Although more than 90% of macular holes close without complication following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peel, refractory macular holes can be a significant problem when they do occur. Few treatment options are available once the ILM has been removed. But an international team of researchers may have solved the problem with a new surgical technique using an autologous neurosensory retinal transplant.

In 41 eyes of 41 patients with refractory macular holes, investigators harvested a full-thickness neurosensory retinal free flap from the mid periphery, typically superior to the superotemporal arcade, to cover the hole. Follow-up of at least six months showed a mean improvement of visual acuity from 1.11 ± 0.66logMAR to 1.03 ± 0.51logMAR. The researchers noted vision improved in 36.6% of eyes, was stable in 41.5% and worsened in 21.9%. Importantly, the procedure led to complete macular hole closure in 87.8% of eyes. Only one patient suffered a retinal detachment during follow up.

The study included a heterogenous population of high myopes from North America, Southern Europe and Asia, the researchers noted in their paper; of the 68.3% who were high myopes, 89.3% achieved anatomical closure—indicating the technique was a success with patients unable to undergo other ILM-based techniques.

“There is some controversy whether it is worthwhile operating on chronic large macular holes with poor baseline vision. Such patients have traditionally not had any surgical options available to them and such large refractory macular holes are often observed without being offered surgical intervention,” the study authors wrote. “An open hole in an eye with high myopia poses the risk of recurrent retinal detachment in addition to contributing to hindered central vision.”

The study presents encouraging data on long-term surgical outcomes of this new technique, which “proved safe in this initial experience for closure of refractory macular holes. Such patients did not previously have viable surgical options available and this technique may provide the basis of a surgical technique upon which other improvements can be built and serve an important tool in the surgical armamentarium for management of such challenging refractory macular holes,” the study concludes. 

Grewal DS, Charles S, Parolini B, et al. Autologous retinal transplant for refractory macular holes: multicenter international collaborative study group. Ophthalmology January 31, 2019. [Epub ahead of print].