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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 2  |  Page : 138-141

Timing for successful intervention in bilateral persistent macular hole

Department of Vitreo-retina, Giridhar Eye Institute, Cochin, Kerala, India

Date of Web Publication27-Aug-2019

Correspondence Address:
Dr. Anubhav Goyal
Giridhar Eye Institute, Ponnath Temple Road, Kadavanthra, Cochin - 682 020, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_43_19

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A case report of a 66-year-old male who presented with bilateral simultaneous full-thickness macular hole (MH) developed persistent MH after the first uncomplicated MH surgery. In persistent MH, early intervention within a month after the first surgery resulted in excellent anatomical MH closure along with significant improvement in final visual acuity.

Keywords: Full-thickness macular hole, internal limiting membrane peeling, spectral-domain optical coherence tomography

How to cite this article:
Goyal A, Anantharaman G, Gopalakrishnan M. Timing for successful intervention in bilateral persistent macular hole. Kerala J Ophthalmol 2019;31:138-41

How to cite this URL:
Goyal A, Anantharaman G, Gopalakrishnan M. Timing for successful intervention in bilateral persistent macular hole. Kerala J Ophthalmol [serial online] 2019 [cited 2020 Aug 8];31:138-41. Available from: http://www.kjophthal.com/text.asp?2019/31/2/138/265501

  Introduction Top

The macular hole (MH) is a full-thickness defect of the retinal tissue involving the fovea, and idiopathic MH (IMH) is one of the major causes of reduced central vision in the elderly. Gass described tangential traction on the fovea as the basic pathogenesis for IMH.[1],[2] Kelly and Wendel first described vitrectomy combined with gas tamponade as a successful treatment to seal MHs and achieved successful anatomical closure in 73% while visual acuity improved in 55% of cases.[3] Later, adjuvant internal limiting membrane (ILM) peeling has increased MH closure success rates in 90%–95% of cases.[4]

The incidence rate of persistent MH is 10%–12% even after complete ILM peeling and gas tamponade in an uncomplicated MH surgery. Resurgery with enlargement of ILM rhexis and additional gas tamponade with or without autologous platelet concentrate has been documented in many studies for persistent and reopened MH.[5],[6],[7]

Hillenkamp et al.[6] described two distinct types of persistent MH configuration: (1) the hole appears flat and punched out without a distinct retinal cuff “without cuff” and (2) the hole with an elevated retinal cuff overlying the hole “with cuff” and documented anatomical closure rates significantly better in “with cuff” as compared to “without cuff.”

Herein, we report a case of simultaneous bilateral persistent MH after the first failed MH surgery, showing flat punched out configuration on optical coherence tomography (OCT), and repeating intervention within a very small time period resulted in successful anatomical closure along with significant improvement in visual acuity.

  Case Report Top

A 66 years old male presented to our clinic for decrease in vision with distorted images for 1-week duration in the right eye. There was no history of ocular trauma or any other ocular intervention in either eye. Best-corrected visual acuity (BCVA) was 20/63 and 20/25 in the right and left eyes, respectively, on Snellen's visual acuity chart. Ocular examination revealed the presence of clear crystalline lens in both the eyes and full-thickness MH in the right eye with altered foveal reflex in the left eye. Spectral-domain OCT (SD-OCT, Spectralis, Heidelberg Engineering) of the right eye revealed full-thickness MH of 393 μm minimum hole diameter and the left eye revealed the presence of focal vitreomacular traction (VMT) [Figure 1].
Figure 1: Baseline spectral-domain optical coherence tomography (a) The right eye showing full-thickness macular hole. (b) The left eye showing vitreomacular traction

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He underwent an uneventful 23-G pars plana vitrectomy with ILM peeling and sulfur hexafluoride (SF6) gas implantation in the right eye with strict instructions to lie face down 90% of the time for 1 week and was counseled with close observation for the left eye. On his 1-week postoperative follow-up, repeated SD-OCT showed the presence of persistent MH having “without cuff” configuration. Minimum hole diameter changed from 393 to 348 μm postoperatively. As the hole was still persisting, he was advised resurgery which was subsequently done on the 10th day of the first surgery. Standard three-port pars plana revitrectomy was repeated with fluid–air exchange (FAE), and instead of short-acting 20% SF6 nonexpansile gas mixture, he was then injected with long-acting nonexpansile mixture of 14% perfluoropropane (C3F8) gas along with strict instructions to lie face down 90% of the time for another 1 week. Following which, he showed successful MH closure on his next follow-up [Figure 2], with BCVA improving to 20/30.
Figure 2: Right eye (a) Spectral-domain optical coherence tomography showing full-thickness macular hole of 383 μm. (b) First surgery postoperative spectral-domain optical coherence tomography persistent macular hole showing “without cuff” configuration. (c) 1 week repeated surgery postoperative spectral-domain optical coherence tomography showing closed hole

