This may place a significant burden on patients and even eliminates the surgical opportunity for some," says Raymond Iezzi Jr., M.D., with Ophthalmology at Mayo Clinic in Rochester, Minnesota. "Macular hole closure using limited face-down posturing has been reported previously with varying rates of success."
Dr. Iezzi's team reviewed all idiopathic macular hole surgeries he performed at Mayo Clinic between March 2009 and December 2012. Broad ILM peeling, 20% SF6 gas and no face-down positioning were employed in all of the surgeries.
Of the 68 eyes studied, 48 were in women and 20 were in men. Their average age was 69 years. Characteristics include:
- Three patients had bilateral macular holes, and nine were referred to Mayo for treatment of their recurrent macular holes.
- 21 eyes had stage 2, 27 had stage 3, and 20 had stage 4 macular holes.
- At the time of surgery, 24 eyes were pseudophakic and 44 eyes were phakic.
- A posterior vitreous detachment was present in 20 eyes before surgery.
Patient outcomes
"We considered the single-procedure macular hole closure rate, the mean postoperative best corrected visual acuity, the incidence of cataract and intraocular pressure to compare this surgical treatment with methods that use longer acting gas endotamponade, face-down positioning or both," says Dr. Iezzi. In this study, all eyes completed one-month follow-up and 61 of 68 eyes completed the three-month follow-up.
Findings, published online in the journal Ophthalmology in July 2013, include:
- The single-procedure macular hole closure rate was 100% (95% confidence interval was 95% to 100%) as observed by optical coherence tomography. No complications were observed.
- Overall, 56 of 68 eyes achieved best corrected visual acuity (BCVA) of 20/50 or better at last follow-up. Of the 61 eyes that completed at least three months' follow-up, 53 eyes achieved 20/50 BCVA or better.
- There were no cases of gas bubble-induced cataract that required prompt cataract surgery. The mean interval from macular hole repair to cataract surgery was 207 days. Over a mean follow-up of 216 days, 79% of phakic eyes eventually proceeded to cataract surgery. The incidence of postoperative retinal detachment or macular hole reopening was zero percent.
- Mean postoperative intraocular pressure (IOP) was 15 mm Hg and 16 mm Hg on postoperative days one, seven and 30, respectively, and did not differ significantly from the mean preoperative IOP of 16 mm Hg.
"Face-down positioning reduces the anterior displacement of the lens-iris diaphragm that often elevates IOP in the presence of gas endotamponade," says Dr. Iezzi. "We needed to demonstrate that our no-face-down approach did not increase IOP."
Older patients benefit
Idiopathic macular holes occur almost exclusively in older patients, who are least able to maintain face-down positioning requirements because of increased incidence of cervical and lower back ailments.
"Closure methods that eliminate the need for face-down positioning and do not compromise closure rates would reduce patient morbidity significantly, improve patient satisfaction and represent a significant advancement in surgery for macular holes," says Dr. Iezzi. "Although this retrospective study has limitations, our data suggest that by using broad ILM peeling, 20% SF6 gas and no face-down positioning, macular hole closure rates are comparable with or better than those of other closure methods."
Additional research
Dr. Iezzi and his team also conducted a retrospective review of chronic macular hole cases of greater than one-year duration that were repaired through pars plana vitrectomy with broad internal limiting membrane peeling and no face-down positioning between March 2009 and December 2017. The results of this review were published in Retina in February 2020.
There were 18 eyes of 18 patients that met inclusion criteria. Patients with MH duration of less than one year and without at least one month of follow-up were excluded. There were no other exclusion criteria. Preoperative evaluation included Snellen BCVA, slit-lamp biomicroscopy, dilated fundus examination, and spectral domain optical coherence tomography (OCT). Spectral domain OCT scans were analyzed by one researcher to avoid interobserver variation. All MHs were staged by OCT, with measurements of MH base diameter and MH minimum linear dimension. Full-thickness MHs with no posterior vitreous detachment on OCT and more than 400 μ m minimum linear dimensions on OCT were categorized as stage 3. Full-thickness MHs with posterior vitreous detachment on OCT were categorized as stage 4.
Mean MH duration was 5.0 ± 6.9 years. Two-thirds of MHs had a basal diameter of more than 1,000 mm. Mean preoperative Snellen visual acuity was 20/302 and improved to a mean postoperative visual acuity of 20/112 (p = 0.0001).
"Visual acuity improved in all patients who achieved successful anatomical closure," says Dr. Iezzi, "which was approximately 95%." This study shows that no-face-down macular hole repair is noninferior to face-down procedures, and vision can improve even when the macular hole has been present for many years.
For more information
Is face-down positioning still needed for macular hole repair? Video. Mayo Clinic; 2023.
Iezzi R, et al. No face-down positioning and broad internal limiting membrane peeling in the surgical repair of idiopathic macular holes. Ophthalmology. 2013;120:1998.
Iezzi R, et al. No face-down positioning surgery for the repair of chronic idiopathic macular holes. Retina. 2020;40:282.
Contact Raymond Iezzi Jr., M.D., at iezzi.raymond@mayo.edu or 507-284-3760.
Refer a patient to Mayo Clinic.