Session Title: Vitreoretinal Surgery I
Session Date/Time: Thursday 17/09/2015 | 08:30-10:30
Paper Time: 09:02
First Author: : M.Awadalla EGYPT
Co Author(s): : A. AbdelKader
PURPOSE:Macular holes with base diameter larger than one disc diameter (DD), which might be referred to as giant macular holes, are rare and generally viewed as having less desirable surgical prognosis. We report excellent anatomic and visual outcome following 23-gauge pars plana vitrectomy (PPV), Internal limiting membrane (ILM) peeling, and silicone oil tamponade in two cases of traumatic macular holes with base diameters of 2262 μm, and 2700 μm respectively.
Faculty of Medicine, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt.
Two patients were included in this surgical case report. The first was a 14-year-old male who presented with 1-month history of decreasing visual acuity (VA) after blunt trauma by a stone to his left eye. Snellen best-corrected visual acuity (BCVA) was 6/6 in the right and 5/60 in the left eye. Clinical examination revealed a large traumatic macular hole. OCT showed basal diameter of 2262 μm with thickened edges by intraretinal cysts. The second patient was 18-year-old male who had 4-month history of decreasing VA following a blunt trauma (blow from a fist) to his left eye. BCVA was 6/6 in the right and 3/60 in the left eye. Examination revealed a large traumatic macular hole. OCT showed basal diameter of 2700 μm with atrophic edges. The surgical procedure consisted of 23-gauge PPV, removal of attached posterior cortical vitreous, Brilliant blue assisted ILM peeling up to the arcades, and fluid-air exchange with passive aspiration over the hole, followed by air-silicone oil (1000 centistokes) exchange. Postoperatively, both patients were asked to maintain face-down position on the first night, with only restriction of supine position thereafter. Silicone oil removal combined with phacoemulsification and intraocular lens (IOL) was done after 3-months duration.
Successful anatomical closure of the macular hole was achieved in both patients during the first postoperative week. Biomicroscopy showed disappearance of the macular hole rim and its attachment to the underlying RPE. OCT scans done on the 4th postoperative day in the first patient, and on the 7th day in the second one confirmed early type 1 closure of the macular holes. OCT of the first case demonstrated some later remodeling of the growing tissue at the hole center into a final smooth U-shaped closure pattern. The second macular hole demonstrated early smooth flat closure pattern from the start, but with maintenance of the retinal thinning seen in preoperative scans. Functionally, both patients had early postoperative improvement of BCVA that was maintained until the last follow-up 2 month following silicone oil removal. Last follow-up BCVA was 20/80 in both patients. Except for posterior subcapsular cataract for which surgery was done, no silicone oil-related complications were reported during the postoperative period.
In contrast to the frequent previous reports of poor prognosis of surgical procedures, mostly involving gas tamponade, for treating very large macular holes, we report excellent structural and functional outcome in two giant macular hole cases. We performed the usual 23-gauge PPV with wide ILM peeling, but with utilization of silicone oil as a tamponade. We assume that silicone oil might provide several advantages in such cases: less postoperative postural constraints, near complete filling of vitreous cavity, in addition to its peculiar dynamics at the silicone bubble-hole interface. The latter is due to its lower surface tension, compared to gas, a characteristic that might allow the silicone bubble to come in actual contact with the large floor of the hole, providing an effective scaffold for the growing tissue, and possibly stimulating the cells involved the process of macular hole closure. The drawback of doing a second surgery is a small price to pay for excellent surgical results.