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After 6 months of the right eye MH surgery, VMT in the left eye worsened to full-thickness MH having minimum hole diameter of 200 μm and BCVA improving to 20/50, for which he underwent the same initial intervention of 23-G pars plana vitrectomy with ILM peeling and 20% SF6 nonexpansile gas mixture implantation with strict face-down position 90% of the time for 1 week in the left eye. Surprisingly, in this eye also 1-week postoperative visit, repeated SD-OCT showed persistent MH, also having “without cuff” configuration and interestingly, the left eye minimum hole diameter increased from 200 μm to 330 μm. Subsequently, in this eye also, he underwent resurgery on the 10th day of the first surgery. This eye also underwent standard 23-G pars plana revitrectomy along with repeat FAE and injection of nonexpansile mixture of 14% C3F8 gas injection along with same instructions to lie face down 90% of the time for another 1 week. Similar to the contralateral eye, this eye also showed successful MH closure on his next follow-up [Figure 3], with BCVA improving to 20/40.
Figure 3: Left eye (a) showing vitreomacular traction. (b) Spectral-domain optical coherence tomography showing full-thickness macular hole of 200 μm. (c) First surgery postoperative spectral-domain optical coherence tomography persistent macular hole showing “without cuff” configuration. (d) 1 week repeated surgery postoperative spectral-domain optical coherence tomography showing closed hole

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On subsequent follow-ups, both the eyes developed cataract, for which both underwent phacoemulsification with intraocular lens implantation, with final BCVA maintaining to 20/30 and 20/40 in the right and left eyes, respectively.

  Discussion Top

The failure of the primary surgery with formation of persistent MH is a common complication of MH surgery. Vitrectomy with ILM peeling and gas tamponade has increased primary surgery success rate to 85%–95%.[8] The basic mechanism of closure of MH is presumed to be release of VMT and/or stimulating centripetal gliosis starting at the base of MH gradually closing it.[8] ILM peeling removes an element of traction or stimulates gliosis.[8],[9] Possible reasons for the persistence of MH in remaining patients can be persistent VMT, insufficient tamponade, or noncompliance to face down position.

Gas tamponade is thought to enhance MH closure by removing tangential force through its flotation force at the macula, its surface tension which excludes vitreous fluid from the subretinal space, and also by its role as a template to direct inner retinal glial cell migration.[10] Sufficient tamponade is required during this process in the form of SF6, C3F8 gas, or silicone oil. Gas tamponade is preferred than silicon oil due to the short-term requirement of tamponade for MH.

D'Souza et al.[5] and Hillenkamp et al.[6] have documented 52% and 68% of closure rates after surgery for persistent MH, respectively. Valldeperas and Wong[7] have documented 76% and 100% of closure rates after the second surgery in cases of persistent and reopened MH, respectively, suggesting a better prognosis for reopened MH compared to persistent MH. Many studies have documented prognostic factors for success rate of resurgery for persistent MH such as duration of symptoms, surrounding cuff of fluid, and baseline diameter of MH.[6],[7],[11],[12] However, none of the studies have emphasized on optimum duration for resurgery and its relation with anatomical closure rate after resurgery.

The eyes with persistent MH repeat intervention within a very short time period, and the use of long-lasting gas tamponade can give an excellent postoperative anatomical success. Since C3F8 has tamponading effect which lasts for 6 weeks, while SF6 gas wears off in 3 weeks, long-term tamponade with C3F8 can lead to the closure of persistent MH.[10] The gradual degenerating changes in the outer retinal layers increase with duration of MH and can affect anatomical closure and BCVA improvement even after uncomplicated MH surgery. As seen in our case also, early detection and early reintervention resulted in complete anatomical closure along with excellent improvement in final BCVA postoperatively. Hussin et al.,[13] Thompson,[14] and Modi.[12] had reported successful MH closure, followed by significant visual improvement after multiple vitreous surgeries.

