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Published in final edited form as: Ophthalmology. 2015 Oct 21;123(1):26–31. doi: 10.1016/j.ophtha.2015.09.015

Rates of Reoperation and Retinal Detachment Following Macular Hole Surgery

Kamyar Vaziri 1, Stephen G Schwartz 1, Krishna S Kishor 1, Jorge A Fortun 1, Andrew A Moshfeghi 2, William E Smiddy 1, Harry W Flynn Jr 1
PMCID: PMC4695225  NIHMSID: NIHMS725162  PMID: 26505804

Abstract

Purpose

To evaluate reoperation rates and to assess the cumulative incidence of retinal detachment (RD) following macular hole surgery.

Design

Retrospective, cross-sectional study.

Subjects

Patients included in the insurance claim-based MarketScan databases from the years 2007–2013 with a record of macular hole surgery.

Methods

Patients with records of macular hole surgery were identified and cases of “definite” (surgeries in which the same eye was coded both times) and “presumed” (surgeries in which the eye laterality was not coded) macular hole reoperations within 2, 3 and 12 months were queried. In addition, cases of postoperative RD occurring within 2, 3, and 12 months were captured.

Main Outcome Measures

Rates of macular hole reoperation and RD following macular hole surgery, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling.

Results

Records of 23,465 macular hole surgeries among 20,764 patients were analyzed. Among ‘presumed’ reoperations, the rates of reoperation were 4.3% (4.1% following ILM peeling and 5.0% following no ILM peeling; P=0.01) within 2 months of the initial surgery, 5.5% (5.3% following ILM peeling and 6.2% following no ILM peeling; P=0.03) within 3 months and 9.5% (9.0% following ILM peeling and 11.0% following no ILM peeling; P=0.01) within 12 months. The rates for ‘definite’ reoperations were 1.3% (1.2% following ILM peeling and 1.8% following no ILM peeling; P=0.04) at 2 months, 1.7% (1.6% following ILM peeling and 2.5% following no ILM peeling; P=0.004) at 3 months and 4.1% (3.3% following ILM peeling and 7.5% following no ILM peeling; P<0.001) at 12 months. The cumulative incidence rate of postoperative RD was 1.81 ± 0.09% to 2.18 ± 0.5% after 2 months, 2.27 ± 0.10% to 3.18 ± 0.67% after 3 months and 3.92 ± 0.16% to 5.70 ± 1.1% after 12 months. ILM peeling was negatively associated with postoperative RD at 2 months (2.3% vs. 1.7%; P=0.007), 3 months (2.8% vs. 2.1%; P=0.004) and 12 months (4.7% vs. 3.3%; P<0.001).

Conclusions

In this large and nationally representative sample, reoperations for macular hole were performed at low rates. ILM peeling was associated with lower rates of reoperation and RD.

INTRODUCTION

In 1991, Kelly and Wendel published pars plana vitrectomy (PPV) as a surgical treatment for macular holes and reported an initial anatomic success rate of 58%.1 Since then, surgical techniques have improved, with recent publications reporting primary closure rates of 84%–100% (Table 1).215

Table 1.

Selected Previously Reported Primary Anatomical Closure rates Following Macular Hole Surgery

Authors Year Vitrectomy Technique N (eyes) Primary closure rate
Haritoglou et al.10 2002 ILMa peeling 99 87%
Jaycock et al.11 2005 ILM peeling 55 78%
Lee et al.4 2005 ILM peeling 37 91.9%
Tognetto et al.8 2006 ILM peeling
No ILM peeling
1100
527
94.1%
89.0%
Patelli et al.20 2007 ILM peeling 24 100%
Lai and Williams5 2007 ILM peeling 59 98%
Muselier et al.2 2010 ILM peeling 120 98.3%
Passemard et al.16 2010 ILM peeling 135 85%
D’souza et al.6 2011 ILM peeling 491 88.8%
Sakaguchi et al.7 2012 No ILM peeling 23 95.7%
Wu and Kung21 2012 ILM peeling High myopia:8
Non-high myopia:34
62.5%
94.1%
a

ILM= Internal limiting membrane

Macular hole surgery, as with any vitrectomy surgery, may be associated with several serious intraoperative and postoperative complications including retinal tear, rhegmatogenous retinal detachment (RD), choroidal hemorrhage, cataract, optic neuropathy, ocular hypertension, cystoid macular edema and endophthalmitis.2,3,16,2,3,79,12,1618 The incidence of RD following macular hole surgery has been reported as high as 17%.3,723 The variability in these reported rates is most likely due to variations in evolving surgical techniques and instrumentation, patient populations, surgical techniques, follow-up times, and sample sizes (Table 2). The majority of studies reporting postoperative RD rates have consisted of relatively small sample sizes (<1000 operated eyes).

