Elsevier

Ophthalmology

Volume 105, Issue 8, 1 August 1998, Pages 1411-1418
Ophthalmology

Photocoagulation and fluid—gas exchange to treat persistent macular holes after prior vitrectomy: A pilot study1Historical vignette,

Presented in part at the 20th Annual Japan Ophthalmic Surgery Meeting, Yokohama, Japan, January 1997.
https://doi.org/10.1016/S0161-6420(98)98021-6Get rights and content

Abstract

Objective

This study aimed to determine the efficacy of photocoagulation to the retinal pigment epithelial (RPE) cells and fluid-gas exchange (FGX) in the treatment of persistent macular holes.

Participants

Thirteen eyes of 12 patients who had undergone photocoagulation to the RPE and FGX for persistent macular holes after initial vitrectomy and gas tamponade were examined. All eyes had persistent full-thickness macular holes (diameter range, 290–820 μm; 610 ± 190, mean ± standard deviation) and no vitreous cortex around the holes on biomicroscopic examination.

Intervention

Argon laser photocoagulation was applied to the RPE in the hole bed, and FGX with 20% sulfur hexafluoride was then performed, followed by 2 weeks with the patient in a prone position. The follow-up period of the patients ranged from 3 to 18 months (10.2 ± 4.2; mean ± standard deviation).

Main outcome measures

Anatomic success and final visual outcome were measured.

Results

Macular holes were closed successfully after treatment in 12 (92%) of 13 eyes, and visual acuity improved 2 or more lines in 6 eyes (46%). Two eyes (15%) attained visual acuities of 20/40 or better, and seven eyes (54%) attained 20/67 or better visual acuity. There were no intraoperative complications. Cataract formation or progression was recognized during follow-up in five (83%) of six phakic eyes.

Conclusions

Although this study includes only a small number of patients, it suggests that photocoagulation and FGX can be effective in the treatment of persistent macular holes.

Section snippets

Patients and methods

We retrospectively reviewed the records of 13 eyes of 12 patients with persistent macular holes after initial vitrectomy who underwent photocoagulation of the RPE in the hole bed followed by FGX at either Osaka National Hospital or Osaka University Medical School from August 1995 to July 1996. One case (case 2) had been reported previously.11 The study group consisted of nine women and three men (age range, 55–74 years; 64.2 ± 7.5, mean ± standard deviation [SD]). Before the initial vitrectomy,

Initial successes

To evaluate the potential efficacy of photocoagulation and FGX, we also reviewed the records of 73 eyes of 70 patients who underwent initial vitrectomy for idiopathic macular holes during the same time period at the same institutions. The patient data and surgical results of these eyes were compared with those of patients treated with photocoagulation and FGX.

Of those eyes initially treated, 47 (82%) of 57 eyes (47 patients; 32 women, 15 men) with more than 3 months’ follow-up were treated

Operations before photocoagulation and fluid-gas exchange

Of the 13 study eyes that underwent photocoagulation and FGX, vitrectomies before photocoagulation were performed at either the Osaka University Medical School or the Osaka National Hospital. A three-port system was used in all vitrectomies. A core vitrectomy was performed, followed by separation and removal of the posterior vitreous cortex from the optic nerve head and macula using a flexible cannula. Special effort was made to ensure that all adherent vitreous was removed from the neural

Statistical analysis

Using Fisher’s exact test, we analyzed the patient data, including age, gender, duration of symptoms, and preoperative visual acuities; type of gas used during initial vitrectomy; and visual outcomes as a comparison between the eyes that underwent a successful initial vitrectomy and those that underwent an unsuccessful initial macular hole surgery but were treated successfully with photocoagulation and FGX; P <0.05 was considered significant.

Case 8

A 65-year-old man was referred to the Osaka National Hospital in August 1994 for visual loss of 2 weeks’ duration in his left eye. Best-corrected visual acuity was 20/20 in the right eye and 20/40 in the left eye. Intraocular pressure was normal bilaterally. A mild cataract was present on the slit-lamp examination in the left eye. Biomicroscopic fundus examination results showed a stage III macular hole in the left eye. The diameter of the hole was 300 μm. One week later, we performed

Results

Patient data are listed in Table 1. The pretreatment visual acuity levels ranged from 2/200 to 20/50, and the intervals from the previous vitrectomy to treatment ranged from 1 to 4 months (1.2 ± 0.8, mean ± SD). The persistent macular holes were all full thickness with diameters ranging from 250 to 650 μm (480 ± 160, mean ± SD) before the initial vitrectomy and from 290 to 820 μm (610 ± 190 mean ± SD) before photocoagulation. Pretreatment lens status was as follows: clear lens in four eyes

Discussion

The persistence of a macular hole after vitrectomy is one of the major complications of this type of surgery, although it occurs in a minority of cases. Kelly and Wendel3 reported that 125 (73%) of 170 study eyes achieved anatomic success, with 45 (27%) of 170 holes failing to close. More recent studies have reported higher success rates, but surgical failures are present in nearly every series to date. In the current series, successful hole closure was achieved after 1 operation in 47 (82%) of

Acknowledgements

The authors thank Dr. John Michael Lewis, Retinal Diagnostic Center, San Jose, California, for his assistance.

References (29)

  • M.P. Varley et al.

    Subretinal neovascularization after focal argon laser for diabetic macular edema

    Ophthalmology

    (1988)
  • J.S. Duker et al.

    Late re-opening of macular holes after initially successful treatment with vitreous surgery

    Ophthalmology

    (1994)
  • J.T. Thompson et al.

    Effects of intraocular bubble duration in the treatment of macular holes by vitrectomy and transforming growth factor-beta 2

    Ophthalmology

    (1994)
  • J.D.M. Gass

    Idiopathic senile macular hole. Its early stages and pathogenesis

    Arch Ophthalmol

    (1988)
  • Cited by (0)

    Supported in part by a grant from the Osaka Eye Bank, Osaka, Japan.

    1

    None of the authors has financial interest in products or devices used in this study.

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