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An Analytical Study with a Novel Surgical
Technique By “Traction Release ILM Peeling”
for Large Diameter Chronic Macular Holes
Rajkumar Maheshwari1, Sajeev Cherian Jacob2, Lavanya Kalikivayi3 M, Linu Raphel4 B and Venkataramana Kalikivayi*
Consultant Ophthalmologist, Ahalia Foundation Eye Hospital, India
Submission: December 16, 2019;Published: February 07, 2020
*Corresponding author: Venkataramana Kalikivayi, Ahalia School of Optometry, Ahalia Foundation Eye Hospital, Palakkad, Kerala, India
How to cite this article:Joseph W Eichenbaum. The Doctor Patient Relationship: A Calculus of Two Languages? A Glimpse at VKH Disease Through the Doctor Patient Relationship. JOJ Ophthalmol. 2020; 8(2): 555734.DOI: 10.19080/JOJO.2020.08.555734
Title: An Analytical Study with a novel Surgical Technique by “Traction Release ILM Peeling” for Large Diameter Chronic Macular holes.
Purpose: To analyze the effect of anatomical and functional outcome of large diameter chronic macular holes by managing through a novel Surgical Technique which includes Traction Release ILM Peeling (TRILMP) without manipulating the flap using only silicone oil tamponade.
Design: Prospective Cohort study.
Subjects: A prospective study of 15 patients having stage 4 chronic large diameter macular holes were recruited by stratified random sampling technique.
Methods: Contrary to the conventional inverse ILM peeling surgery, a modified TRILMP technique was used for all chronic macular hole cases. Surgical procedure was performed in 15 patients by a single surgeon. Functional visual outcome was measured by Log MAR visual acuity charts and anatomical closure by OCT imaging to calculate the basal hole diameter, the minimum hole diameter and hole form factor (HFF).
Main outcome measures: Both anatomical and functional factors involving hole form factor, basal hole diameter and visual improvement postoperatively were analyzed.
Results: Fourteen of 15 eyes (93%) had type 1 closure with a mean basal hole diameter of 1249 ± 174μm and one eye (7%) had type 2 closure with a basal hole diameter of 1683μm. A statistically significant improvement in the visual outcome with p<0.05 was found between pre and post-operative Log MAR values. A significant negative correlation (p=0.04) was found between hole form factor (HFF) (Mean = 0.54) and post-operative Log MAR visual acuity. Similarly, a significant positive correlation (p=0.001) was found between basal hole diameter and post-operative Log MAR visual acuity. Functional visual improvement of 61% was achieved 6 months postoperatively where the maximum visual acuity improved from log 1.3-log 0.3.
Conclusion: A lone tamponade of silicone oil was used along with a novel Surgical Technique adopting traction release ILM peeling without manipulating the flap remnant around macular hole edge, which gave an enhanced anatomical and functional result even in macular holes with larger basal diameter and a medium HFF.
Keywords: ILM peeling; Silicone oil; Chronic macular hole; Hole form factor; Basal diameter
Idiopathic macular holes are one of the commonest causes of central vision impairment in the elderly group. The prevalence rates are 0.02% in Australia, 0.09 % in China, 0.17% in southern India and 0.3% in Baltimore [1-4]. “The Eye Disease Case-Control Study” reported that more than 50% of the patients were between the age of 65–74 years and 72% of idiopathic holes occurred in women . In 1988, Gass proposed that the contraction of foveolar cortical vitreous resulted in tangential traction which led to
a predictable progression through multiple stages . Since the 1990s, the emergence of Optical Coherence Tomography (OCT) led to a significant appreciation of the tractional forces and the sequence of events from vitreomacular traction to the formation of a full-thickness macular hole. The first calculated OCT index used as a prognostic factor was the hole form factor (HFF) . It is the quotient of the summation of the left and right arm lengths divided by the basal hole diameter. The basal hole diameter is the diameter of the macular hole measured at the level of retinal pigment
epithelium. The technique proposed by Kelly and Wendel in
1991  remains the basis for the standard surgical repair of macular
hole even today. This includes, 3 port pars plana vitrectomy
with removal of cortical vitreous and epiretinal membrane (ERM)
followed by an intraocular tamponade by C3F8 gas. After the surgery,
the patient had to maintain a strict face-down position for
no less than a week in order to attain a maximum tamponade of
the macula. Currently, several modifications of the standard technique
are developed. The newer techniques include internal limiting
membrane (ILM) peeling  and use of surgical adjuvants like
TGF beta 2, autologous serum, platelets, and whole blood [8-11].
