ABSTRACT
To present the efficacy of autologous neurosensory retinal transplantation in macular holes surgery with rhegmatogenous retinal detachment. Eleven eyes of 11 patients with rhegmatogenous retinal detachment associated to a large macular hole were enrolled between January 2019 and January 2021 in the Department A of the Hedi Rais Institute of Ophthalmology (Tunis, Tunisia). All patients underwent a 23 G pars plana vitrectomy. An autologous neurosensory retinal patch was placed inside the macular hole. Long-acting silicone tamponade was carried out. Clinical features of the macular area, best-corrected visual acuity (BCVA), fundus examination, and SD-OCT were recorded before surgery, at 1- and 3-month follow-up after surgery. The mean age of our population was 56.6 ± 10.33 years old, ranged from 45 to 76 years old. Final retinal reattachment was achieved clinically in all eyes. The Spectral domain-Optical Coherence Tomography (SD-OCT) follow-up showed the macular hole closure. The retinal patch was demonstrated by OCT at each control. BCVA improved from 1.52 ± 0.23 Logarithm of the Minimum Angle of Resolution (LogMAR) to 0.89 ± 0.16 LogMAR 3 months after surgery (p= 0.014). No adverse events were registered during the study. Autologous neurosensory retinal transplantation has been efficient to treat macular hole associated to rhegmatogenous retinal detachment. Further multicentric studies with a large number of patients are needed to establish the results of this technique in complex cases.
Keywords: large macular hole, retinal detachment, autologous retinal graft, surgery, optical coherence tomography
1. Introduction
Internal limiting membrane (ILM) peeling is the conventional treatment for macular holes (MHs). Most studies report a closure rate over 90% [1–3]. The inverted flap technique has considerably improved visual results in large MHs [4]. The closure rate decreases when MHs are associated to rhegmatogenous retinal detachment (RRD). This is due to detached macula, posterior vitreoretinal proliferation, and macular hole diameter (large MHs) [4]. Therefore, retinal tissue was taken to close difficult MHs using autologous neurosensory retinal free flap. The aim of this study was to present the efficacy of this technique in the management of MHs associated to RRD.
2. Methods
2.1. Study design
This is a prospective interventional study of consecutive patients with rhegmatogenous retinal detachment associated to macular hole treated with pars plana vitrectomy (PPV) and macular retinal patching. This technique was performed by experimented vitreoretinal surgeon at the Department A of the Hedi Rais Institute of Ophthalmology (Tunis, Tunisia) between January 2019 and January 2021.
2.2. Participants
Eleven patients with RRD caused by peripheral tear(s) and associated to large idiopathic macular hole were enrolled. Written informed consent for participation was obtained from all patients. The study was adherent to the Declaration of Helsinki.
Patients were examined at the time of surgery, and then 1 and 3 months after management. At each visit, patients underwent a complete ophthalmologic examination including best-corrected visual acuity (BCVA), slit-lamp biomicroscopy to evaluate anterior and posterior eye segment, intraocular pressure measure, and fundus examination. An optical coherence tomography and retinography were performed at each control.
2.3. Surgical technique
We first performed a central vitrectomy with mechanical detachment of the posterior vitreous. Then, a peripheral vitrectomy under indentation was done. Vitreoretinal proliferations were dissected. The retinal patch was taken by performing a circular retinectomy of one papillary diameter at the superior temporal level under Perfluorocarbon liquid (PFCL). The retinal tissue was prehended by a 23 G microforceps (Figure 1a) then inserted at the level of the macular hole (Figure 1b). Laser retinopexy was performed for the peripheral tears as well as the iatrogenic posterior tear. Air-PFCL exchange was performed and then a final silicone oil tamponade (Polydimethylsiloxane, Baush and Lomb Oxane® 1300) was performed while ensuring that the patch was still in place.
Figure 1.
Intraoperative photos: (a) Taking of retinal graft from the superotemporal retina. (b) Final placement of the retinal graft on the macular hole.
2.4. Statistical analysis
IBM SPSS Statistics version 23 was used for the statistical analysis. In the descriptive statistics, we calculated means and standard deviations for quantitative variables; and for qualitative variables, the absolute and the relative frequency. In order to compare two means at two time-points, we used the Student’s t-test for paired samples. In all statistical tests, the significance level was set at 0.05.
3. Results
We included eleven eyes of 11 patients who underwent vitrectomy with macular retinal patch for rhegmatogenous retinal detachment associate to macular hole. Table I summarizes patient’s characteristics.
Table I.
Demographic and clinical characteristics of our population.
| Patient | Age and sex | Lens status | VRP* stage | Preoperative visual acuity (LogMAR) | Postoperative visual acuity (Log Mar) |
|---|---|---|---|---|---|
| 1 | 55/M | PHAKIC | B | 1.7 | 1 |
| 2 | 76/M | PHAKIC | B | 1.6 | 1 |
| 3 | 45/M | PHAKIC | B | 1.6 | 1.6 |
| 4 | 55/F | PHAKIC | C | 1.1 | 0.82 |
| 5 | 52/M | PHAKIC | C | 1.7 | 1.6 |
| 6 | 71/F | PHAKIC | C | 1.4 | 0.69 |
| 7 | 68/F | PSEUDOPHAKIC | B | 1.3 | 0.69 |
| 8 | 62/M | PHAKIC | B | 1.7 | 1.6 |
| 9 | 48/F | PHAKIC | C | 1.7 | 0.83 |
| 10 | 69/M | PSEUDOPHAKIC | B | 1.3 | 0.69 |
| 11 | 56/F | PHAKIC | B | 1.6 | 0.83 |
*Vitreoretinal proliferation.
