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1. Borgomanero
How to Avoid Failures
in Macula Hole
Surgery
Vincenzo Ferrara, MD
SS. Trinità Hospital
Borgomanero - ITALY

2. Primary failures 2% to 15%
• Olsen TW et al. Retina 1998
• Park DW et al. Ophthalmology 1999
• Mester V, Kuhn F. Am J Ophthalmol 2000
• Haritoglou C et al. Am J Ophthalmol 2002 and Retina 2006
• Da Mata AP, et al. Ophthalmology 2004
• Schumann RG et al. Am J Ophthalmol 2006
• Hillenkamp J et al Br J Ophthalmol 2007

3. It is not possible to
determine the anatomic
success rate of MH surgery
in this study, but 4.2% of
eyes underwent further MH
surgery.
… not all patients with failed
surgery will elect to undergo
reoperation, and this
proportion is likely to be
greater than the
approximately 6%
Ophthalmology 2013;120:629–634

4. It is not possible to
determine the anatomic
success rate of MH surgery
in this study, but 4.2% of
eyes underwent further MH
surgery.
… not all patients with failed
surgery will elect to undergo
reoperation, and this
proportion is likely to be
greater than the
approximately 6%
Ophthalmology 2013;120:629–634

5. How can it happen that we still
have so many failures?

6. c + d
Hole Form Factor (HFF) =
aAnatomy of the Hole
≥ 800 μ = Lower success rate
Anatomic Reasons for failure in Macular Hole

7. c + d
Hole Form Factor (HFF) =
a
Better postoperative
success and VA
HFF > 0,5
Anatomy of the Hole
≥ 800 μ = Lower success rate
Anatomic Reasons for failure in Macular Hole

8. c + d
Hole Form Factor (HFF) =
a
Worse postoperative
success and VA
HFF < 0,5
Anatomy of the Hole
≥ 800 μ = Lower success rate
Anatomic Reasons for failure in Macular Hole

9. Hole Form Factor (HFF)Anatomy of the Hole
Duration of Symptoms
Holes with cystic degeneration
older than 2 years
 less chances of success !
≥ 800 μ = Lower success rate
Anatomic Reasons for failure in Macular Hole

10. Surgical Reasons for failure in Macular Hole
Relieve of Tractions
Tamponade
Drop of vitreous

11. Surgical Reasons for failure in Macular Hole
Failed Relieve of Tractions

12. Failed Relieve of Tractions
Surgical Reasons for failure in Macular Hole

13. PERSISTANCE OF THE ILM1Failed Relieve of Tractions
Surgical Reasons for failure in Macular Hole
1st op 2nd op

14. PERSISTANCE OF AN INNER RING OF ILMFailed Relieve of Tractions
Surgical Reasons for failure in Macular Hole

15. The ILM is a thin basement membrane in the
pit of the fovea which gradually becomes a
thick basement membrane in the parafovea.
Topographic Variations in the Rabbit and Primate Internal Limiting Membrane Brian
Marsumoro, Janer C. Blanks, and Stephen J. Ryan Invest Ophthalmol Vis Sci 25:71-82,
1984.
Traction during the peeling could induce the
ILM to tear off at the transitional site between
areas of different thickness leaving a rigid ring
Surgical Reasons for failure in Macular Hole
PERSISTANCE OF AN INNER RING OF ILMFailed Relieve of Tractions

16. Surgical Reasons for failure in Macular Hole
Tamponade We need a tamponade …

17. Surgical Reasons for failure in Macular Hole
Tamponade
bubbles keep
dry the edges
of the hole
provides a compartment and
smooth surface for the glial
proliferation which will seal it
Dhawahir-Scala FE, et al.
To posture or not to posture after macular hole
surgery. Retina 2008

18. Surgical Reasons for failure in Macular Hole
Failed Tamponade Holes can be closed in 93% after two
days of face-down positioning
Hasler PW, Prünte C. Early foveal
recovery after macular hole surgery.
Br J Ophthalmol 2008; 92:645– 649