Table 2.

Selected Previously Reported Retinal Detachment Rates Following Macular Hole Surgery

Authors Year Vitrectomy Technique N (eyes) Follow-up time (months) RDa rate
Park et al.22 1995 ERMb removal 98 11 (mean) 14%
Banker et al.18 1997 No ILMc peeling 95 12 11%
Tabandeh et al.19 1999 ERM peeling; No ILM peeling 438 30 (mean) 1.8%
Brooks HL, Jr.9 2000 ILM peeling
No ILM peeling
116
44
44.5 (mean) 2.7%
4.5%
Haritoglou et al.10 2002 ILM peeling 99 32 (mean) 2%
Ezra et al.23 2004 ERM peeling; non-ILM peeling 124 24 5.6%
Kwok et al.13 2005 ILM peeling
No ILM peeling
26
25
12 (mean) 7.7%
4%
Tognetto et al.8 2006 ILM peeling
No ILM peeling
1100
527
15 (median) 2.3%
2.9%
Guillaubey et al.12 2007 ILM peeling 272 28 (mean) 6.6%
Patelli et al.20 2007 ILM peeling 24 10 (mean) 16.6%
Christenen14 2009 ILM peeling
Non-ILM peeling
54
25
12 2.2%
Rizzo et al.17 2010 ILM peeling in all cases
20 gauge
23/25 sutureless
301
656
6 1.2%
1.7%
Passemard et al.16 2010 ILM peeling 135 37 (mean) 7.4%
Lois et al.15 2011 ILM peeling
Non-ILM peeling
64
62
6 5%
3%
Sakaguchi et al.7 2012 No ILM peeling 23 83.4 (mean) 0%
Wu and Kung21 2012 ILM peeling High myopia:8
Non-high myopia:34
7.0 (mean)
8.12 (mean)
12.5%
0%
Jackson et al.3 2013 ILM peeling
Non-ILM peeling
1014
64
Unspecified 2.4% (RD surgery)
a

RD= Retinal detachment;

b

ERM= Epiretinal membrane;

c

ILM= Internal limiting membrane

Surgical techniques have evolved to include small-gauge surgery and internal limiting membrane (ILM) peeling. The purpose of this study was to assess the reoperation rates following macular hole surgery and also to evaluate the rates of postoperative RD utilizing a large commercial insurance-claim based database.

METHODS

Data Source

This is a retrospective, cross-sectional study, utilizing the MarketScan commercial Claims and Encounters, and Medicare Supplemental and Coordination of Benefit outpatient Services (Truven Health Analytics, Ann Arbor, MI, USA) from the years 2007 to 2013. The MarketScan family of databases comprises the largest convenience-based proprietary database in the US, annually encompassing approximately 40–50 million patients with employer-sponsored or supplemental insurance. These databases consist of de-identified, individual-level health records (inpatient and outpatient), obtained from large employers, hospitals, and Medicare programs. Because the MarketScan databases contain de-identified and anonymized records and complies with the privacy requirements of the Health Information Portability and Accountability Act of 1996 (HIPAA), Institutional Review Board (IRB) approval was not required.

The MarketScan Outpatient Services databases include demographic, provider type and insurance information along with up to four diagnosis codes and one procedure code per recorded insurance claim (Coded using the International Classification of Disease, ICD-9; and Current Procedural Terminology, CPT, respectively). Only one modifier (such as eye laterality or other modifiers, such as −79) is recorded per surgery. Further details regarding the structure and HIPPA compliance of the MarketScan databases can be found elsewhere.24 These databases have been previously used to study outcomes of other ophthalmic procedures.2528 This search included both the MarketScan and Medicare claims databases. All patients in these databases have unique identifiers, which prevents the possibility of overlap (patients being counted twice).

Study Sample and Statistical Analysis

The present study used Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD-9) codes to identify all patients with macular hole surgery records (vitrectomy CPT codes 67036, 67038, 67039, 67040, 67041, 67042, 67043 and accompanying ICD-9 code 362.54). The 2-, 3- and 12- month cumulative incidence rates of RD following macular hole surgery were calculated using only patients with 2, 3 and 12 months of continuous follow-up within the databases. The most likely explanation for a termination of follow-up within the databases is loss of health insurance.

