Result of vitrectomy for traumatic macular holes using an inverted internal limiting membrane flap

Session Details

Session Title: Free Paper Session 13: Vitreoretinal Surgery IV

Session Date/Time: Friday 08/09/2017 | 14:30-16:00

Paper Time: 15:18

Venue: Room 117

First Author: : S.Sheta EGYPT

Co Author(s): :                                 

Abstract Details

Purpose:

Traumatic macular holes can result from blunt traumata, from rupture of a traumatic macular cyst, or from thermal damage.The functional outcome depends on the collateral damage to nearby structures.Vitrectomy with removal of the posterior hyaloid and peeling the ILM can decrease tangential traction and increase retinal elasticity that may help in closure of the macular hole. If the macular hole is large or chronic this might not be sufficient. Using a flap of the ILM to cover the macular hole this will act as a scaffold and help in its closure.

Setting:

A retrospective study to evaluate the functional and anatomical results of vitrectomy with inverted Internal Limiting Membrane (ILM) flap for the treatment of traumatic macular holes.

Methods:

24 cases of traumatic macular holes were studied. there were 18 males. Average age was 21 years old. 23 cases were due to blunt trauma to the eye and one case was due to thermal damage by a laser pointer. Optical coherence tomography confirmed the presence of macular hole, measured the hole size, and demonstrated the presence of edema of the hole edges. The average hole size was 330 microns. 23 gauge vitrectomy was done in all cases with separation of the posterior hyaloid using suction by the vitreous cutter. this was followed by peeling the ILM using Tryban blue stain. A flap of the stained ILM was created using Tano scraper or a fenestrated loop. In few cases the ILM was directly pinched by an ILM forceps and peeled in a circular fashion. The ILM peel was not completed but a temporal-hinged flap was inverted and used to cover the macular hole. Fluid/air exchange was done with the extrusion needle placed above the optic disc and away from the hole so as not to un-intentionally aspirate the ILM flap. 12% C3F8 gas was used to tamponade the hole and face-down positioning was adopted 8 hours daily for a week postoperatively.

Results:

Anatomical closure of the macular hole occurred in 22 cases (91.6%). Visual improvement improved from 3/60 preoperatively to an average of 6/36 postoperatively. Postoperative OCT's confirmed closure of the macular hole and demonstrated the ILM plug that helped in closure of the macular hole. In some cases the visual improvement was limited by the associated RPE damage, optic nerve damage, or lens opacity. The intra ocular pressure was temporally elevated in the postoperative period (probably from mechanical trauma or steroid induced) in 5 cases and was controlled by topical anti-glaucoma medications.

Conclusions:

Pars plana vitrectomy using an inverted ILM flap can help in increasing the closure rate in cases of traumatic macular holes. This is especially needed in cases with large and chronic holes. This may also decrease the need for long post operative face-down positioning which may be needed in the young age group.The functional improvement is limited by the collateral damage to adjacent structures like the choroid, Bruch's membrane and RPE. the worst visual improvement occurred in one case where there was a thermal burn of the fovea by laser pointer. A temporal-hinged ILM flap rather than a free ILM flap help in keeping the ILM in proper position covering the macular hole.The flap was not intended to be placed inside the macular hole as this may risk damaging the RPE and limit functional recovery.

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