Macular Hole Hydrodissection for Persistent, Chronic, and Large Macular Holes

Maxwell S. Stem, MD  |  June 24, 2019

Felfeli T, Mandelcorn ED. MACULAR HOLE HYDRODISSECTION: Surgical Technique for the Treatment of Persistent, Chronic, and Large Macular Holes. Retina. 2019;39(4):743-752.

While the vast majority of full thickness macular holes (MH) close with standard vitrectomy surgery, peeling of the internal limiting membrane (ILM), and gas tamponade, there exists a subset of MH that continue to pose challenges for the vitreoretinal surgeon.  Recently, Felfeli and Mandelcorn described a novel surgical technique that can be used to increase the surgical success rate for persistent, chronic, and/or large MH.  They refer to the technique as macular hole hydrodissection (MHH), and a video of the procedure is available online at http://links.lww.com/IAE/A792.  With this novel technique, a standard vitrectomy with ILM peeling is performed; next, a soft tip cannula is used to reflux fluid into the MH, thus releasing any retina to retinal pigment epithelium adhesions at the margin of the hole.  The soft tip is then used to gently manipulate the hole edges together.  A fluid air exchange followed by injection of SF6 or C3F8 gas is performed with face down positioning for 5 days.

Their retrospective analysis included 39 eyes with stage 3 or 4 MH that were either: 1) persistent (failed prior vitrectomy surgery); 2) chronic (symptoms of central vision loss for ³ 2 years or a clinical diagnosis of MH and not treated for ³ 1 year); or 3) large (aperture diameter ³ 400 microns).  Eyes meeting more than one of these criteria were classified as “complex”. The anatomic and functional results using the MHH technique combined with vitrectomy and ILM peeling were impressive: 34/39 of all eyes (87.2%) and 17/19 (89.5%) of complex eyes achieved complete anatomic closure. Vision improved by 2 or more lines in 31/39 (79.5%) of eyes, and overall the mean preoperative vision improved from 20/289 to 20/91 postoperatively at last follow up.

In sum, the novel technique of MHH yielded excellent structural and functional results in the treatment of persistent, large, and/or chronic MH.  The rationale for the procedure makes sense, as lysing the retina to retina pigment epithelium adhesions should facilitate apposition of the MH edges.  The technique should serve as a nice addition to the retina surgeon’s toolbox in the management of stubborn MH.

Maxwell S. Stem, MD

Mid Atlantic Retina
Wills Eye Hospital

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