Ophthalmology, October 2019
In 2016, Grewal et al. described use of the autologous neurosensory retinal free flap to close myopic macular holes (MHs) associated with foveoschisis. Since then, the technique has been adopted for various other indications. In a new study, these authors looked at structural and functional outcomes for patients with large refractory MHs that were closed with this procedure. In this initial experience, the technique was safe and successful in most patients.
The multicenter, retrospective, consecutive series included 41 patients (41 eyes) who had a full-thickness MH that persisted after vitrectomy with internal limiting membrane (ILM) peel and tamponade. The subsequent treatment included pars plana vitrectomy, autologous neurosensory retinal transplantation with gas, and tamponade with silicone oil or short-term perfluoro-n-octane heavy liquid. All patients had follow-up for at least six months. Main outcome measures were anatomic closure of the hole, ellipsoid zone (EZ) changes and external limiting membrane (ELM) defects noted on optical coherence tomography (OCT), recovery of visual acuity (VA), and surgical complications. The mean number of previous surgeries in the study group was 1.5 (range, 1-3).
The mean follow-up period after retinal transplantation was 11.1 months (range, 6-36 months). Per OCT findings, complete anatomic closure of the MH was achieved in 36 eyes (87.8%). Mean corrected VA (logMAR units) improved from 1.11 to 1.03 (p = .03) by the last postoperative visit. VA improved in 15 eyes (36.6%), was stable in 17 (41.5%), and declined in nine (21.9%). Of the 36 eyes with anatomic closure, VA improved in 52.3% and worsened in 13.8%. Among the other five eyes, VA worsened in two and improved in none.
Before transplantation, the mean largest basal diameter was 1,468.1 μm (range, 621-2,600 μm), and the mean inner-opening diameter was 825 μm (range, 336-1,649 μm). The mean diameter of the EZ defect was reduced from 1,777.3 μm preoperatively (range, 963-2,808 μm) to 1,370 μm (range, 288-2,000 μm) by the final follow-up exam (p = .007). The mean preoperative ELM defect diameter was 1,681.5 μm (range, 1,172-2,606 μm), which decreased to 1,408.5 μm (range, 200-2,000 μm) by the final follow-up (p = .017). The major postoperative complications were retinal detachment (n = 1) and vitreous hemorrhage (n = 1). There were no cases of proliferative vitreoretinopathy, endophthalmitis, suprachoroidal hemorrhage, or choroidal neovascularization.
Despite the large thick retinal flap, displacement of the flap was the most common complication intraoperatively and immediately afterward (with silicone or gas tamponade). The authors noted that further refinement of the surgical techniques should help sustain the flap’s position. (Also see related commentary by Michael J. Koss, MD, in the same issue.)
The original article can be found here.