19. Surgical Reasons for failure in Macular Hole
Failed Tamponade Watertight tamponade mandatory
during the first 48 hours
Kasuga Y, Arai J, Akimoto M, et al. Optical
coherence tomograghy to confirm early closure of
macular holes. Am J Ophthalmol 2000;130:675–6

20. Surgical Reasons for failure in Macular Hole
VITREOUS GEL ?
Ferrara V. Belloli V.
The Surgery Of Macular Holes:
Why We Still Cannot Close All Of Them ?
Retinal Physician, April 2010
Failed Tamponade
Failed Release of Tractions
X
X

21. Surgical Reasons for failure in Macular Hole
Drop of vitreous
Vitreous body is not uniform and compact
but contains lacunae and cisterns

22. Surgical Reasons for failure in Macular Hole
During vitrectomy we remove all the visible or the
stained cortical vitreous (collagen)

23. Surgical Reasons for failure in Macular Hole
… but there is an invisible liquid component
(hyaluronic acid - HA) which is delivered from the
lacunae and collects at the posterior pole

24. Surgical Reasons for failure in Macular Hole
At the end of fluidair exchange
HA appears at the posterior pole

25. Surgical Reasons for failure in Macular Hole
and collects into the macular hole

26. Surgical Reasons for failure in Macular Hole

27. Surgical Reasons for failure in Macular Hole
This drop of gel left could become an obstacle to
glial migration and closure of the hole
Schubert HD et al . Macular holes: migratory gaps and vitreous as obstacles to glial closure
Graefes Arch Clin Exp Ophthalmol 1997;235: 523–529

28. Hyaluronic Acid (HA) has inhibitory
effect and realizes with a
viscoseparation an obstacle for the
migration of glial cells
DROP OF VITREOUS

29. DROP OF VITREOUS

30. But HA dissolves in water …
it disappears!
if we search it one week later …

31. Avoiding Failures

32. Tips to avoid failures in Macular Holes
Avoid inner macular rexisRing of ILM
Spreading the force along an arc

33. Tips to avoid failures in Macular Holes
Gently grasp the bordersRing of ILM
Yooh HS, Brooks HL Jr, Capone A Jr , L’Hernault NL, Grossniklaus HE:
Ultrastructural features of tissue removed du ring idiopathic macular hole
surgery. Am J Ophthalmol 1996;122:67 – 75.
Stimulating gliosis by activation of myofibroblasts at foveal ILM

34. Tips to avoid failures in Macular Holes
Radially cutting the bordersRing of ILM

35. Tips to avoid failures in Macular Holes
Gentle suction of the bordersRing of ILM
Approximating the borders of the hole

36. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

37. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

38. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

39. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

40. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

41. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

42. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

43. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

44. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
31
Gauges

45. SILICON OIL SILICON OIL
III EAKO
Ekaterinburg 26-29 April 2003
V. Ferrara - ITALY
"SILICONE OIL IN MACULAR HOLE SURGERY "
Pre-op 1 day Post-op
31
Gauges

46. Macular Hole and Silicone Oil

47. Tips to avoid failures in Macular Holes
Avoid exchange over the hole or drainDrop of HA

48. Tips to avoid failures in Macular Holes
Inverted ILM flapLarge Holes
Ophthalmology 2010;117:2018–2025

49. Tips to avoid failures in Macular Holes
Inverted ILM flapLarge Holes
Ophthalmology 2010;117:2018–2025
Inverted ILM flap technique may
induce glial cell proliferation,
resulting in the macular hole
filling with proliferating cells
that enhance closure.

50. Tips to avoid failures in Macular Holes
Inverted ILM flapLarge Holes
Inverted ILM flap technique may
induce glial cell proliferation,
resulting in the macular hole
filling with proliferating cells
that enhance closure.

51. Tips to avoid failures in Macular Holes
Inverted ILM flap

52. Tips to avoid failures in Macular Holes
Inverted ILM flap

53. TAKE HOME MESSAGE
Don’t touch
Don’t harmRespect