Fig. 9.77 This patient, unfortunately, had subretinal ICG during ICG injection. This has resulted in an area of retinal pigment epithelial damage, thankfully away from the fovea which retains 20/30 vision (see Fig. 9.78)

Fig. 9.79 On occasion, in the postoperative period, paracentral holes are seen in the retina as a result of macular hole surgery. The origin of these holes is uncertain but may be related to ILM peeling. The foveal architecture has been restored after this macular hole surgery, but a full thickness paracentral hole is demonstrated (see Fig. 9.80)

Iatrogenic eccentric full thickness macular holes have been associated with ILM peel and require no treatment (Rubinstein et al. 2005).

Visual field loss.

9.2.4.9 Visual Field Loss

Visual field loss (Ezra et al. 1996) has been described with arcuate or paracentral scotomata or peripheral loss in as many as 23 % of patients (Paques et al. 1997) and attributed to loss of nerve fibres at the time of posterior hyaloid peel (Ezra et al. 1996; Haritoglou et al. 2001) or dehydration of the nerve fibre layer of the retina during air–fluid exchange (Welch 1997) or to a variety of changes such as RPE degeneration, choroidal filling delay or epiretinal membrane (Yonemura et al. 2001). Nasal visual field loss has been attributed to ICG usage (Kanda et al. 2004).

9.2.5Success Rates

These depend on the mix of grades of macular hole and the duration of the symptoms and vary from 80 to 100 % for hole closure (Da Mata et al. 2001, 2004; Dori et al. 2003; Ezra and Gregor 2004).

•Treatment of grade 1 holes to try to help prevent progression has shown no benefit (Smiddy et al. 1988; de Bustros 1994).

•In groups with stage 2, success is 88 % (Ruby et al. 1994) hole closure with 60 % achieving 20/50 or better.

•With stages 3 and 4, the success rate is less at 69 % (Freeman et al. 1997) hole closure and 60 % with 20/80 or better.

•Smaller holes under 400 mm (measured on OCT) have an increased chance of closure 94 % compared with 56 % for those 400 mm or larger (Ip et al. 2002).

•Partly, the hole may be closed by a glial cell plug thought to come from the Muller cells (Rosa et al. 1996).

•In patients with macular holes of more than 1 year’s duration, the use of ILM peel has been associated with success rates of 81 % (Stec et al. 2004), but success rates can be much lower at 47 % (Jaycock et al. 2004).

•Those patients with better postoperative vision have thicker foveas on OCT (Villate et al. 2005).

•Larger initial holes are more prone to late reopening.

•Traumatic macular holes can be closed after operation in 96 % (Johnson et al. 2001).

•Visual outcome is improved by reduced age, increased preoperative visual acuity and reduced hole size (Gupta et al. 2009).

9.2.6Reoperation

Reoperation for failed surgery has a success rate for closure of 74 % if performed within 2 months of the initial surgery (Johnson et al. 1997; Valldeperas and Wong 2008). Patients in whom the hole was closed and then reopened postoperatively are more likely to achieve closure of the hole with reoperation than those in whom the hole has never closed (Valldeperas and Wong 2008). ILM does not appear to regenerate (Mittleman et al. 1989) and should therefore be absent in the peeled area on reoperation. Patients with a cuff of fluid visible on OCT are more likely to close after

IS/OS ELM

Fig. 9.81 The recovery of the lines indicating the external limiting membrane (ELM) and the inner segment/outer segment juncture (IS/OS) are good prognostic factors for improved visual recovery after macular hole repair, as in this eye postoperatively

Fig. 9.82 In this postoperative macular hole at 5 weeks, the IS/ OS junction is still disrupted and vision is 20/70; time is required for the retina to remodel and for the vision to improve over 6–12 months. Notice the corrugation on the macula temporal to the fovea, a common feature after macular hole surgery and associated with poorer nasal paracentral vision in these eyes (this is more problematic in the left eye where the nasal paracentral visual field is used when reading words)

Fig. 9.83 Although the hole is closed in this patient, the fovea is very thin and is related to poor visual recover of 20/200