Dr.ABHISHEK ANAND, Dr.Shalabh Sinha,Dr.Raj Vardhan Azad
Dr.Abhishek Anand1, Dr. Shalabh Sinha2
1Assistant Professor, Regional Institute of Ophthalmology, IGIMS
2Director, NayandeepNethralaya, Muzaffarpur
Purpose: To review the outcomes of pars planavitrectomy, internal limiting membrane (ILM) peel with inverted flap, and gas tamponade in the management of traumatic macular holes.
Methods: Prospective case series of Traumatic Macular hole undergoing vitrectomy, ILM peel and inverted flap, and gas tamponade for traumatic mac- ular hole between June 2014 and May 2017. Main outcome measures were postoperative visual acuity at 1 and 3months, anatomic closure rate, and surgical complications.
Seven eyes of non resolving TMH underwent pars planavitrectomy with inverted ILM flap and gas Tamponade. Mean age of TMH was 22.8 months on history. Preoperative mean base diameter and minimum diameter were 1746.2μ and 632.8μ r:esp.
Results: 4 eyes had type 2 closure and 3 eye had Type 1 closure. one eye had a unique presentation with large subretinal fibrous band temporal to TMH elevating the hole and retina. Post operatively a thin layer of retinal tissue bridged the gap between the two edges.Another eye had an elevated Chorio retinal scar with dipping of the chorioscleral complex which initially had non closure but on subsequent follow up had tytpe 1 closure. All eyes had 2-3 line gain on snellen chart.
Conclusion: Positive gain can be expected in cases of old and large TMH’s even with adjacent subretinal rupture or scar tissue.
Introduction
Macular holes can cause significant central vision loss. The most common type of macular hole is idiopathic macular holes (IMH), which is caused by the both anteroposterior and tangential vitreous traction on the foveal center1.
Traumatic macular hole (TMH) is the second most common cause of macular hole. It is defined to macular hole caused by mechanic blunt injury of the eye. Although TMH occurs in 1.4% among closed globe injury cases and to a less extent (0.15%) among open globe injury cases2, it may sometimes lead to permanent significant vision loss, due to being usually associated with other retinal pathologies, including commotio retinae, diffuse retinal edema, retinal hemorrhage, vitreous hemorrhage, choroidal rupture, photoreceptor and RPE damage, and retinal tears and dialysis.TMHs are usually associated with sport, recreation, work, and transportation2,3.
While the surgical strategy for the repair of idiopathic and traumatic macular holes is generally similar, vitrectomy and posterior vitreous removal, internal limiting membrane (ILM) peeling/removal, gas bubble, and postoperative face-down positioning. The success rate of surgery for traumatic macular hole is lower as compared to idiopathic Mcular holes. In order of high failure rates of TMH in comparison to IMH we did an inverted ILM flap for all TMHs irrespective of size or chronicity.
We present a series of 7 consecutive cases of traumatic macular holes treated with pars planavitrectomy and inverted ILM flap with gas tamponade and review their outcome in these cases. We focus the efficacy of inverted ILM flap on producing closure in TMH and improving visual function.
Methods
All patients under 18 years of age underwent vitrectomy between hole between June 2014 and May 2017 at Max Eye hospital, Patna and were followed up prospectively. Two senior surgeons performed the procedure. Informed consent was obtained from patients or their parent or guardian prior to surgery. Patients presenting with a known history of trauma and Traumatic macular hole were followed up to a minimum for 3 months and advised surgery if on evidence of non closure of holes.Patiens with chronic TMHs were advised surgery at the first evaluation. Patients were followed up Post-operatively at 1 and 3 months for BCVA, Applanation Tonometry, Best Corrected Visual Acuity, Optical Coherence Tomography and any secondary complications.
A standard 3-port pars planavitrectomy with posterior vitreous detachment induction was used in all cases. Complete Vitreous detatchment was ensured, by using Triamcinolone Acetonide for staining any posterior hyaloid remnants. ILM peeling was achieved after staining with brilliant blue G (Aurolab). 23 Gauge ILM peeling forceps DORC make was used to lift initial ILM flap using pinch and lift technique. 360° ILM peeling was achieved leaving a large temporal flap which was trimmed with vitrectomy probe if required. Staining and satisfactory ILM removal was achieved in all cases. C3F8 14% gas tamponade was used in all cases and face-down posturing was advised. All cases were operated with 23 Gauge Pars Plana Vitrectomy System. Ports were sutured with 8-0 Vicryl sutures in patients requiring General Anaesthesia. 2 patients were operated under General Anaethesia and 5 patients were operated under peribulbar block.
Topcon 3D-OCT Maestro was used for pre and post operative documentation of Macular hole status and hole closure status.
Results
In total 7 eyes of 7 patients who underwent 23 Gauge Pars Plana Vitrectomy for non resolving TMH were followed up post-operatively and observed at 1 and 3 month.
All patients were under 18 years of age.The age of patient ranged from 63 months to 210 months. The mean age of the patients was 8 years 9 months.There were 5 males and 2 females in the study group.
