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How Much Surgery Is Enough? What Is Necessary to Repair a Macular Hole?

Macular hole surgery is one of the most successful operations performed on the retina with most studies reporting single-operation success rates exceeding 90%.1,2 It conventionally consists of four steps: central vitrectomy with release of the posterior hyaloid from the macula, internal limiting membrane (ILM) peeling, fluid/air/gas exchange, and facedown positioning. Occasionally, holes spontaneously close with no surgery,3–5 occasionally close with anti-inflammatory drops to resolve cystoid macular edema,6,7 sometimes close with pneumatic retinopexy and facedown posturing,8–10 sometimes close with an ocriplasmin injection and no gas or positioning,11 frequently close with just posterior hyaloid peeling, gas, and facedown posturing,2,12 and almost always close with vitrectomy, posterior hyaloid removal, ILM peeling, gas, and facedown positioning.13–16 Most retina surgeons agree that, at the very least, posterior hyaloid traction must be released in the macular area, but other manipulations may or may not be necessary. It probably depends on several factors including the size of the hole (which is also related to the duration of the hole), potential membranes about the hole from schisis of the posterior hyaloid resulting in residual traction about the hole, and epiretinal membranes or epiretinal/subretinal membranes curling beneath the hole and adhering to the retinal pigment epithelium. Each additional surgical manipulation may have negative consequences. Peeling the ILM exposes the retina to possible harmful dyes and traumatizes Muller’s footplates, and pinch/peeling of the ILM can result in hemorrhage, visual field defects, an eccentric hole, and subretinal fibrosis.17–25 Gas expansion may raise the intraocular pressure, compromising retinal blood flow, and facedown posturing may precipitate shallowing of the anterior chamber, raising the intraocular pressure to levels, which compromise retinal blood flow.26 The duration of the gas bubble needed to close the macular hole is debatable,27 and positioning remains controversial. Some patients are denied macular hole surgery because they cannot tolerate facedown positioning for their surgeon feels such positioning is crucial for success, whereas other surgeons feel positioning is not necessary.