A Patient Develops a Refractory Macular Hole
A woman aged 53 years with highly myopic eyes underwent pars plana vitrectomy with internal-limiting membrane (ILM) peel to treat a macular hole in 1 of her eyes. Six months later, she developed a refractory macular hole and retinal detachment. To treat the retinal detachment, the patient underwent a scleral buckle and repeat pars plana vitrectomy. However, the macular hole persisted even after treatment.
To prevent the patient’s vision from further deteriorating, she was referred to the Duke Eye Center. Her treatment options were limited because she had an open posterior capsule and insufficient ILM for use as a flap.
Question: For this patient, what was the most effective treatment option to repair the macular hole, prevent reopening, and reduce her risk of retinal detachment?
Macular holes associated with myopic traction maculopathy or retinal detachment tend to have high reopening rates, and patients with them have limited treatment options. In general, commonly used procedures require positioning an ILM flap inside the macular hole, which may cause iatrogenic trauma to the retinal pigment epithelium, and offer very limited vision improvement.
By contrast, the neurosensory retinal flap is thicker, easier to handle, and may also offer some functional benefits. In this case, after Tamer Mahmoud, MD, performed autologous retinal transplantation, the patient's eye did not exhibit retinal detachment or reopening of the macular hole; in addition, the harvest site did not show any complications.
Following the surgery, the patient also noticed progressive reduction of her central scotoma, increased retinal sensitivity, and improved visual acuity, suggesting that the transplant retained her retinal function.
“That was very exciting and entirely unexpected,” says Mahmoud. “We tested the sensitivity of the retina using microperimetry and found that her sensitivity had indeed significantly improved.”
Mahmoud and his colleagues are working to understand the mechanism and the long-term outcomes of this type of transplantation to further refine their technique, which he says may represent a viable new option for patients who previously did not have any surgical options.
“It is incredibly gratifying to have success—not only in developing a new way to close macular holes but also to see this completely unanticipated functional improvement in retinal sensitivity and vision,” Mahmoud remarks. “Now we need to understand more about those cells because the surgery itself isn’t very complicated, but the implications go far beyond macular holes. ”
This procedure may also benefit patients with other types of retinal conditions, he says. “If the retina from the periphery starts changing behavior, then there may be applications for other types of retinal diseases where the central vision is lost. That’s what’s truly exciting.”