Macular Hole Formation after Vitrectomy: Preventable?

Rebecca Kim; Yu Cheol Kim; Kwang Soo Kim

doi:10.3341/jkos.2014.55.2.230

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Kim, Kim, and Kim: Macular Hole Formation after Vitrectomy: Preventable?

Original Article

J Korean Ophthalmol Soc 2014;55(2):230-236.

Published online: 7 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.2.230

Macular Hole Formation after Vitrectomy: Preventable?

Rebecca Kim, MD, Yu Cheol Kim, MD, Kwang Soo Kim, MD, PhD

Department of Ophthalmology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea

Address reprint requests to Kwang Soo Kim, MD, PhD Department of Ophthalmology, Keimyung University Dongsan Medical Center, #56 Dalseong-ro, Jung-gu, Daegu 700-712, Korea, Tel: 82-53-250-7706, Fax: 82-53-250-7705, E-mail: kimks@dsmc.or.kr

Received 8 June 20139 September 2013 Accepted 7 December 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the causes of secondary macular hole after vitrectomy and the possibility of their prevention.

Methods

27 patients (28 eyes) who experienced macular hole formation after vitrectomy were reviewed retrospectively. Age, sex, operation methods, duration between the vitrectomy and the secondary macular hole surgery and causes of the primary vitrectomy were recorded. Best-corrected visual acuity (BCVA) before and after primary vitrectomy; preoperative and postoperative macular findings with optical coherence tomography and fundus examination; and BCVA before and after macular hole surgery were analyzed.

Results

Of the 2945 eyes that had undergone vitrectomy, 28 eyes (0.96%) experienced macular hole formation. As causes of primary vitrectomy, 12 eyes had proliferative diabetic retinopathy, 6 eyes had rhegmatogenous retinal detachment, 2 eyes had branch retinal vein occlusion, 3 eyes had age-related macular degeneration and 5 eyes had trauma such as eyeball rupture or intraocular foreign body. The mean duration between primary vitrectomy and macular hole formation was 20.4 months (4 days-115 months). The estimated causes of macular hole formation included cystoid macular edema (CME) (n = 13), thinning of the macula (n = 6), thickening of internal limiting membrane or recurrence of preretinal membrane (PRM) (n = 7), recurrence of subretinal hemorrhage (n = 1) and macular damage during vitrectomy (n = 2). Final BCVA after macular hole surgery decreased in most cases compared to BCVA before macular hole formation except in 7 eyes (25%).

Conclusions

Close observation of the macula after primary vitrectomy especially in eyes with continuous CME, and recurrent PRM and proper management on them including timely removal of the tangential traction force are necessary for preventing macular hole formation. In addition, surgeons should make efforts not to exert excessive tractional force on the macula to avoid iatrogenic damage during removal of the preretinal membrane.

Keywords: Cystoid macular edema, Macular hole, Preretinal membrane, Vitrectomy

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Fiagure 1.

Serial optical coherence tomography of macular hole formation due to cystoid macular edema 3 months (A) and 36 months (B) after primary vitrectomy.

Figure 2.

Serial optical coherence tomography of macular hole formation due to macular thinning 1 months (A) and 6 months (B) after primary vitrectomy.

Figure 3.

Serial optical coherence tomography of macular hole formation due to internal limiting membrane thickening and/or epiretinal membrane recurrence after primary vitrectomy. Macular image before (A, B) and after (C, D) macular hole formation.

Table 1.

Causes of primary pars plana vitrectomy

Causes	No. of cases (n = 28)	Percentage (%)
Rhegmatogenous retinal detachment	6	22
Proliferative diabetic retinopathy	12	43
Branch retinal vein occlusion	2	7
Age related macular degeneration	3	11
Trauma (eyeball rupture, IOFB)	5	18

IOFB = intraocular foreign body.

Table 2.

Estimated causes of macular hole formation after primary vitrectomy

Estimated causes	No of cases (n = 28)	Percentage (%)
Cystoid macular edema	12	43
Thickening of ILM and/or recurrence of ERM	7	25
Macular thinning	6	21
Iatrogenic macular damage	2	7
Recurrence of SMH	1	4

ERM = epiretinal membrane; ILM = internal limiting membrane; SMH = submacular hemorrhage.

Table 3.

Clinical characteristics of primary vitrectomy groups with secondary macular hole formation

	Group1^*	Group2^†	Group3^‡	Group4^§	Group5^∏	p-value^#
No. of subjects	6	12	2	3	5
Age at primary PPV (years)	51.7 ± 14.5	52.9 ± 11.5	70.2 ± 2.8	77.7 ± 12.1	46.4 ± 13.1	0.025
Duration between primary PPV and MH formation (months)	22.1 ± 36.2	19.6 ± 34.1	8.5 ± 10.6	2.0 ± 2.0	36.1 ± 0.0	0.530
MH size (DD)	0.36 ± 0.36	0.53 ± 0.79	0.33 ± 0.11	0.20 ± 0.0	0.40 ± 0.13	0.446
Spherical equivalent (diopter)	-6.10 ± 10.2	-0.76 ± 1.7	-1.93 ± 1.5	-0.75 ± 0.9	-3.92 ± 4.5	0.228
Axial length (mm)	25.90 ± 2.92	22.53 ± 0.72	21.87 ± 0.88	22.45 ± 1.69	23.50 ± 1.71	0.062

Values are presented as mean ± SD.