Mean age of TMH was 22.8 months on patientshistory. Preoperative mean base diameter and minimum diameter were 1746.2μ and 632.8μ respectively. 3 patient had lifted edges. One eye had temporal subretinal scar lifting the temporal part of the hole. Two cases had coexistent ocular morbidity from trauma. One eye had subluxated lens and other had a subtotal retinal detatchment with submacular hemorrhage.
In only 1 patient was a posterior vitreous detachment present preoperatively, with the remainder requiring a surgically induced posterior vitreous detachment. No intraoperative complications were reported and specifically no intraoperative iatrogenic retinal breaks were identified. Late postoperative complicaions were limited to early posterior subcapsular cataract in 1 case at 6 months follow up. No other complications were noted post surgery at last follow up.
4 eyes had type 2 closure and 3 eye had Type 1 closure. One eye had a unique presentation with large subretinal fibrous band temporal to TMH elevating the hole and retina. Post operatively a thin layer of retinal tissue bridged the gap between the two edges. Another eye had an elevated Chorio retinal scar with dipping of the chorioscleralcomplex which initially had non closure but on subsequent follow up had type 1 closure. All eyes had 2-3 line gain on snellen chart.
DISCUSSION
Traumatic Paediatric macular holes are an uncommon ophthalmological problem, most commonly developing after trauma. They are much less common than adult macular holes, which have an estimated incidence of 7.8/100,000 per year 4.
The mechanism of development of a macular hole after trauma is not entirely clear. It has been suggested that vitreous detachment and subsequent traction on the macular region may be causative; however, in many cases the vitreous is still firmly adherent to the retina and an alter- native mechanism would therefore seem likely, such as direct rupture of the fovea due to transmitted force of impact. Other suggested pathogenic mechanisms, based on OCT examination of a developing macular hole, in- clude the degeneration of cystoid macular oedema, subfovealhaemorrhage, contusion necrosis, and choroidal rupture as well as subclinical changes to the fovea2,5,6.
The ILM of the retina has been hypothesised to produce traction on the edges of the macular hole and keeps it open. This is the rationale for ILM peeling as part of the surgical repair of a macular hole to relieve the tangential traction achieveing macular hole closure7.
The inverted internal limiting membrane (ILM) flap technique, first described by Michalewska et al in 2010, is an effective surgical technique for treating large idiopathic full thickness macular holes (MHs) and myopic MHs8. In the inverted ILM flap technique, after core vitrectomy and dye staining, the ILM is not completely removed from the retina but is left in place, attached to the edges of the MH. This ILM remnant is then inverted to cover and fill the MH. Finally, fluid-air exchange is performed.
Several mechanisms have been proposed to explain the tissue repair that occurs following use of the inverted ILM flap technique. The inverted ILM, containing Müller cell fragments, may induce glial cell proliferation, filling the MH and supporting MH closure. It may also work as a scaffold for tissue proliferation, creating a microenvironment that encourages correct photoreceptor positioning and finally improving postoperative anatomic and functional outcome.
Variants of the classic inverted flap technique have been described, including autologous extramacular retinal free flap autotransplantation for reoperation cases in which there is no ILM bordering the MH9.
Traumatic Macular holes commonly occurs in Paediatric age group (<18 years) of age. Currently the best practice in management of paediatric macular holes has not been defined by clinical trials; the rarity of paediatric holes means that conducting such a trial would be technically difficult to organise and therefore individual cases and case series thus far provide the evidence base for treatment decisions. Vitrectomy with ILM peeling with or without flap and gas tamponade remains the standard surgical modality of the treatment.
It has been noted that Traumatic macular holes may spontaneously close in some patients, and therefore a period of watchful waiting has been advised10. However, the risk of Amblyopia must be considered and weighed upon.
Most of the literature on TMH is case series and on paediatric TMHs is mostly in single digits. Series by Azevedo and colleagues11, Wachtlinet al12 and Margherio et al13 were small case series and achieved almost universal closure rate and significant improvement in post-operative visual acuity.
In our case series of 7 patients we achieved 100 percent closure rates and significant gain in post-operative visual acuity. We used the current gold standard of inverted ILM flap in all cases. Our case series is unique in view of the very high chronicity of the Traumatic macular hole presentation as we cater mostly to rural population and still there was significant gain in postoperative visual acuity despite their late presentation.
We could successfully conclude that even in neglected TMH surgical option should be kept open after talking about the risks involved and chances of significant gain in postoperative visual acuity. Both risks and gains become more and more paramount as age profile in TMH is of young age. Both should be duly considered.
CONCLUSION
TMHs are well-known complications of ocular blunt injury. TMHs are relatively rare compared to their idiopathic counterpart, but their visual outcomes and associated injuries can be severe. Vitrectomy with the inverted ILM flap technique seems to be a safe and effective surgery for Paediatric TMHs. Positive gain can be expected in cases of old and large TMH’s even with adjacent subretinal rupture or scar tissue.
DISCLOSURE STATEMENT
The authors have no conflicts of interest to report. No funding was received with respect to this paper.
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