The mean age of our population was 56.6 ± 10.33 years old; sex ratio was 6/5. The mean preoperative BCVA was 1.52 ± 0.23 LogMAR. Fundus examination showed the retinal detachment, the peripheral tear(s), the vitreoretinal proliferation stage, and the macular hole (Figures 2a,4a). Preoperative optical coherence tomography (SD-OCT) showed the macula off RRD associated to the macular hole (Figures 2b,3a,4b).
Figure 2.
A 68-year-old woman, pseudophakic with rhegmatogenous retinal detachment associated to macular hole: (a) preoperative retinography showing the retinal detachment associated to a macular hole (high magnification); (b) preoperative SD-OCT showing the retinal detachment with large macular hole (diameter: 488 µm); (c,d) retinography and corresponding macular OCT, 7 days after surgery, showing the re-attachment of the retina with macula filled by the retinal patch; (e) SD-OCT 1 month after surgery showing complete adhesion of the patch to the edges of the macular hole and restoration of retinal continuity, best corrected visual acuity was 1/10 Snellen (1 LogMAR); (f) SD- OCT 3 month post-operatively: reconstruction of a pseudo foveolar depression with complete restoration of macular continuity. The retro foveolar IS/OS line still discontinuous.
Figure 4.
A 76-year-old man, phakic with rhegmatogenous retinal detachment, PVR stage B, associated to a macular hole : (a) preoperative retinography showing the inferotemporal retinal detachment associated to the macular hole; (b) preoperative SD OCT showing the retinal detachment associated to large macular hole (diameter: 442 µm); (c) 1 month postoperative retinography showing the re-attachment of the retina and closure of the macular hole; (d) 1 month postoperative SD-OCT showing the restoration of retinal layers, filling of the macular hole and re-establishment of the continuity between the two edges of the hole associated with temporal atrophy and non-restoration of the retrofoveal neuroretina.
Figure 3.
A 45-year-old man, phakic with rhegmatogenous retinal detachment, PVR stage C associated to macular hole: (a) preoperative SD OCT showing the retinal detachment associated to large macular hole (diameter: 462 µm); (b) 7 days postoperative SD-OCT showing the retinal reattachment, the retinal patch is well individualized within the macular hole; (c) 1 month post-operative SD-OCT showing decrease in retrofoveolar sub-retinal fluid; the patch still filling the macular hole; (d) wield field retinography showing the complete reattachment of the central and peripheral retina.
A complete and durable re-attachment of the retina was observed in all patients at 3 months post-operatively. No patient developed post-operative proliferative vitreo-retinopathy. At 3 months after surgery, we observed macular hole closure with restoration of foveal continuity in 8 patients (73%). The retinal patch detached after 7 days in one patient and 45 days in another. In one patient, the retinal patch did not cover the entire macular hole resulting in a decrease in hole size without restoration of foveal continuity. At 3-month follow-up after surgery, the mean BCVA was 0.89 ± 0.16 LogMAR. The improvement of the visual acuity was statistically significant (p = 0,014) (Table I). The retinal patch was well individualized on the control SD-OCT (Figures 2, 3, 4). No postoperative adverse events were registered during the follow-ups.
4. Discussion
Since its description by Kelly and Wendel [5], gas vitrectomy has become the gold standard for treating macular holes. This technique is efficient to treat small holes. However, it can be insufficient for large and chronic macular holes. Therefore, improvements and modifications of this technique continue to be described. In 2010, Michalewska and associates [4] reported the inverted ILM flap technique and the temporal inverted ILM flap technique, reporting a higher macular hole closure rate. Free ILM patch graft has also been tried with a patch placed in the macular hole without any attachment and fixed by various methods such as hyaluronate-based viscoelastic [6], autologous blood [7], and perfluorocarbon liquid [8].
More recently, Ding [9] conducted a prospective case-series study including five patients with large MH-induced retinal detachment after failed surgery with ILM removal or transplantation. All patients underwent autologous neurosensory retinal patch transplantation. Complete sealing was achieved in all patients and no complications were observed. The mean BCVA improved from 2.38 ± 0.57 pre-operatively to 1.46 ± 0.51 at 6-month postoperative follow-up (p < 0.05). In our study, we included 11 patients with chronic MH naïve from any vitreoretinal surgery. Successful MH closure was achieved in eight patients (73%). The mean BCVA improved from 1.52 ± 0.23 to 0.89 ± 0.16 LogMAR at 3 months postoperatively (p = 0.014).
Most publications described isolated case reports of free flap transplantation of a neurosensory retina patch in MHs [10,11]. Although being a quite invasive technique, the neurosensory patch seems to be easier to manipulate as it is less thin compared to an ILM alone, with good anatomical and functional outcomes.
Finally, it is important to note that further studies with a large number of patients are needed to establish the advantages of this technique and to see whether there are long-term surgery-related complications.
Funding Statement
The authors received no financial support.
Disclosure statement
No potential conflict of interest was reported by the authors.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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