The ILM peeling around the macular hole was found to increase
the success rate close to 88-100% possibly by removing all the
tractional elements, [12-16] thereby aiding better hole closure. In
2010, an additional “Inverted ILM flap” technique, was put forth
which was proved to increase the rate of complete closure of the
macular hole with improved visual outcome . This technique
involved leaving remnants of ILM at the macular hole margin to
about 2 disc diameters (DD). This ILM remnant was then inverted
upside-down to cover the macular hole and the fluid-air exchange
was performed. Studies done by Kannan et al.  and Chabblani
et al.  showed that inverted ILM flap technique did not lead to
significantly higher closure rates as opposed to conventional ILM
peeling in large macula hole (MH) > 800μm. In the study by Shukla
et al.  it was found that 81% of chronic macular holes achieved
anatomical closure by using ILM peeling and C3F8 tamponade. It
was also reported that 62% attained type 1 closure, 19% attained
type 2 closure and larger holes with a mean of 1205μm remained
open postoperatively. In their study, larger holes were more likely
to remain open after surgical repair. Several studies had used
silicone oil tamponade for treatment of idiopathic macular holes
predominantly to avoid postoperative head posturing and the results
achieved were comparable with C3F8 tamponade [21-23].
Lai and McCuen compared silicone oil versus gas tamponade
and found that C3F8 gas proved to be a more effective tamponade
than silicone oil with respect to achieving initial closure of macular
holes . Eyes receiving an oil tamponade required significantly
more reoperations to achieve a similar rate of hole closure
compared with eyes undergoing a gas tamponade. Final visual
acuity was better for gas-operated eyes than for silicone-operated
eyes. The aim of this study was to analyze the results of a novel
surgical technique for chronic macular holes with pars plana vitrectomy
adopting traction release ILM peeling (TRILMP), leaving
a circular remnant of 2/3rd DD of ILM around the MH edges with
silicone oil tamponade.
This prospective cohort study recruited patients from a single
surgeon who were diagnosed to have chronic (duration >6
months) full-thickness stage 4 macular hole. Patients with previous
history of trauma and vitreoretinal surgeries were excluded.
Institutional ethics committee approval was obtained, and this
study followed the tenets of the declaration of Helsinki. Surgical
procedure was performed in 15 eyes of 15 patients after obtaining
written informed consent. Preoperative evaluation included objective
and subjective refraction, intraocular pressure (IOP) measurement,
slit lamp biomicroscopy along with retinal evaluation
with indirect ophthalmoscopy. OCT imaging was performed to
calculate the basal hole diameter, the minimum hole diameter and
hole form factor (HFF). All the patients underwent 25G pars plana
vitrectomy using Zeiss resight biome wide field lens. The removal
of posterior hyaloid was aided using triamcinolone acetonide.
Brilliant Blue dye was used under air for <5 seconds for better
visualization of the ILM. Alcon ILM forceps was used to pinch and
elevate the ILM. Unlike earlier works, the ILM remnant was not
inverted and placed into the MH which was the customary procedure.
Instead ILM peeling was performed in a doughnut-shaped
fashion leaving approximately a circular remnant of 2/3rd DD of
ILM still attached to the margins of the macular hole. Once the
traction on the edges of MH was released, hole closure was more
rapid and rewarding. Exchange of fluid-air was followed by filling
of silicone oil (1500cs) tamponade. Complete fill of the vitreous
cavity devoid of air bubbles was ensured. Patients were followed
up on day 1, 1 week, 1 month, 2 months and 6 months postoperatively.
At each visit best corrected visual acuity (BCVA) and IOP
were recorded. OCT imaging was done on the next day and at 1
month post op review. Silicone oil removal was done between
2-3 months. Anatomical outcome and final visual acuity were assessed
for each patient at the end of 6 months follow up.
