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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 57  |  Issue : 1  |  Page : 65-67

Use of air tamponade in macular hole surgery


Department of Retina, MN Eye Hospital, Chennai, Tamil Nadu, India

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. M Nivean
No 781, MN Eye Hospital, TH Road, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_112_18

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  Abstract 


A full-thickness macular hole is a defect in the fovea involving full-thickness extending from internal limiting membrane (ILM) to photoreceptor layer. It needs surgical treatment with the maintenance of prone position postoperatively. Over the years, our understanding regarding the closure of macular hole has improved with optical coherence tomography and various studies have shown varying success results. Conventionally, following vitrectomy and ILM peeing, tamponade of intraocular gas is done to keep the macula dry in the postoperative period. Controversy exists regarding the type of tamponade and the duration of prone position. In this case report, we discuss a case of full-thickness macular hole that was managed surgically with air tamponade.

Keywords: Air tamponade, macular hole, vitrectomy


How to cite this article:
Rajagopal S, Tejaswi Prasad P V, Nivean M, Nivean PD. Use of air tamponade in macular hole surgery. TNOA J Ophthalmic Sci Res 2019;57:65-7

How to cite this URL:
Rajagopal S, Tejaswi Prasad P V, Nivean M, Nivean PD. Use of air tamponade in macular hole surgery. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Aug 24];57:65-7. Available from: http://www.tnoajosr.com/text.asp?2019/57/1/65/259871




  Introduction Top


Macular hole was first described by Knapp in 1869 in a patient with blunt ocular trauma, now we recognize various nontraumatic causes and most common being idiopathic. In 1988, Johnson and Gass first described the classification of macular hole focused on idiopathic cause due to antero-posterior and tangential vitreous traction.[1],[2] Stage 1 macular hole is managed conservatively with regular follow-up. Symptomatic patients with Stage 2 full-thickness macular holes are managed surgically with pars plana vitrectomy, internal limiting membrane (ILM) peeling, fluid-gas exchange, tamponade, and the maintenance of prone position postoperatively. Complications of sulfur hexafluoride and perfluoropropane such as transient rise in intraocular pressure postoperatively, flat anterior chamber, and development of cataract in phakic eyes can be avoided using air for tamponade.


  Case Report Top


A 68-year-old man presented with 6 months history of gradual, painless diminution of vision in the left eye. The patient underwent cataract surgery in both eyes 6 years back. On examination, the best-corrected visual acuity of the right eye was 6/9, N6 and left eye was 6/24, N10, with a positive Amsler's test in the left eye. Anterior segment examination showed posterior chamber intraocular lens in both eyes. Fundus examination of the right eye showed a cup–disc ratio of 0.6 and the rest were within normal limits. The left eye showed cup–disc ratio of 0.6 and full-thickness macular hole. On optical coherence tomography (OCT), macula of the right eye showed a normal foveal contour with early epiretinal membrane and ILM striae [Figure 1]. OCT macula of the left eye showed a full-thickness macular hole with cystic spaces and incomplete posterior vitreous detachment attached to the edge of the hole with macular thickness measuring 221 μ [Figure 2]. Kusuhara et al. suggested macular hole index which is the ratio of macular hole height to base diameter of the hole can be used to represents the preoperative configuration of a macular hole and a prognostic factor for visual outcome.[3]
Figure 1: OD optical coherence tomography normal foveal contour with early epiretinal membrane and internal limiting membrane striae

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Figure 2: OS optical coherence tomography macula full-thickness macular hole with cystic spaces and incomplete posterior vitreous detachment attached to the edge of the hole

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The patient underwent 23G pars plana vitrectomy, ILM peeling after staining with brilliant blue followed by tamponade was done with air in the left eye. The patient was asked to maintain prone position for 5 days postsurgery. A combination of antibiotic and steroid eye drops was applied 6 times/day in tapering dosage. The postoperative period was uneventful. On examination after 6 weeks, the best-corrected visual acuity of the left eye improved to 6/12, N 10. OCT scan of the macula in the left eye showed normal foveal contour and a closed macular hole with a subfoveal small defect was seen. The central macular thickness was 151 μ.