DD = disc diameter; MH = macular hole; PPV = pars plana vitrectomy.

^* Rhegmatogenous retinal detachment

^† Proliferative diabetic retinopathy

^‡ Branch retinal vein occlusion

^§ Age- related macular degeneration

^∏ Trauma;

^# Kruskal-Wallis test, p < 0.05.

Table 4.

Clinical characteristics by estimated causes of macular hole formation

	CME	EMR and/or ILM thickening	Macular thinning	Iatrogenic macular damage	Recurrence of SMH	p-value^*
No. of subjects	12	7	6	2	1
Sex distribution (male : female)	3 : 9	5 : 2	2 : 4	2 : 0	0 : 1
Diabetes mellitus	8	3	2	1	0
Age at primary PPV (years)	55.2 ± 11.5	40.3 ± 10.4	62.5 ± 6.4	71.0 ± 11.3	89.0 ± 0.00	0.006
Duration between primary PPV and MH formation (months)	16.7 ± 31.1	31.4 ± 43.9	24.0 ± 35.8	3.0 ± 4.2	2.0 ± 0.00	0.790
MH size (DD)	0.61 ± 0.83	0.44 ± 0.14	0.22 ± 0.05	0.17 ± 0.02	0.2 ± 0.00	0.072
Spherical equivalent (diopter)	-1.6 ± 2.8	-3.2 ± 4.4	-3.4 ± 9.7	0.4 ± 0.9	-0.3 ± 0.0	0.545
Axial length (mm)	22.8 ± 1.82	23.8 ± 1.7	24.3 ± 3.5	23.4 ± 0.8	22.7 ± 0.0	0.568

Values are presented as mean ± SD.

CME = cystoid macular edema; DD = disc diameter; ERM = epiretinal membrane; ILM = inner limiting membrane; MG = macular hole; PPV = pars plana vitrectomy; SMH = submacular hemorrhage.

^* Kruskal-Wallis test, p < 0.05.

Table 5.

Surgical outcome of primary vitrectomy and secondary macular hole surgery by primary vitrectomy groups

Primary PPV groups	BCVA at primary PPV (log MAR)			BCVA at MH surgery (log MAR)
Primary PPV groups	Preoperative	Postoperative	p-value^*	Preoperative	Postoperative	p-value^*
Group1^†	-1.65 ± 0.85	-0.85 ± 0.50	0.005	-1.30 ± 0.76	-0.87 ±0.95	0.087
Group2^‡	-1.09 ± 0.64	-1.08 ± 0.75	0.930	-1.65 ± 0.82	-1.61 ± 1.34	0.860
Group3^§	-1.40 ± 0.00	-1.05 ± 0.49	0.500	-1.20 ± 0.28	-1.40 ± 0.00	0.500
Group4^∏	-1.83 ± 0.75	-1.60 ± 1.01	0.317	-1.40 ± 0.79	-1.57 ± 1.05	0.655
Group5^#	-2.10 ± 1.34	-1.10 ± 1.14	0.104	-1.47 ± 0.79	-0.83 ± 0.67	0.069
Total	-1.49 ± 0.87	-1.08 ± 0.77	0.007	-1.49 ± 0.70	-1.29 ± 1.08	0.176
p-value^**		0.814			0.738

Values are presented as mean ± SD.

BCVA = best corrected visual acuity; MH = macular hole; PPV = pars plana vitrectomy.

^* Wilcoxon test, p < 0.05

^† Rhegmatogenous retinal detachment

^‡ Proliferative diabetic retinopathy

^§ Branch retinal vein occlusion

^∏ Age- related macular degeneration

^# Trauma

^** Kruskal-Wallis test, p < 0.05.

Table 6.

Surgical outcome of primary vitrectomy and secondary macular hole surgery by the estimated causes of macular hole formation

Primary PPV groups	BCVA at primary PPV (log MAR)			BCVA at MH surgery (log MAR)
Primary PPV groups	Preoperative	Postoperative	p-value^*	Preoperative	Postoperative	p-value^*
CME	-1.24 ± 0.76	-1.13 ± 0.69	0.544	-1.64 ± 0.82	-1.55 ± 1.06	0.589
ERM and/or ILM thickening	-1.76 ± 1.26	-1.11 ± 1.21	0.141	-1.54 ± 0.87	-1.28 ± 1.61	0.498
Macular thinning	-1.70 ± 0.81	-0.92 ± 0.55	0.042	-1.21 ± 0.29	-0.87 ± 0.48	0.109
Iatrogenic macular damage	-1.40 ± 0.00	-1.40 ± 0.00	1.000	-1.40 ± 0.00	-1.00 ± 0.57	0.655
Recurrence of SMH	-1.40 ± 0.00	-0.70 ± 0.00	-	-1.40 ± 0.00	-1.40 ± 0.00	-
p-value^†		0.845			0.417

Values are presented as mean ± SD.

BCVA = best corrected visual acuity; CME = cystoid macular edema; DD = disc diameter; ERM = epiretinal membrane; ILM = inner limiting membrane; MH = macular hole; PPV = pars plana vitrectomy; SMH = submacular hemorrhage.

^* Wilcoxon test, p < 0.05

^† Kruskal-Wallis test, p < 0.05.

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