The databases were queried for cataract extraction CPT codes 66850, 66982, 66983, and 66984 recorded on the same day as macular hole surgeries to identify instances of combined surgeries. RD cases were queried using ICD-9 codes 361.00 to 361.05 and 361.81.

Since some records did not designate the operated eye, two approaches were utilized to evaluate the proportion of re-operations following the initial macular hole surgery. The first approach (‘presumed’ reoperations) included all macular hole surgeries regardless of whether the eye laterality was recorded. This analysis assumed that any macular hole operation using the same CPT and ICD-9 codes within 2, 3, or 12 months of an original surgery was a reoperation on the same eye. The second approach (‘definite’ reoperations) included the subset of ‘presumed’ cases in which the surgical record which specifically designated the same operated eye for the subsequent operation.

Descriptive statistics and cross-tabulations were used to report demographic information. Kaplan Meier survival analysis was utilized to calculate cumulative incidence of RD following macular hole surgeries. Fisher’s exact test was used to calculate P values where appropriate. A P value of <0.05 was considered to be statistically significant. All statistical analyses were performed with SPSS (version 22, SPSS Inc., Chicago, IL, USA).

RESULTS

The database included records of 23,465 macular hole surgeries among 20,764 patients during this timeframe. In 2008, 73.9% (2,273/3075) of surgeries meeting the inclusion criteria were coded utilizing CPT code 67042 (introduced in 2008), which includes ILM peeling; most of the remaining cases were coded using 67039 (10.4%) or 67041 (9.1%). In contrast, 2013 CPT code 67042 was recorded in 88.0% (3,094/3,516) of cases (P<0.05); most of the remaining cases were coded using 67041 (6.4%). The age ranged from age 3 to 99 years with a mean of 65.2 ± 9.9 years. There were 6,929 males (33.4%) and 13,835 females (66.6%).

The ‘presumed’ reoperations cohort included all cases in which reoperation was performed, whether or not the eye laterality was specified. Among ‘presumed’ reoperations, the overall rate of reoperation within 2 months of the initial surgery was 4.3% (841/19,429); these rates were 4.1% after ILM peeling and 5.0% after no ILM peeling (P=0.01). The overall rate of reoperation within 3 months of the initial surgery was 5.5% (1,027/18,668); these rates were 5.3% after ILM peeling and 6.2% after no ILM peeling (P=0.03). The overall rate of reoperation within 12 months of the initial surgery was 9.5% (1234/12,966). These rates were 9.0% after ILM peeling and 11.0% after no ILM peeling (P=0.01) (Table 3). The denominators decrease from the 2 month time point (19,429) through the 12 month time point (12,966) because some patients were lost to follow-up or otherwise excluded from this study.

Table 3.

Proportion of Macular Hole Reoperations Following Initial Surgery

‘Presumed’ reoperations ‘Definite’ reoperations
2 months 4.3% 1.3%
3 months 5.5% 1.7%
12 months 9.5% 4.1%

The ‘definite’ reoperations cohort included only cases in which the eye laterality was specified and the same eye underwent reoperation. The −79 modifier was used in only 2.3% of all macular hole surgeries (545/23,465) in the databases. In addition, the databases only recorded one modifier per surgery, so either the eye laterality or another modifier was coded, but not both. Therefore, for this analysis, only eye laterality was considered. The ‘definite’ reoperations cohort was thus a subgroup within the ‘presumed’ reoperations cohort. Among ‘definite’ reoperations, the overall rate of reoperation within 2 months of the initial surgery was 1.3% (145/11,225); these rates were 1.2% after ILM peeling and 1.8% after no ILM peeling (P=0.04). The overall rate of reoperation within 3 months of the initial surgery was 1.7% (185/10,712); these rates were 1.6% after ILM peeling and 2.5% after no ILM peeling (P=0.004). The overall rate of reoperation within 12 months of the initial surgery was 4.1% (264/6,664); these rates were 3.3% after ILM peeling and 7.5% after no ILM peeling (P<0.001) (Table 3). Similarly, the denominators decrease from the 2 month time point (11,225) through the 12 month time point (6,664) because some patients were lost to follow-up or otherwise excluded from the study.

There were 21,924 macular hole surgeries among 19,429 patients that had at least 2 months of continuous follow-up within the databases. Among these, there were 395 cases of postoperative RD within 2 months of macular hole surgery, and Kaplan-Meier analysis showed that the overall 2-month cumulative incidence rate of RD following macular hole surgery was 1.82 ± 0.09%. This rate was 2.18 ± 0.5% for combined phacovitrectomies and 1.81 ± 0.09% for isolated macular hole surgeries (P=0.48). Of this group, 2 patients underwent additional surgery between the macular hole surgery and the RD repair, both cataract surgeries. Excluding these patients did not materially change the results (Table 4).