  Discussion Top


Full-thickness macular hole with Stage 2 and above (Gass classification) is an indication for surgical management. Gonvers and Machmer first recommended vitrectomy with intravitreal gas tamponade and postoperative prone position in a patient with retinal detachment due to macular hole.[4] Later, Kelly and Wendell demonstrated that removing cortical vitreous by vitrectomy, epiretinal membrane removal, gas tamponade, and strict face-down position can successfully treat macular hole. They reported that by relieving tangential traction on macula, cystic changes reduces, and reattaches the detached retina surrounding the macular hole. This will stabilize or even improve the vision of the patient.[5]

At present, the basic surgical techniques are standard three port pars plana vitrectomy (23 gauges, 25 gauges) to remove anterior and middle vitreous, surgical posterior vitreous detachment is induced. The critical step is to relieve perimacular traction. ILM is stained using trypan blue or indocyanine green for better visualization, and ILM peeling is done using forceps or soft-tipped silicone cannula.

There are a lot of controversies regarding gas tamponade and timing of prone positioning postoperatively. According to the surgeon's preference, room air or long-acting nonexpansile gas such as 10% sulfur hexafluoride (SF6) and 14% octafluoropropane (C3F8) are commonly used as gas tamponade. These gases can last for a month, whereas room air has much shorter half-life of only 1 day. Conventionally, prone position for 5 days is followed but with advent of OCT, it has become easy to assess anatomical closure of macular hole during the early postoperative period.

Studies have shown room air had higher primary closure rate in spite of the shorter prone positioning period when compared to SF6 gas.[6] Eckardt et al. reported vitrectomy and air tamponade combined with 1–3 day face-down positioning produced an excellent rate of macular hole closure (75.7%).[7] Whereas, a study done by Dhawahir-Scala et al. reported no statistically significant difference between patients who postured and those who did not posture provided eye has >70% gas fill (beyond the inferior retinal vascular arcade) on the 1st postoperative day.[8] Conventionally, prone position for 5 days is followed but with advent of OCT, it has become easy to assess anatomical closure of macular hole during the early postoperative period.

A study reported anatomical closure was achieved in 91%–97% of macular holes with size <0.4 disc diameter with ILM removal followed by 1 day prone positioning.[9],[10] Good prognostic indicators for anatomical closure in macular hole are a size <400 μ, meticulous vitrectomy with ILM peeling, younger patient and macular hole duration of <9 months.

We present a case of successful full-thickness macular hole closure with air tamponade and postoperative prone positioning for 5 days. Long-acting gas can cause prolonged visual impairment. Our patient demonstrated that a short-acting gas like room air and possibly no prolonged prone positioning (5 days) can be sufficient for the closure of the macular hole. Due to technical advances, the success rate of macular hole closure after vitrectomy has increased, and our report shows that room air tamponade is not inferior to those with long-acting gas, with proper prone positioning postoperatively.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johnson RN, Gass JD. Idiopathic macular holes. Observations, stages of formation, and implications for surgical intervention. Ophthalmology 1988;95:917-24.  Back to cited text no. 1
    
2.
Lister W. Holes in the retina and their clinical significance. Br J Ophthalmol 1924;8:i4-20.  Back to cited text no. 2
    
3.
Kusuhara S, Teraoka Escaño MF, Fujii S, Nakanishi Y, Tamura Y, Nagai A, et al. Prediction of postoperative visual outcome based on hole configuration by optical coherence tomography in eyes with idiopathic macular holes. Am J Ophthalmol 2004;138:709-16.  Back to cited text no. 3
    
4.
Gonvers M, Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthalmol 1982;94:468-72.  Back to cited text no. 4
    
5.
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-9.  Back to cited text no. 5
    
6.
Hasegawa Y, Hata Y, Mochizuki Y, Arita R, Kawahara S, Kita T, et al. Equivalent tamponade by room air as compared with SF(6) after macular hole surgery. Graefes Arch Clin Exp Ophthalmol 2009;247:1455-9.  Back to cited text no. 6
    
7.
Eckardt C, Eckert T, Eckardt U, Porkert U, Gesser C. Macular hole surgery with air tamponade and optical coherence tomography-based duration of face-down positioning. Retina 2008;28:1087-96.  Back to cited text no. 7
    
8.
Dhawahir-Scala FE, Maino A, Saha K, Mokashi AA, McLauchlan R, Charles S, et al. To posture or not to posture after macular hole surgery. Retina 2008;28:60-5.  Back to cited text no. 8
    
9.
Guillaubey A, Malvitte L, Lafontaine PO, Jay N, Hubert I, Bron A, et al. Comparison of face-down and seated position after idiopathic macular hole surgery: A randomized clinical trial. Am J Ophthalmol 2008;146:128-34.  Back to cited text no. 9
    
10.
Sato Y, Isomae T. Macular hole surgery with internal limiting membrane removal, air tamponade, and 1-day prone positioning. Jpn J Ophthalmol 2003;47:503-6.  Back to cited text no. 10
    


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