other than macular

holes. Studies have

reported

incidence

of

nuclear

sclerotic

cataract

progression

in the range

of 13-95%

after MHS,~o

Although

the precise

etiology

of the

progressive

nuclear scle-

rosis

is

unknown,

altered

lens rnctabolisrn

after

vitreciorny

is

believed

to

play a role.?" Poor

posi-

tioning also

increases

contact

between

the gas bub-

ble and the lens capsule,

which facilitates

cataract

formation. Other

risk

factors

are increased

patient

age and increased

time interval after surgery. This

complication

is managed

by cataract

surgery

and

lens implantation.

Finally,

retinal pigment

epithelial

changes

have

been "described

and

have been attrib-

uted

to phototox

icity, mechanical

damage

to the

pigment epithelium

during suction

of subretinal

fluid through

the macular

hole, and pressure

effects

of the gas bubble

on the choriocapillaris

and pigment

epithelium during

prolonged face-down

position-

ing.~3 Later

series

in which prolonged

illumination

of the foveal

area

with the fibcroptic

illuminator

was

avoided

have

noted

this finding

less

fre-

quently."

Other rare

complications included

cystoid

neo-

vascular membrane,

postoperative cndophthalmitis,

and ulnar

nerve paralysis.

Vitrectomy is

an effective procedure for closure

of

macular hole,

While a variety of modifications

in

116

MANUAL

OF RETINAL

SURGERY

surgical

technique

have

been

reported. the

same

basic principles

are present

in all methods

used. The

ffi:l\Y'I ob)ecti.'Ie

i.s to

remove

anterior-posterior

and

tangential

tractions,

which cause

a central

retinal

dehiscence

that

eventually

leads

to formation

of

a

macular hole.

A complete

pars

plana

vitrectomy

is

performed with

elevation and

removal

of the

poste-

rior cortical

vitreous.

Any

epiretinal

membrane

should be removed.

Some

surgeons

also advocate

the

removal of

the

internal limiting membrane

(ILM).

The retinal

periphery

is carefully

examined

by indi-

rect ophthalmoscopy.

and

a fluid-air exchange

is per-

formed. followed

by

exchange

of

the

air

with

a

long-acting

gas.

In

selected

patients who

are

not

good candidates

for surgery

with

gas,

the use

of sili-

cone oil

provides

an

alternative

for surgical

repair.

Some investigators

have

reported

a greater

than

90% success

rate

in

macular

hole closure

by more

aggressively

peeling off

the

ILM

at

the

time of

macular hole surgery. Others

have reported

achiev-

ing similar

results

by

using

a variety

of adjuvants,

including

autologous

serum.

autologous

plasma

or

cryoprecipitate

with

bovine

thrombin. and

autolo-

gous platelet

concentrate without

ILM

removal

to

improve closure

rates

of primary

idiopathic

macular

holes, as

well

as to close

reopened

holes.

Regardless

of the technique

used to

repair

the

macular hole.

it is widely

recognized

that strict

post-

operative face-down

positioning

is a successful

tech-

nique used by most

surgeons. Face-down positioning

helps to effectively

tamponade the

macular

hole and

promotes

macular

hole

closure.

The

continual

improvement

of techniques

and early surgical

inter-

vention

has

indeed

made

this a gratifying

procedure.

I. Kelly

pathic

4. Rubin JS.

Glaser BM. Thompson

JT. et al, Vitrectorny,

fluid-gas

exchange

and transforming

growth

factor

beta-Z for the treatment

of macular holes. Ophthalmol-

ogy 1(}(})~\m·.\MG-\?>4S.

5. Huang

SS, Wendel

RT. Vitreous

surgery

for

full-

thickness

macular

holes.

In: Madreperla

SA,

McCuen

II BW, eds. Macular

Hole:

Pathogenesis,

Diagnosis,

and Treatment.

Boston:

Butterworth.

Heinemann;

1999:95-104.

6. Smiddy

WE.

Pharmacologic

adjuncts and

macular

hole surgery.

In: Madreperla

SA, McCuen

II

BW,

eds. Macular

Hole; Pathogenesis,

Diagnosis,

and

1999:

105-114.

7. Ryan EH. Gilbert HO. Results

of surgical

treatment

of

recent-onset

full-thickness

idiopathic

macular

holes.

Arch Ophthalmol1994;

112:545-553.

8. Haller JA. Clinical

characteristics

and

epidemiology

of

macular

holes. In: Madreperla

SA. McCuen

U BW. eds.

Macular

Hole: Pathogenesis.

Diagnosis.

and

Treat-

ment. Boston: Butterworth-Heinemann;

1999:25-36.

9. Martinez

J. Smiddy WE. Kim J. Gass

JOM. Differenti-

ating

macular holes

from

macular

pseuduholes.

Am J

ence tomography

of macular

holes. Ophthalmology

1995; 102:748-756.

II. Rice TA. Internal

limiting

membrane

removal in

surgery for full-thickness macular

holes.

In: Madreperla

SA. McCuen II BW. eds. Macular

Hole:

Pathogenesis,

intraocular

bubble duration

in the treatment

of macular

holes by vitrectorny

and transforming

growth faclor-p~.

Ophthalmology

1994; 10 l: 1195-1200.

13. Thompson

Jf', Smiddy

WE. Glaser BM. et al. Intraocu-

lar tamponade

duration

and success

of macular

hole

surgery. Retina

1996; 16:373-382.

