|Year : 2022 | Volume
| Issue : 2 | Page : 183-185
Tapping and Autologous Serum - A Novel Technique for Macular Hole
Taranpreet K Chitkara1, Preetam Singh2, Vipan K Vig3, Rajbir Singh2
1 Department of Ophthalmology, Sri Guru Ramdas Institute of Medical Sciences and Research, Amritsar, Punjab, India
2 Sardar Bahadur Dr Sohan Singh Eye Hospital, Amritsar, Punjab, India
3 Amritsar Eye Hospital, Amritsar, Punjab, India
|Date of Submission||06-Nov-2021|
|Date of Decision||20-Mar-2022|
|Date of Acceptance||21-May-2022|
|Date of Web Publication||30-Jun-2022|
Taranpreet K Chitkara
Department of Ophthalmology, Sri Guru Ramdas Institute of Medical Sciences and research, House Number 25, Krishan Garh Colony, Inside Chati Wind Gate, Amritsar - 143001, Punjab
Source of Support: None, Conflict of Interest: None
We describe here a case of a large, chronic idiopathic macular hole in a patient which was treated using autologous blood serum in combination with tapping the macular hole edges. We achieved successful macular hole closure and improvement in postoperative visual acuity. According to the literature, inverted flap technique continues to be the most accepted form of technique. It also requires experience and skill on the part of surgeon, on the contrary autologous serum in combination with tapping the macular hole edges is a simple, effortless, and relatively non-traumatic option. The combined use of tapping the macular hole edges and applying autologous blood serum is advantageous because the autologous blood serum in proper position probably acts like a natural glue to the tapped edges of macular hole and promotes the proliferation of glial cells. This novel combination technique may be particularly advantageous in chronic or recalcitrant holes particularly large macular holes.
Keywords: Autologous serum, macular hole, serum, tapping the macular hole edges
|How to cite this article:|
Chitkara TK, Singh P, Vig VK, Singh R. Tapping and Autologous Serum - A Novel Technique for Macular Hole. TNOA J Ophthalmic Sci Res 2022;60:183-5
|How to cite this URL:|
Chitkara TK, Singh P, Vig VK, Singh R. Tapping and Autologous Serum - A Novel Technique for Macular Hole. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Nov 30];60:183-5. Available from: https://www.tnoajosr.com/text.asp?2022/60/2/183/349511
| Introduction|| |
Macular hole is a defect in the macular retina, was first described in the ophthalmic literature in 1869 by Herman Knapp. Optical Coherence Tomography (OCT) is a great tool to measure the dimensions of the macular hole accurately. In addition, OCT can accurately confirm the anatomical closure of the macular hole postoperatively. Surgical intervention is the best management of macular holes. Autologous serum can be used as an adjuvant. Liggett et al. first used autologous serum as an adjuvant to increase the macular hole closure rate, and all 11 (100%) eyes had resolution of the surrounding subretinal fluid and flattening of the hole.
| Case Report|| |
A 60-year-old female presented with distortion of vision in right eye since one year. Her visual acuity was 20/320 in the affected right eye N/36 whereas 20/20 and N/6 in the left eye. She was psuedophakic both eyes. Optical coherence tomography showed a macular hole with 979 microns minimum linear diameter (MLD) and 1531 microns basal diameter. In the surrounding retina, there were intraretinal cystic changes [[Figure 1]a, [Figure 1]b, [Figure 1]c corresponds to basal diameter, minimum linear diameter and maximum hole height which are 1531, 979, and 450 microns, respectively]. Patient underwent macular hole surgery for the same.