Table 4.

Cumulative Incidence rate of Retinal Detachment (RD) Following Macular Hole Surgery

2 months 3 months 12 months
Including other ocular surgeries prior to RD Excluding other ocular surgeries prior to RD Including other ocular surgeries prior to RD Excluding other ocular surgeries prior to RD Including other ocular surgeries prior to RD Excluding other ocular surgeries prior to RD
Combined phacovitrectomy 2.18 ± 0.5% 2.17 ± 0.5% 3.18 ± 0.67% 3.18 ± 0.67% 5.70 ±1.1% 5.47 ± 1.1%
Isolated vitrectomy 1.81 ± 0.09% 1.80 ± 0.09% 2.27 ± 0.10% 2.24 ± 0.10% 3.92 ± 0.16% 3.65 ± 0.16%
All macular hole surgeries 1.82 ± 0.09% 1.81 ± 0.09% 2.30 ± 0.10% 2.27 ± 0.10% 3.97 ± 0.16% 3.70 ± 0.15
P value 0.480 0.470 0.13 0.13 0.12 0.058
a

N/A = Not applicable

There were 21,056 macular hole surgeries among 18,668 patients that had at least 3 months of continuous follow-up within the databases. Among these, there were 478 cases of postoperative RD within 3 months of surgery, and Kaplan-Meier analysis showed that the overall 3-month cumulative incidence rate of RD following macular hole surgery was 2.30 ± 0.10%. This rate was 3.18 ± 0.67% for combined phacovitrectomies and 2.27 ± 0.10% for isolated macular hole surgeries (P=0.13). Of this group, 5 patients underwent additional surgery between the macular hole surgery and the RD repair: 2 cataract surgeries, 1 trabeculectomy, 1 vitrectomy for postoperative endophthalmitis and 1 vitrectomy for retained lens fragments. Excluding these patients did not materially change the results (Table 4).

There were 14,663 macular hole surgeries among 12,966 patients that had 12 months of continuous follow-up with in the databases. Among these, there were 571 cases of postoperative RD within 12 months of macular hole surgery, and Kaplan-Meier analysis showed that the overall 12-month cumulative incidence rate of RD was 3.97±0.16%. This rate was 5.70 ± 1.1% for combined phacovitrectomies and 3.92 ± 0.16% for isolated macular hole surgeries (P=0.12). Of this group, 40 patients underwent a total of 45 additional surgeries between the macular hole surgery and the RD repair: 40 cataract surgeries, 2 trabeculectomies, 2 vitrectomies for retained lens fragments and 1 vitrectomy for endophthalmitis. Excluding these patients did not materially change the results (Table 4).

ILM peeling during the initial macular hole surgery was significantly associated with lower rates of postoperative RD. When all patients who had undergone additional surgeries between the macular hole surgery and the RD repair were excluded, the rates of postoperative RD were 1.7% (285/17,129) among ILM-peeling surgeries compared with 2.3% (108/4,793) among non-ILM-peeling surgeries (P=0.007) within 2 months; 2.1% (343/16,407) among ILM-peeling surgeries compared with 2.8% (130/4,644) among non-ILM-peeling surgeries (P=0.004) within 3 months; and 3.3% (367/11,104) among ILM-peeling surgeries compared with 4.7% (164/3,519) among non-ILM-peeling surgeries (P<0.001) within 12 months.

DISCUSSION

The present study utilized a group of large insurance databases to investigate the success and complication rates of contemporary macular hole surgery. The databases contained patients from all 50 states, yielding large numbers of surgeries and minimizing the potential biases inherent to single-center, surgeon-specific and surgical technique-specific data.

A principal finding was that macular hole patients receiving ILM peeling were less likely to undergo reoperation and less likely to develop postoperative RD than patients not receiving ILM peeling. The lower reoperation rate with ILM peeling is consistent with previously published outcomes reporting higher primary macular hole closure rates with ILM peeling.33

The cumulative incidence rate of RD following macular hole surgery was low, but even lower in eyes with ILM peeling. Others have reported RD rates for both ILM and non-ILM groups with conflicting results, although none of these studies provided statistical significance levels between the two groups. Kwok et al13 and Lois et al15 reported higher rates of RD following ILM peeling, but Brooks et al9 and Tognetto et al8 reported lower rates of RD following ILM peeling (Table 2). It is uncertain and perhaps counterintuitive that ILM peeling was associated with lower rates of RD, although this step does not necessarily induce additional traction on the vitreous base. It is possible that, during the time period studied, surgeons who performed ILM peeling may have been on average more experienced or higher-volume surgeons than those who did not perform ILM peeling, and thus less likely to experience this complication.

