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Danielle M Lo, Michael R Chua, Kenneth J Wald; Augmented Posterior Hyaloid Adhesion Associated with Retinal Detachment after Macular Hole Repair. Invest. Ophthalmol. Vis. Sci. 2018;59(9):857. doi: https://doi.org/.
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© ARVO (1962-2015); The Authors (2016-present)
Despite advances in vitreoretinal surgery to improve closure rate and visual acuity for idiopathic macular holes (MH), there remains a low but intractable rate of rhegmatogenous retinal detachment (RRD) in the postoperative period. The purpose of this retrospective observational clinical study is to identify potential causes for RRDs after MH surgery.
We retrospectively examined a single surgeon series of 332 stage III macular hole surgeries over a 5-year period (2012-2017). All patients underwent uniform surgical approach with pars plana vitrectomy (PPV), elevation of the posterior hyaloid face, internal limiting membrane peeling, and use of 20% SF6 gas. In all eyes, intraoperative scleral indentation and laser treatment to any pathology was performed. The charts of patients with postoperative RRD were analyzed for potential causes.
Of the 332 eyes that received MH surgery, 12 (3.6%) developed postoperative RRD. Mean postoperative time to RRD was 55.2 days (SD 62.5). Mean improvement in visual acuity in patients with postoperative RRD was 1.4 lines (SD 2.1). 4 eyes had preexisting pathology such as lattice that was treated with preoperative and intraoperative laser. A retinal break was found superiorly in 2 eyes and inferiorly in 10 eyes. 7 eyes had equatorial type retinal breaks with no evident precursor pathology. These 7 cases were observed intraoperatively and post-operatively to have an augmented posterior hyaloid adhesion (APHA). (Fig.1)
A primary surgical objective of MH surgery is separation of the posterior hyaloid face, thereby producing an inherent risk factor for RRD. When PPV is performed, the vitreous typically separates to the peripheral vitreous base. During this process, breaks can be detected and treated. Some eyes, however, have APHA near the equator that cannot be elevated—this may be related to the strong vitreomacular adhesion that is a hallmark of MHs. We believe that these cases have a high rate of postoperative RRD as ongoing elevation of the hyaloid occurs in the postoperative period. The presence of gas may further increase vitreoretinal tractional forces especially at the inferior areas. We do not have a specific recommendation on the management of such cases, though one can consider prophylactic laser treatment along this zone.
This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.
Fig. 1: Ultra-wide field image depicting APHA temporally in an eye that later developed RRD after MH surgery.
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