Descriptive analyses were computed for all the patients. Student’s
t test was performed to analyze the pre-op and post-op results.
A simple linear regression was carried out to estimate the
influence of basal hole diameter, minimum diameter and hole
form factor on the functional visual outcome postoperatively.
A total of 15 eyes from 15 patients with chronic idiopathic
macular holes were included in the study. There were 6 males and
9 females in the group with an average age of 65±5.64 years and
65±3.63 years respectively. All the patients had a full-thickness
stage 4 macular hole (according to Gass classification). OCT imaging
was done to measure the basal hole diameter, the minimum
hole diameter and the hole form factor (HFF) was calculated. The
mean basal hole diameter in the group was 1270±203 microns
with a minimum of 851 microns and maximum of 1683 microns.
The minimum hole diameter ranged between 338 to 844μm with
a mean of 697±141 um. The average HFF in the group was calculated
and was found to be 0.54 ± 0.09 with a minimum of 0.41 and
a maximum of 0.77. Fourteen of 15 eyes (93%) had type 1 closure
with a mean basal hole diameter of 1249±174μm and mean minimum
hole diameter of 687±141μm). One eye (7%) had type 2 closure
with a basal diameter of 1683μm and minimum hole diameter
of 826μm. The mean preoperative visual acuity was 1.15± 0.17 Log MAR with a range of 0.8 to 1.5 Log MAR. The mean postoperative
visual acuity was 0.91 ± 0.36 and 0.75±0.33 Log MAR after
2 weeks and 2 months respectively. At 6 months review, the mean
visual acuity was 0.7±0.39 Log MAR units. There was a statistically
significant improvement in visual acuity between pre-operative
and 2 weeks (p = 0.01) and 2 months (p < 0.001) postoperative
Log MAR values respectively, whereas there was no statistical significance
with 6 months postoperative Log MAR values.
In this study, 93% had anatomical type 1 closure and only one
case (7%) had a type 2 closure. At 6 months follow up, functional
visual improvement of 61% was achieved postoperatively. A sample
OCT image, before and after macular hole surgery is depicted
in Figure 1 & 2 respectively. There was a positive correlation with
no statistical significance between HFF and preoperative Log MAR
acuity, whereas a non-significant negative correlation was found
between HFF and 2 weeks and 2-months postoperative Log MAR
acuity. However, HFF and 6-month postoperative Log MAR showed
a significant negative correlation with p = 0.04 and R2=0.38 as
shown in Figure 3. A statistically significant positive correlation
was found between basal hole diameter and 2-week postoperative
Log MAR acuity with p = 0.001 and R2 = 0.55 as shown in Figure
4. Nevertheless, a positive correlation between basal hole diameter
and 2-month and 6-month postoperative Log MAR acuity
was present with no statistical significance with p>0.05. A statistically
significant positive correlation was found between minimum
diameter and postoperative 2 weeks and 2-month postoperative
Log MAR acuity (p = 0.008 & 0.02; R2 = 0.43 & 0.46) as represented
in Figure 5 & 6 respectively.
Macular hole surgeries are constantly evolving through time
as a result of various modifications attempted to the classic procedure.
Earlier works [9-11,17,25,26] discussed in detail about the
success of surgeries with C3F8 gas tamponade which necessitate
a strict postoperative face-down position. Anatomical success rate
of 90% and visual improvement in 70% of the operated eyes were
reported by Ivanovska Adjievska et al.  by combining conventional
ILM peeling and silicone oil tamponade (mean pre-op BCVA
was 0.8 log MAR and post-op BCVA at 3 months was 0.6). Compared
with conventional ILM peeling, the inverted ILM flap technique
was more effective for macular hole closure when combined
with silicon oil tamponade. In this study, the anatomical success
rate was 93% and 61% had functional vision improvement after
MH surgery with silicone oil. The inverted ILM is usually folded
into the MH. In the current study, a new technique was attempted
in which the additional manipulation of the ILM remnant by
folding it into the hole (inverse ILM flap) was not performed.
