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Retina
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RETINA-224-1154
10.1097/IAE.0000000000004180
00014
3
Original Study
SEQUENTIAL PARS PLANA VITRECTOMY AND INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR RHEGMATOGENOUS RETINAL DETACHMENTS WITH PERIPHERAL BREAKS AND CONCOMITANT NONCAUSATIVE MACULAR HOLE IN NONHIGHLY MYOPIC PATIENTS
Baltă George MD *†george.balta@drd.umfcd.ro

Tofolean Ioana Teodora MD, PhD †‡§
Tiu Tamara MD §tamarabarsan@gmail.com

Dinu Valentin MD, PhD †¶valentin.dinu@umfcd.ro

Alexandrescu Cristina-Mihaela MD, PHD ¶**alexandrescucristina76@yahoo.com

Baltă Florian MD, PhD †§¶††florianbalta@gmail.com

Voinea Liliana-Mary MD, PhD ¶**voineamliliana@yahoo.com

* Doctoral School, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania;
† Bucharest Emergency Eye Hospital, Bucharest, Romania;
‡ Department of Biophysics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania;
§ Retina Clinic, Bucharest, Romania;
¶ Department of Ophthalmology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania;
** Department of Ophthalmology, University Emergency Hospital, Bucharest, Romania; and
†† Academy of Romanian Scientists, Romania.
Reprint requests: Ioana Teodora Tofolean, MD, PhD, Department of Biophysics, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Street, 020021, Bucharest, Romania; e-mail: ioana.tofolean@umfcd.ro
10 2024
12 9 2024
44 10 17771784
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

This study showed that performing sequential surgery using the inverted internal limiting membrane flap technique and air/gas endotamponade produced favorable anatomical and functional outcomes in nonhighly myopic patients with rhegmatogenous retinal detachment with peripheral breaks and concomitant noncausative macular holes.

Purpose:

To present the anatomical and functional results of sequential pars plana vitrectomy for treating rhegmatogenous retinal detachment with peripheral breaks and concomitant noncausative macular holes (MHs) in nonhighly myopic patients.

Methods:

Medical records of patients who underwent rhegmatogenous retinal detachment surgical repair between 2017 and 2023 were reviewed. Of 980 patients with rhegmatogenous retinal detachment, 10 had concurrent MH and underwent sequential pars plana vitrectomy for rhegmatogenous retinal detachment repair and air endotamponade, followed by MH repair using the inverted internal limiting membrane flap technique and C2F6 endotamponade after a minimum of 1 week. The main outcomes measured were best-corrected visual acuity change, retinal reattachment rate, MH closure rate, and closure type.

Results:

The retinal reattachment rate was 90% after the primary surgery and 100% after subsequent surgery. Macular hole closure was achieved in all cases. Macular hole diameters ranged from 291 to 702 µm. Anatomical recovery showed mainly 1A closure types (90%). Functional recovery demonstrated significant best-corrected visual acuity improvement, with a mean visual acuity gain of 1.58 ± 0.41 the logarithm of the minimum angle of resolution.

Conclusion:

For this infrequent pathology, sequential surgery using the inverted internal limiting membrane flap technique and air/gas endotamponade yielded favorable anatomical and functional outcomes. This controlled and standardized approach using sequential surgeries contributes to the achievement of consistent results.

Key words:

air/gas endotamponade
inverted internal limiting membrane flap technique
noncausative macular holes
pars plana vitrectomy
rhegmatogenous retinal detachment
OPEN-ACCESSTRUE
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pmcRhegmatogenous retinal detachment (RRD) with peripheral breaks coexisting with noncausative macular holes (MHs) in nonhighly myopic eyes is rare. Previous studies have reported an incidence range of 1% to 4%.1–7 Despite numerous studies shedding light on the inverted internal limiting membrane (ILM) flap technique as a surgical approach for MH,8–12 literature addressing its use in the association of RRD with concomitant MH is rare.1

Previous studies have classified MH using optical coherence tomography (OCT)-based anatomic systems,13 and new techniques have been developed to treat large MHs.12 However, for this unique association of pathologies, the MH is most commonly found in a macula-off RRD scenario, and OCT-based analysis of the hole cannot be conducted. Therefore, by performing sequential surgeries after meeting the primary goal of attaching the retina, further MH OCT-related assessment can be performed.

This study investigated the outcomes of such sequential pars plana vitrectomy for treating this distinctive pathology.

