Short abstract
Treating myopic macular hole with a central retinal detachment with HDSO and the anatomical success of this procedure
In this issue, Cheung et al1 (see page 719) report successful surgery for myopic macular hole with retinal detachment using high‐density silicone oil (Oxane HD, Bausch & Lomb, Feldkirchen, Germany) as an endotamponade. Myopic macular hole with a central retinal detachment represents a special therapeutic challenge. For this condition, vitrectomy with various endotamponades, retinopexy, photocoagulation and removal of the inner limiting membrane is still under discussion. Several surgical approaches have been described, including vitrectomy with gas tamponade,2 additional laser photocoagulation to the hole margin3 and episcleral buckling of the macular area.4 The success rate of vitrectomy with gas endotamponade for myopic eyes with central retinal detachments ranges between 45% and 68%.5,6,7,8 Success rates up to 79% have been described when using silicone oil as an endotamponade.9 In 1999, Wolfensberger and Gonvers10 described a series of 11 eyes having myopic macular hole with a central retinal detachment vitrectomy with silicone oil tamponade, including photocoagulation of the hole margin that resulted in an anatomical success in >90% of eyes. However, laser coagulation leads to destruction of retinal tissue and limits the functional outcome, and should be considered only in eyes with poor visual prognosis. Factors for the limited success rate in myopic central retinal detachment with macular hole formation could be the loss of chorioretinal tissue, myopic retinal pigment epithelium atrophy and poor compliance to face‐down positioning after surgery with conventional endotamponades (eg, gas, silicone oil).
Recently, high‐density silicone oils (HDSOs) have been developed as a vitreous substitute.11,12,13,14,15 The advantage of HDSO in comparison with gas and standard silicone oil is that no restriction of posturing is required postoperatively. Furthermore, it has been demonstrated that in the upright position a standard silicone oil bubble does not conform with the foveal depression.16 This results in a lack of effective tamponade on the fovea. The poor tamponade might be an explanation why visual recovery after silicone oil tamponade is less favourable than after gas tamponade.17 By contrast, HDSO shows a good tamponade effect on the foveal region in optical coherence tomography images.14 Therefore, HDSO may overcome the limitations of silicone oil in complicated macular hole surgery.
In their uncontrolled pilot study of 12 eyes, Cheung et al1 describe the use of Oxane HD for myopic macular hole with retinal detachment. The surgical outcomes were promising, with 83% successful macular hole closure and reattachment after a single surgery with a mean follow‐up of 12 months. The results compared favourably with other surgical techniques for myopic macular hole retinal detachment. Significant side effects related to the HDSO were not observed in this pilot study. In particular, no intraocular inflammation18 or problems during silicone oil removal19 have been observed.
Oxane HD is a mixture of silicone oil and a mixed fluorinated and hydrocarbonated olefin (RMN3). The mixture is homogeneous and stable in the presence of water, air or perfluorocarbon. This HDSO has a specific gravity of 1.03 g/cm3 and a viscosity of 3.800 mPas. The good tamponade effect in the foveal region is probably due to the RMN3 compound of the endotamponade. A hydrophobic tamponade agent such as silicone oil shows a small contact angle with the hydrophilic retina, whereas hydrophilic perfluorocarbons, semifluorinated alkanes and RMN3 have a large contact angle with the hydrophilic retina.20
HDSO seems to be a promising endotamponade for complicated retinal detachments including retinal detachment secondary to myopic macular hole. Several controlled trials are under way to compare the efficacy of heavier than‐water silicone oil in complicated retinal detachment. These will evaluate the role of HDSO in complicated retinal detachment of the inferior retina. In macular hole surgery, the major advantage of HDSO is the lack of requirement for prone positioning postoperatively. However, further work is necessary to evaluate potential issues such as inflammation, retinal toxicity and sticky silicone oil observed with the use of HDSO.
Footnotes
Competing interests: None.
References
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