14. Park OW. Sipperley

JO. Sneed

SR. et al. Macular

hole

surgery with internal-limiting

membrane

peeling

and

intravitreous air. Ophthalmology

1999; 106(7):1392-

1397.

15. Funata M, Wendel

RT. de la Cruz Z. Green

WR.

Clini-

copathologic

study of bilateral

macular holes

treated

with pars

plana vitrectorny

and

gas

tamponade.

Retina

parison

of recombinant

TGF-P2

and placebo

as an

adjunctive agent for macular

hole

surgery. Ophthulmol-

ogy 1998;105:700-706.

17. Ezra E. Wells JA. Charteris

DG. et al. Macular

hole

surgery

with and without

autologous serum:

a prospec-

tive study of 109 consecutive

eyes. Invest

Ophthalmol

Vis Sci

1996:37:5474.

18. Gaudric

A, Massin

P. Paques

M, et al. Autologous

platelet

concentrate

for the treatment

of full-thickness

macular

holes. Graefes

Arch

Clin

Exp Ophthalmol

1995;233:549-554.

rc. Combined

19. Miller JH, Googe JM, Hoskins

macular

hole and cataract

surgery.

Am

J Ophthalmol

1997;

123(5):705-707.

20. Pendergast SD, Williams

GA. Complications

of macular

hole surgery. In: Madreperla

SA, McCuen

II BW. eds.

Macular

Hole: Pathogenesis.

Diagnosis. and Treatment,

Boston:

Butterworth-Heinemann:

1999: 155-168.

21. Freeman

WR, Azen SP, Kim

JW, et al. Vitrectomy

for the

treatment

of full-thickness

stage

3 or

4 mac-

Macular Hole

Surgery

117

ular

holes.

Results

of

a multicentered

randomized

clinical

trial.

The vitrectorny

for treatment

of macu-

lar

hole

study

group.

Arch Ophthalmol

1997;

115:11-21.

22. Duker

JS. Wendel

RT,

Patel

AC. Puliafito

CA. Late

reopening

of macular

holes following

initial success-

ful

vitreous

surgery.

Ophthalmology

1994;101:

1373-1378.

23. Kokame

GT. Vitrectomy

for

macular

hole: the ran-

domized

multicenter

clinical

trials. In: Madreperla

SA. McCuen

II

BW, eds. Macular Hole: Pathogene-

sis, Diagnosis, and

Treatment.

Boston:

Butterworth.

Heinemann;

1999:1I5-124.

The

primary

objective

of

retinal reattachment

surgery

is to restore

normal

anatomic

relationships

between

the neurosensory

retina

and

the

retinal

pigment

epithelium

(RPE)

by methods

that

result

in the maintenance

or maximal

restoration

of

cen-

tral and

peripheral

visual

function. Experienced

retinal surgeons

using

the

techniques

outlined

in

previous

chapters

of

this

book can achieve

this

objective

in

the

majority

of

cases

with

a

single

operation

and

a minimum

number

of

complica-

tions. Complications

are undesirable

for

two

rea-

sons: (I)

they

may

lessen

the chances

for

retinal

reattachment

with

a

single

operation

(as

in

the

case

of retinal

incarceration)

or (2) they may

result

in reduced

visual

function

in

cases

in

which

anatomic retinal

reattachment

is

achieved

(as

in

the case of subretinal

hemorrhage).

As

in all

surgi-

cal disciplines,

the

most effective

treatment

for

surgical complications

is to

avoid

them.

By using

atraurnatic surgical

technique

and

following

estab-

lished surgical

principles,

complications

can

be

minimized.

Complications

of

retinal

reattachment

surgery

can be broadly

grouped

into

those

that

occur

in the

intraoperative environment

or

those

in

the postop-

erative period. The

latter can

in

tum

be

classified

into early and late complications,

with

the

former

being

the

major

subject of

this chapter.

Intraoperative

Complications

Penetration

with Scleral Suture

The necessity

of achieving

adequate

length

and

depth

of

scleral

bites

to produce

suitable

buckle

height has

already

been addressed

in

Chapter

7.

Occasionally,

especially

in

myopic

eyes

or those

with localized

radial

staphylornata,

the

needle

will

penetrate

the

choroid

and pigment

epithelium.

This

risk can be reduced

by using

a spatula

rather than

a

CUlling needle.

In eyes

in which

the

retina

is suffi-

ciently detached

in

that quadrant,

subretinal

fluid

will be released

as

the needle

hub

is

withdrawn

from

the scleral

pass,

with

immediate

softening

of

the globe. If

the

retina

is attached

in

that quadrant,

no outward

sign

may

occur

although

occasionally

a

small

bead

of vitreous

may

be

seen

at the site.

In

either case,

if blood

emanates from

the needle

tract

externally,

the suture

must be immediately

but

care-

fully

removed

from

the

tract

after cutting

it close

to

the sclera

to

reduce

the chance

of intravitreal

or

subretinal bleeding.

The site should

then be

care-

fully inspected

by

indirect

ophthalmoscopy

and

treated by cryopexy

or indirect

laser

if there is evi-

dence

of a traumatic

retinal tear. If there

is evidence

of localized

subretinaI

hemorrhage,

the

intraocular

pressure

should

be increased

and the

eye

and

head