Methods

We conducted a retrospective observational study that reviewed the medical records of patients who underwent surgical repair of RRD between 2017 and 2023. This study was approved by the Ethics Committee of Ponderas Academic Hospital, Bucharest, Romania, and the Emergency Eye Hospital and Clinic, Bucharest, Romania, and was conducted in accordance with the principles of the Declaration of Helsinki of the World Medical Association. Written informed consent was obtained from all participants.

In this single-center, single-surgeon (F.B.) study, we identified patients with RRD and concomitant MH in nonhighly myopic eyes. Considering previously conducted studies, high myopia was defined as axial length ≥ 26 mm.14,15 The diagnosis was made preoperatively with slit-lamp ophthalmoscopy and swept-source OCT (DRI-OCT Triton, Topcon, Tokyo, Japan), intraoperatively with direct visualization, or by using intraoperative OCT (OPMI Lumera 700, Zeiss, Oberkochen, Germany).

Eyes with high myopia, prior known macular pathology, ocular trauma, MH-associated retinal detachment, in which no other retinal break except for the MH was identified, or past ocular surgery, except for uneventful cataract surgery, were excluded from this study. Demographic data (age and sex), axial length (after retinal reattachment), best-corrected visual acuity (BCVA), size of the MH, lens status, intraocular pressure (IOP), slit-lamp ophthalmoscopy, and swept-source OCT data were collected.

Patients underwent sequential surgical interventions: RRD repair was performed on the day of diagnosis, and MH surgery using the inverted ILM flap technique was conducted at least 1 week later, on a completely attached retina.

Follow-up was performed at 1 day, 1 week, 1 month, and 6 months postoperatively and consisted of BCVA assessment, IOP measurement, slit-lamp ophthalmoscopy, and OCT. The outcomes measured were BCVA change, retinal reattachment rate, MH closure rate, and closure type.

Retinal reattachment refers to the successful restoration of the neurosensory retina to its normal position against the retinal pigment epithelium. Macular hole closure was defined as a flattened and reattached hole rim along the entire circumference of the MH. Rossi et al16 described closure patterns ranging from Type 0, open MH; type T, closed MH; and Type 2, MH closed with autologous or heterologous filling tissue that interrupts the normal foveal layers. The minimum linear diameter (MLD) was defined as the smallest distance across the hole aperture. The basal hole diameter (BHD) refers to the diameter of the base or the widest part of the MH. Both were measured using the caliper of the OCT on the attached macula (as exemplified in Figures 1 and 2), one week after the primary surgery for RRD, before the macular hole closure (the second surgery), and expressed in micrometers (μm). The CLOSE study group12 proposed a surgical classification for MHs, and based on the MLD, it varied from small (<250 µm) to giant (>1,000 µm) holes.

Fig. 1. Optical coherence tomography images of Patient 6 after RRD surgery. The scan shows an attached retina and a macular hole with an MLD of 560 µm and a BHD of 809 µm (A). After 1 month, the MH shows swelling of the borders, with an MLD of 560 µm and a BHD of 1,043 µm (B).

Fig. 2. Optical coherence tomography images of Patient 8 after RRD surgery. The scan shows an attached retina and an MH with 468-µm MLD and 823-µm BHD (A). After 1 month, the MH shows swelling of the borders with an MLD of 525 µm and a BHD of 1,257 µm (B).

Surgical Procedure

The chosen approach involved sequential surgery, commencing with RRD repair, followed by MH repair. Simultaneous cataract surgery with IOL implantation was performed, when necessary, preferably after retinal attachment, to facilitate standard optical biometry and obtain the best refraction results.

All patients underwent standard three-port, 25-gauge pars plana vitrectomy using Alcon Constellation (Alcon Laboratories, Fort Worth, TX). The surgical microscope used was either a Topcon OMS-800 with an OFFIS viewing system or a Zeiss Lumera 700 with a Resight viewing system.

First surgery

After core vitrectomy and posterior vitreous detachment induction, perfluorocarbon liquid (PFCL) was used to secure the posterior pole. All retinal breaks were identified using scleral depression. The release of the anteroposterior traction at the site of each break was accomplished either by shaving the vitreous at the site of every break or by a bimanual technique using an illuminated spatula and forceps and by mechanically dissecting the vitreous situated anteriorly to the retinal breaks. Subsequently, the subretinal fluid was aspirated, followed by air–fluid exchange to remove any residual fluid from the anterior pole. After PFCL aspiration, the retina was attached under air, and endolaser photocoagulation was performed circumferentially around the breaks. The endotamponade of choice for nine of 10 cases was air, whereas in one case, hexafluoroethane (C2F6) was used. The 24-hour postoperative positioning was determined in each case, based on the location of the retinal breaks. Follow-ups were performed at 1 day and 1 week postoperatively.