This technique involved ILM peeling leaving a circular remnant
of approximately 2/3rd DD of ILM attached to the margins of the
macular hole. The peeled circular ILM was about 1DD width. After
the ILM peeling, the existing traction on ILM got released and
the entire procedure’s schematic depiction is shown in Figure 7.
The tangential force on the inner circular ILM (B) was towards
the fovea, whereas the outer circular ILM (D) was away from the
fovea. This alone relieved all the tangential tractional forces which
kept the hole open preoperatively. This relieved tangential tractional
force retaining the centripetal force there by facilitating the
chronic macular hole to close and attain type 1 closure (93%).
One of the subjects OCT was taken pre-operatively and immediately
after 2 hours of surgery by the above-mentioned technique
and is shown in Figures 8 & 9 respectively. Within 2 hours of the
surgery, the macular hole got closed suggesting that the traction
on ILM was the primary reason for the formation of the macular
hole. By releasing the traction, the macular hole closed naturally.
Hence this novel procedure is proposed as more appropriate
surgical technique for all the chronic large diameter macular hole
surgeries. In their prospective  randomized study of 21 consecutive
patients with large idiopathic macular holes who had an
unsuccessful previous surgery noted that tamponade with a mixture
of silicone oil and perfluorohexyl octane (Densiron 68) was
more efficacious than gas tamponade. After 12 months follow up,
macular hole closure rate was 82% (9/11) in the F6H8 group and
only 30% (3/10) of patients in the C2F6 group. In this study, TRILMP
technique with silicone oil tamponade achieved much higher
rate of closure. In few studies, closure rates were dependent
upon the minimum hole diameters, basal diameters of the MH
and the HFF. Ullrich et al.  reported that a significant negative
correlation was noted between both the base and the minimum
diameter of the hole and the postoperative visual outcome. They
concluded that higher HFF resulted in a better outcome, where an
HFF of >0.9, the macular hole was closed following a single surgical
procedure, while in eyes with HFF <0.5 anatomical success
rate was only 67%. On the contrary in this work, HFF showed a
significant near perfect negative correlation with Log MAR visual
acuity, indicating that the postoperative visual acuity improved
significantly even with a mean higher HFF value of 0.54. Base diameter
and minimum diameters also revealed moderate negative
correlation with Log MAR acuity indicating that the postoperative
visual acuity improved significantly despite larger diameters.
The success of silicone oil was credited to its anti-wetting
properties and the ability to prevent the fluid from reaching the
hole. The density of silicone oil was 3 percent less than that of
the water. Hence intraocular silicone oil bubble would float to the
superior position and thrust on the retina. But the floatation force
exerted by silicone oil was only 1/30 of that exerted by air or gas.
Hence it was not the buoyancy but the hydraulic force of silicone
oil which played an essential role. Silicone oil has a positive surface
tension against water and forms the physical basis of the tamponade
. The completeness of oil fill thus plays an important
role in the success rate of anatomical macular hole closure. The
use of silicone oil for macular hole surgery has other advantages
as well. Silicone oil tamponade is more comfortable to patients
especially the elderly as no long term postoperative posturing is
required. The patients can resume their normal routine lifestyle
during the period of tamponade. Air travel is not contraindicated
for patients with silicone oil in the eye.
The drawback in the use of silicone oil is the need for a second
surgical procedure to remove the oil. The most common complication
of macular hole surgery with either gas tamponade or silicone
oil is cataract formation. Hence the need for a second procedure
alone need not defer the surgeon from choosing silicone oil
as a combined cataract silicone oil removal can be performed after
3 months. With silicon oil tamponade, a type 2 closure in the immediate
post-op period got converted into type 1 closure during
their subsequent follow-ups.
A lone tamponade of silicone oil was used along with a novel
surgical technique adopting TRILMP without manipulating the
flap remnant around MH edge gave an enhanced anatomical and
functional result even in macular holes with larger basal diameter
and a medium HFF. The need of postoperative posturing was alleviated.
The need of cataract surgery due to the consequence of
macular hole surgery either with gas or silicone oil tamponade is addressed by a second surgery during which the silicone oil can
be removed which has enhanced sequel compared to the other