Combining the macular hole surgery with cataract extraction did not alter the rates of postoperative RD. Surgical decision-making regarding the phakic macular hole patient is complex and should be based on individual aspects of each patient.

The major weakness of this study relates to the use of databases based on insurance claims. The medical diagnoses and surgical procedures were recorded as ICD-9 and CPT codes respectively, so the accuracy of the data depends upon accurate coding. This is especially important with ICD-9 code 362.54, “macular cyst, hole, or pseudohole”. Some of the included cases may not have been macular holes; they may have represented chronic cystoid macular edema, lamellar macular holes, or other entities. The proportion of non-macular hole cases appears to be small but the statistical analyses used in this study cannot provide a specific estimate.

The possible inclusion of non-macular-hole cases may have biased the reported results. If, for example, some lamellar macular holes were not treated with gas-fluid exchange, it is possible that the rate of postoperative RD might be lower in these eyes, which might underestimate the overall reported RD rate. Similarly, it is possible that some reoperations represented non-macular-hole cases progressing to macular holes after the initial surgery. Therefore, the reported reoperation may have represented the first operation of a true full-thickness macular hole, which might overestimate the reported reoperation rate. The frequency of this occurrence is probably small, and such a bias is likely minimal.

Similarly, this study treated reoperation cases as eyes with either persistent (never closed) or recurrent (closed, but then re-opened) macular holes. The study methodology could not distinguish between these two situations. Some reoperations may have been performed for postoperative epiretinal membrane, rather than persistent or recurrent macular hole. These eyes most likely would not have received ICD-9 code 362.54 for the reoperation, although again the methodology could not estimate if this occurred.

An additional weakness of this study is that, in many cases, the laterality of the eye undergoing surgery could not be ascertained because it was not coded at the time of surgery. This is the reason for stratifying the results into ‘presumed’ reoperations (the eye was not coded) and ‘definite’ reoperations (the eye was coded and was the same for both surgeries). The ‘definite’ cohort may represent a ‘minimum’ reoperation rate or a ‘best-case scenario’ while the ‘presumed’ cohort may represent a ‘maximum’ reoperation rate or a ‘worst-case scenario.’ The actual reoperation rate likely falls between these two results.

Bilateral macular holes are uncommon, as a reported 0%–7% of patients have bilateral macular holes on presentation.8,23,2932 However, the rate of macular hole bilaterality increases with time, and a reported 13% of patients with unilateral full-thickness macular hole develop a macular hole in the fellow eye within 2 years.34 Therefore, it is logical to suspect that operated fellow eyes miscounted as reoperations in the ‘presumed’ cohort would be most likely to occur in the 12- month subgroup.

In addition, the rate of reoperation may not perfectly reflect primary hole closure rates, because at least some patients with failed initial surgery may decline a reoperation.4,6

For the purposes of this analysis, any eye that received CPT code 67042 (which includes ILM peeling) was considered to have undergone ILM peeling and any eye that received a different CPT code was considered to have not undergone ILM peeling. The study methodology would not allow a comparison of surgeons who utilized ILM-peeling codes versus surgeons who did not. This represents another potential source of bias and another example of the weakness of a study design employing a large, anonymized database. Alternative study designs, such as attempting to retrieve operative notes or individual patient charts, might lead to more accurate data.

In conclusion, the approximately 4% rate of reoperation for macular hole is low and ILM peeling was associated with decreased reoperation rates. Further, the rates of postoperative RD were also low and consistent with most recent reports, but ILM peeling was associated with decreased RD rates. These data may be useful in counseling patients regarding specific risks and benefits of macular hole surgery.

Acknowledgments

Financial Support: Partially supported by NIH Center Core Grant P30EY014801 and an unrestricted grant from Research to Prevent Blindness, New York, NY.

Footnotes

Meeting Presentation: Data reported in this manuscript are to be presented at the American Academy of Ophthalmology (AAO) Annual Meeting, 2015.

Conflict of Interest: Dr. Schwartz has received consulting fees from Alimera and Bausch + Lomb and writers’ fees from Vindico. All other authors have no financial disclosures.

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