Second surgery

A standard three-port, 25-gauge pars plana vitrectomy, using a wide-angle noncontact viewing system was employed. We stained the ILM with triamcinolone acetonide and aspirated the excess over the macula, particularly over the macular hole, to avoid direct contact with the retinal pigment epithelium. The ILM was pinched with ILM forceps, and peeling started in a circular manner, 360° around the MH, to create a multilayered flap. The dimension was approximately 1.5- to 2-disk diameters circumferentially. Peeling was performed up to the edges of the macular hole, but not too close to the MH, to minimize the risk of flap dislocation. No trimming was needed. The flap was positioned to cover the hole, and a fluid–air exchange was performed, followed by an injection of 2.5 mL of pure hexafluoroethane. Patients were asked to remain in a face-down position or laterally for 24 hours.

Statistical Analysis

Best-corrected visual acuity was measured using a Snellen chart and converted to the logarithm of the minimum angle of resolution (logMAR). SPSS v. 23.0 (IBM Corp., Armonk, NY) was used for statistical analysis, and statistical significance was set at P < 0.05. Changes in pre- and postoperative BCVA were assessed using the Wilcoxon signed-rank test for nonparametric data. The MLD and BHD were measured using the caliper tool from the IMAGEnet 6 software.

Results

We identified 980 RRD cases treated between 2017 and 2023, 10 of which met the inclusion and exclusion criteria. The calculated incidence rate for RRD with peripheral breaks and concomitant noncausal MH was 1.02%, affecting 10 of the 980 patients, which corresponds to similarly low values reported in other studies.2,4–7

Patient characteristics are presented in Table 1. A completely positive diagnosis was made preoperatively in seven cases. Three patients required further intraoperative assessment (by direct visualization and/or intraoperative OCT), given the presence of bullous retinal detachments that challenged direct visualization of the macula preoperatively. All retinal detachments were macula-off, with the number of retinal breaks ranging from one to six.

Table 1. Characteristics of the Patients Included in This Study

Case	Age	Sex	Lens	AL (mm)	Retina Attached	No. of Breaks	Size*	MH Closure	MLD (μm)	BHD (μm)	MH Closure Type†	Endotamponade‡	Preop BCVA	Intermediate BCVA	Final Postop BCVA	Follow-up	HT Sign	
1	69	M	PPK	23.83	Yes	4	Medium	Yes	351	1,181	1A	Air/2.5 mL pure C2F6	20/400	20/100	20/40	8	No	
2	51	M	PPK	25.80	Yes	6	Medium	Yes	319	681	1A	2.5 mL pure C2F6/2.5 mL pure C2F6	HM	20/200	20/32	13	No	
3	68	F	PPK	23.92	Yes	1	X-large	Yes	606	1,481	1A	Air/2.5 mL pure C2F6	HM	CF	20/100	39	No	
4	63	F	CAT	24.44	Yes	1	Large	Yes	415	798	1A	Air/2.5 mL pure C2F6	CF	20/100	20/63	6	No	
5	66	F	PPK	23.01	Yes	1	Medium	Yes	378	757	1A	Air/2.5 mL pure C2F6	CF	20/100	20/100	11	Yes	
6	58	F	PK	23.33	Yes	2	X-large	Yes	588	1,021	2C	Air/2.5 mL pure C2F6	HM	20/125	20/100	4	Yes	
7	67	F	PPK	24.06	Yes	1	Medium	Yes	291	560	1A	Air/2.5 mL pure C2F6	HM	20/200	20/40	17	No	
8	61	F	PPK	23.67	Yes	3	Large	Yes	490	991	1A	Air/2.5 mL pure C2F6	HM	20/100	20/50	10	No	
9	71	F	PPK	23.01	No	2	X-large	Yes	702	1,220	1A	Air/2.5 mL pure C2F6	HM	20/63	20/40	1	Yes	
10	67	F	PPK	23.57	Yes	1	Medium	Yes	376	709	1A	Air/2.5 mL pure C2F6	20/400	20/100	20/25	21	Yes	
* CLOSE group classification.

† Closure type as described by Rossi et al.

‡ Endotamponade for RRD repair/Endotamponade for MH repair.