In our case, a careful postoperative scan in both the eyes done after 7 days ruled out incomplete ILM peeling or the presence of posterior hyaloid remnants at the hole edge. Even though preoperative hole diameter was small, additionally OCT findings of the absence of subretinal cuff of fluid and absence of hyporeflective spaces in the hole wall were noted in the preoperative scan in both the eyes of our case, which can be one of the reasons of persistent MH with postoperatively minimum hole diameter changing from 393 μm to 348 μm and 200 μm to 330 μm in the right and left eyes, respectively.[15] In persistent MH, an elevated cuff of subretinal fluid at the margin of MH (with cuff) is a strong prognostic indicator for both anatomical closure and BCVA improvement.[6],[12] Even though both the eyes of our case showed OCT configuration of “without cuff” persistent MH, still early reintervention proved to be the key for successful postoperative anatomical closure and BCVA improvement.

Interestingly, both the eyes in our study presented with simultaneous MH within a 6-month duration. The first surgery failed in a similar pattern in both the eyes with formation of persistent MH. Later, both the eyes with persistent MH underwent resurgery within 10 days of the first surgery but later with additional long-lasting tamponade effect of nonexpansile C3F8 gas mixture in the resurgery, leading to successful closure of MH and significant improvement in BCVA. Cataract can worsen significantly after multiple macular surgeries and warrant early cataract surgery,[14] and the same was observed in both eyes of our case.

Although the duration of resurgery is quite variable according to the literature,[6],[13],[14] our case underwent resurgery with similar schedule in both the eyes simultaneously. To the best of my knowledge, time interval of only 10 days between the two MH surgeries is the shortest duration reported so far showing excellent anatomical and functional results in a case of persistent MH. In spite of uncomplicated resurgery, both the eyes showed cataract worsening and were taken for cataract surgery later on.

  Conclusion Top

Thus, the occurrence of persistent is a common finding seen after uncomplicated MH surgery. Early detection, early reintervention within a month after the first surgery, and the use of long-lasting gas tamponade can cause successful closure in persistent MH cases.


Persistent MH is a common complication after MH surgery. Early repeated intervention within a month and additional use of long-lasting gas tamponade can lead to its successful closure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gass JD. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629-39.  Back to cited text no. 1
Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752-9.  Back to cited text no. 2
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-9.  Back to cited text no. 3
Christensen UC. Value of internal limiting membrane peeling in surgery for idiopathic macular hole and the correlation between function and retinal morphology. Acta Ophthalmol 2009;87:1-23.  Back to cited text no. 4
D'Souza MJ, Chaudhary V, Devenyi R, Kertes PJ, Lam WC. Re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel. Br J Ophthalmol 2011;95:1564-7.  Back to cited text no. 5
Hillenkamp J, Kraus J, Framme C, Jackson TL, Roider J, Gabel VP. Retreatment of full-thickness macular hole: Predictive value of optical coherence tomography. Br J Ophthalmol 2007;91:1445-9.  Back to cited text no. 6
Valldeperas X, Wong D. Is it worth reoperating on macular holes? Ophthalmology 2008;115:158-63.  Back to cited text no. 7
Brooks HL Jr. Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology 2000;107:1939-48.  Back to cited text no. 8
Schubert HD, Kuang K, Kang F, Head MW, Fischbarg J. Macular holes: Migratory gaps and vitreous as obstacles to glial closure. Graefes Arch Clin Exp Ophthalmol 1997;235:523-9.  Back to cited text no. 9
Berger JW, Brucker AJ. The magnitude of the bubble buoyant pressure: Implications for macular hole surgery. Retina 1998;18:84-6.  Back to cited text no. 10
Kusuhara S, Negi A. Predicting visual outcome following surgery for idiopathic macular holes. Ophthalmologica 2014;231:125-32.  Back to cited text no. 11
Modi A, Giridhar A, Gopalakrishnan M. Sulfurhexafluoride (SF6) versus perfluoropropane (C3f8) gas as tamponade in macular hole surgery. Retina 2017;37:283-90.  Back to cited text no. 12
Hussin HM, Asaria RH, Knox Cartwright NE, Grey RH. Fourth time lucky: A case of multiple recurrence of a macular hole. Br J Ophthalmol 2006;90:659.  Back to cited text no. 13
Thompson JT, Sjaarda RN. Surgical treatment of macular holes with multiple recurrences. Ophthalmology 2000;107:1073-7.  Back to cited text no. 14
Ip MS, Baker BJ, Duker JS, Reichel E, Baumal CR, Gangnon R, et al. Anatomical outcomes of surgery for idiopathic macular hole as determined by optical coherence tomography. Arch Ophthalmol 2002;120:29-35.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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