Repeat Procedure Shows Success for Persistent Macular Holes

Optometrist examing patient’s eyes
The study also shows the minimum linear diameter and macular hole index on OCT can be used as markers for prognostic guidance.

Simple repeat pars plana vitrectomy (PPV) with gas tamponade has good anatomical and functional success rates in some cases of persistent idiopathic macular holes, according to research published in Retina. 

Researchers conducted a retrospective, nonrandomized, interventional case series study to evaluate the efficacy of simple repeat PPV with gas tamponade for persistent macular hole, as well as to analyze changes in optical coherence tomography (OCT) following failed primary surgery to determine their applicability as prognostic markers for macular hole closure. 

Data from consecutive eyes that underwent the primary standard 3-port 23/25-gauge pars plana vitrectomy, internal limiting membrane (ILM) peeling with Brilliant Blue G, and fluid-air-gas exchange with 20% perfluoroethane or 14% perfluoropropane between 2010 and 2019 were included. 

The total cohort included 27 patients (18 women; median age, 71±6.6 years). Seven patients were pseudophakic, 19 underwent combined phacoemulsification and posterior chamber intraocular lens implantation combined with their first, and 1 patient with his second vitrectomy. All 27 patients were pseudophakic after their revisional surgery; mean symptom duration prior to the first operation was 10.24±6.64 months and mean surgical interval was 5.3±5.5 months. 

Before the first surgery, 24 macular holes were larger than 400 µm, 2 macular holes were smaller than 400 µm, and 1 patient had no preoperative OCT scan available. Following initial PPV, 21 macular holes were larger than 400 µm and 6 were smaller than 400µm. 

Of all macular holes, 88.9% closed after revisional surgery. When comparing those that closed with those that did not, there were no differences in age, sex, symptom length before surgery, and macular hole size or stage. All 3 hole closure failures were confirmed to have a large ILM peel; 2 received ILM peel extension at their revisional procedure. 

Mean preoperative best corrected visual acuity (BCVA) was 0.86 logMAR; this did not change following the first surgery but improved after successful revisional surgery to 0.69±0.15 logMAR. At 3 and 12 month follow-up, 11 patients improved to 0.65±0.13 logMAR and 0.49±0.15 logMAR at each time point, respectively. Results of a Pearson’s correlation coefficient did not demonstrate an association between symptom duration and final BCVA (r=-0.05) or between interval length from primary to revisional surgery and final BCVA (r=-0.05). 

The OCT analysis included 22 patients. Mean minimum linear diameter of all patients decreased from 640±150 µm to 523±140 µm after the first surgery. Minimum linear diameter of the 19 macular holes that closed decreased from 649±157 µm to 497±126 µm, and all 14 macular holes that demonstrated a decrease in minimum linear diameter after their first surgery closed following the revisional surgery (decrease, 690±145 µm to 484±125 µm). 

Mean base diameter before surgery was 1311±699 µm, decreasing to 1219±472 µm. Mean cuff height before surgery was 425±122 µm and 506±173 µm after surgery. 

Study limitations include those inherent to a retrospective analysis, limited follow-up for all patients and inconsistent performance of OCT evaluation. 

“We demonstrate that repeat vitrectomy with gas tamponade (with or without extension of the previous ILM peel) can be a simple and effective method with good anatomical function and outcomes for revisional surgery in selected cases of persistent idiopathic [macular holes],” the researchers conclude. “A decrease in [minimum linear diameter] and an increase in [macular hole index] after the first surgery may be two OCT parameters for prognostic guidance that can be taken into consideration…when advising patients regarding revisional surgery.” 


Baumann C, El-Faouri M, Ivanova T, et al. Manchester revisional macular hole study: Predictive value of optical coherence tomography parameters on outcomes of repeat vitrectomy, extension if internal limiting membrane peel, and gas tamponade for persistent macular holes. Retina. 2021;41(5):908-914. doi:10.1097/IAE.0000000000002959