AL, axial length; Cat, cataract after vitrectomy; CF, count fingers; F, female; HM, hand movement; HT, hypertransmission; Intermediate BCVA, BCVA assessed one week after RRD surgery; M, male; PPK, pseudophakic; PK, phakic; Preop BCVA, BCVA assessed before RRD surgery; Postop BCVA, BCVA assessed at final available follow-up.

All patients included in this study underwent primary RRD repair on the day of diagnosis and MH repair sequentially after retinal reattachment, which was 1 week later for the majority of the patients. One patient underwent MH surgery 10 months after RRD repair by the patient's choice.

The retina was completely attached 1 week after the primary surgery in nine of the 10 eyes included in the postoperative analysis. Secondary surgery for MH repair using the inverted ILM flap technique was successful in all cases. None of the patients required the use of silicone oil. No intraoperative complications occurred, and no postoperative IOP spikes were recorded during follow-up. The postoperative follow-up period ranged from 1 to 39 months. The results are summarized in Table 1.

Anatomical Recovery

The retinal reattachment rate was 90% in the primary surgery and 100% after the second intervention. In one patient, the surgeon encountered another peripheral break with shallow peripheral detachment, leaving the macula intact, in which the retina was reattached during the sequential surgery for MH repair. MH closure was successful in all patients (10/10) after the second surgery.

Two dimensions of the macular hole were of interest in this study: the MLD and BHD, which ranged from 291 to 702 µm for MLD and from 560 to 1,481 µm for BHD. According to the CLOSE study,12 there were five medium, two large, and three X-large holes in our cohort. The closure type was 1A in nine cases (90%) and Type 2C in one (10%).

Functional Recovery

Functional recovery was statistically significant in all patients (Figure 3). Preoperative visual acuity was less than 1.3 logMAR in all cases, with a mean value of 2 ± 0.42 logMAR, while the postoperative mean BCVA measured during the final follow-up was 0.42 ± 0.22 logMAR. The global mean visual acuity gain was 1.58 ± 0.41 logMAR. It was 1.14 ± 0.45 logMAR after the first surgery and 0.44 ± 0.35 logMAR after the subsequent MH repair. The Wilcoxon signed-rank test was performed to evaluate the difference between the postoperative (second surgery) and preoperative (first surgery) logMAR BCVA scores. The analysis revealed a statistically significant improvement in BCVA postoperatively compared with the preoperative values (W = 0, Z =-2.81, r = 0.89, P = 0.003).

Fig. 3. Boxplot showing the difference in BCVA (in logMAR) among the before RRD repair group, after RRD repair group, and after MH repair group.

For Patient 5, sequential surgical intervention for MH repair was delayed by 10 months. Given this chronology, improvement in BCVA was notable after RRD repair (from hand motion to 0.7 logMAR), although no further significant improvement was achieved after MH repair. Furthermore, the patient attended only the 1-week check-up and was lost to follow-up. This limited availability made it difficult to assess the long-term outcome of this patient and to decide whether the increased duration between surgeries contributed to the modest visual acuity gain. Considering the low incidence of the pathology, we decided not to exclude Patient 5 from our analysis.

Discussion

This study assessed the functional and anatomical results of patients undergoing sequential repair for RRD with peripheral breaks and concomitant noncausal MH in our clinic from 2017 to 2023, the calculated incidence rate for this combined pathology being compatible with the already published literature data.2,4–7 We have excluded from our statistical analysis the retinal detachment cases (shallow or extensive) caused exclusively by macular holes (1/980 cases, 0.1%) and the macular holes that developed after RRD surgeries (1/980 cases, 0.1%). Being aware that there are studies revealing MH closure after vitrectomy without ILM peeling,17 we report one complete anatomical success (retinal attachment and MH closure) after RRD surgery alone, which we have excluded from the evaluation.

Questioning the preoperative OCT indication in RRD cases, we deem it to be valuable.18 Sometimes image acquisition is hindered by various factors, such as vitreous hemorrhage, bullous detachment that obscures the macula, and retinal mobility, thus not allowing high-resolution images to be obtained. Despite poor-quality images, we were able to identify a hypertransmission sign at the level of the retinal pigment epithelium in three patients, which indirectly indicates a presumed overlying MH, as shown in Figure 4, A–C. Nevertheless, this sign shall not be used as a single diagnostic criterion for this pathology.

Fig. 4. Optical coherence tomography images of different MHs revealed by the hypertransmission sign in MH concomitant with RRD in Patient 10 (A), Patient 9 (B), and Patient 6 (C).

Although the choroidal hypertransmission sign has been proposed by Louzada et al19 as an alternative method to assess MH size, we believe that in RRD cases, it can only be used as a sign revealing the presence of a concomitant MH, bringing further arguments that the MH is not a consequence of RRD repair, but rather a shared surgical pathology. In our study, MLD and BHD were measured using the OCT on the attached macula. Assessing these parameters on a detached, floating macula may be in some cases technically possible; however, we presume this would bring no relevant data for further comparison, given the high intermeasurement variability.

In our series, Patients 6 and 8 underwent slightly delayed sequential MH repair: 1 month after the primary RRD surgery. Interestingly, between surgeries, we noticed swelling of the borders of the MH, a very slight increase in size (Figures 1 and 2), and a concomitant decrease in BCVA (from 0.7 logMAR [Snellen 20/100] to 1.0 logMAR [Snellen 20/200] and 0.8 logMAR [Snellen 20/125] to 1.0 logMAR [Snellen 20/200] in these patients, respectively). According to Tornambe,18 this behavior can be explained by the hydration theory of MH, which holds that the edges of the MH become swollen over time if left untreated.

Few studies have addressed concomitant RRD and MH surgical repair strategies. A study conducted by Iros et al2 assessed the functional results in 11 eyes undergoing vitrectomy, ILM peeling, and 20% SF6 endotamponade, with a final visual acuity lower than 0.65 logMAR (Snellen 20/89). Even more modest results were observed in another series of 43 cases using similar surgical approaches, with a mean final visual acuity ranging from 0.7 logMAR (Snellen 20/100) to 0.8 logMAR (Snellen 20/120), as reported by Ryan et al.7

Stappler et al1 combined vitrectomy with the inverted ILM flap technique and silicone oil endotamponade in 11 eyes, with a mean postoperative BCVA of 0.6 logMAR (Snellen 20/80) This appeared to be the first study investigating the anatomical and functional results of the inverted ILM flap technique used in cases of concomitant RRD and MH. However, the authors report a combined technique and the use of silicone oil as an endotamponade. This approach requires a second surgery for silicone oil extraction, with the inherent risk of complications posed by emulsification, which are seemingly unavoidable.20

Whether the inverted ILM flap technique provides better functional results remains controversial. It appears that MHs smaller than 400 µm have similar outcomes when the inverted ILM flap is compared with the traditional technique.11 By contrast, Ramtohul et al.10 argued that the inverted flap technique is more effective for the closure of large (>400 µm) MHs, improving both functional and anatomical results. It is worth mentioning that both previously cited studies assessed traditional idiopathic MHs. Therefore, it is unclear whether RRD cases with concomitant MH in nonhighly myopic eyes should be approached similarly.

Singh et al3 compared the combined approach with the sequential surgical approach for the management of RRD with MH, using the ILM peeling technique. Good anatomical and functional outcomes were achieved using both methods (mean BCVA of 1.0 logMAR [Snellen 20/200] vs. 0.7 logMAR [Snellen 20/100], not statistically significant). Furthermore, some MHs seem to close spontaneously, and the combined approach has the clinical and cost benefits of a single procedure.

One of the challenges of the combined approach is ILM peeling from a detached mobile retina, which can be overcome using PFCL. However, ILM peeling under PFCL is not as controlled as standard ILM peeling on an attached retina. Moreover, it poses the risk of microbubbles of PFCL entering under the retina through the patent MH, as well as the risk of toxicity posed by dyes used for ILM staining, in direct contact with the retinal pigment epithelium.

A significant advantage of sequential surgeries is that both RRD repair and MH repair can be performed in a standardized manner, by approaching the surgeries completely separately, as if the pathologies were not concomitant. Therefore, every maneuver was performed with precise surgical control. Moreover, we had the opportunity to measure the MHD; MH dimensions for free-floating macula-off detachments are not obtainable.

The limitations of our study included its small sample size, retrospective nature, and unrandomized, uncontrolled design. Given that five of the presented cases had medium-sized MHs, the appropriateness of using the inverted ILM flap technique can be questioned. However, given the rare nature of this condition and the good functional results, further studies should be conducted to assess the best surgical strategy for such cases more appropriately.

In conclusion, sequential surgeries for the treatment of RRD with concomitant MH in nonhighly myopic eyes, using the inverted ILM flap technique and air/gas endotamponade may yield favorable anatomical and functional results in a controlled and standardized manner.

Acknowledgments

Publication of this article was supported by the University of Medicine and Pharmacy Carol Davila, through the institutional program Publish not Perish.

None of the authors has any financial/conflicting interests to disclose.
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