|Figure 1: Points a, b, c corresponds to basal diameter (BD), minimum linear diameter (MLD), and maximum hole height (MHH) which are 1531, 979, and 450 microns, respectively|
Click here to view
Before starting the surgery, autologous blood was harvested from the patient's antecubital vein with a 5 cc syringe under aseptic precautions and collected in a test tube, where it was allowed to clot so that serum separates from whole blood and collects on top. Then surgery was started. In this technique, we first performed a 23-gauge pars plana vitrectomy (Constellation; Alcon) and detached the firmly adherent posterior hyaloid with the vitreous cutter from optic disc to the midperiphery. Intravitreal triamcinolone was used to make sure of complete posterior vitreous detachment. Diluted indocyanine green dye was injected and used to stain the Internal limiting membrane. An end gripping forcep was used to elevate an edge, and internal limiting membrane (ILM) forcep was used to first remove the epiretinal membrane and the ILM. Next, fluid-air exchange with repeated soft-tip aspiration over the optic nerve was performed to verify that all of the residual fluid was removed. Tapping of macular hole edges was performed on all sides using 23 gauge soft tip cannula.
Now under aseptic precautions serum was withdrawn with 1 cc syringe from preplaced test tube without shaking the test tube as the later would result in remixing of serum with clot. Using a soft-tip cannula, three drops of the autologous blood serum were put over the macular hole. Twenty percent Sulfur hexafluoride gas was used as an internal tamponade. The patient was instructed to lie prone for one week. Spectral domain OCT was done one month after surgery and type 1 closure was seen. There was restoration of the external limiting membrane and the ellipsoid zone, as early as 1 month after surgery [[Figure 2]-One month post-operative spectral domain-OCT showing Type-1 closure of macular hole with residual intra-retinal cystoids spaces. Area of absent ellipsoid zone marked by two index fingers] which gradually decreased over time [[Figure 3] – Seven months postoperative spectral domain OCT showing resolved intra retinal cystoids spaces with restored ellipsoid zone]. Her best corrected visual acuity (BCVA) after seven months of surgery was improvement in distant vision to 20/125 and two lines improvement in near vision to N/18. The macular hole remained closed even after seven months of follow up showing no-reopening which is common with large macular hole.
|Figure 2: One month postoperative SD-OCT showing Type-1 closure of macular hole with residual intra-retinal cystoids spaces. Area of absent ellipsoid zone marked by two index fingers|
Click here to view
|Figure 3: Seven months postoperative SD-OCT showing resolved intra retinal cystoids spaces with restored ellipsoid zone as area between two index fingers|
Click here to view
| Discussion|| |
Macular hole is a defect in the macular retina involving its full thickness from the ILM to the outer segment of the photoreceptor layer. The primary goal of macular hole surgery is to close the macular hole, re-oppose the detached neurosensory retina to the retinal pigment epithelium and thus improve visual function.
Kelly and Wendel pioneered vitrectomy as treatment of macular holes and concluded surgical intervention to be the best surgical option as it offers better anatomical and functional results. Ben Simon GJ, et al. did retrospective analysis of vitrectomy with and without internal limiting membrane peeling for stages 3 and 4 macular hole and showed higher (81%) macular hole closure in ILM peeled group as compared to non-peeled group (50%).
In order to achieve greater success in large macular holes, the use of various adjuvants in MHS has been advocated by many authors. First adjuvant used to treat macular hole was transforming growth factor beta. Other adjuvants include autologous platelet concentrate, serum, thrombin, and autologous whole blood.
A combination of different treatment options has been described. Hoerauf et al. described no touch technique using autologous adjuvants in macular hole surgery and advocated that if autologous platelet concentrate is available, high anatomic success rates can be achieved without aggressive membrane removal. However the Moorefield's Macular Hole Study Group carried out a randomized clinical trial to evaluate the outcome of macular hole surgery and found that autologous serum application did not enhance the results.
Alpatov et al. tried to close the macular hole with forcep giving birth to the idea of opposing hole edges mechanically. Kumar A, et al. tapped the hole edges with soft tip for unfailed hole closure.
Even after diversifications in macular hole surgical techniques like relaxing retinotomy, retinal graft implantation, ILM free flap, lens capsular flap, inverted flap technique continues to be the most accepted form of surgical technique.
Autologous serum used in this case is prepared by simply keeping aside the harvested patient's blood in the syringe for 15 min unlike autologous platelet concentrate where centrifuge machine is a must. This makes use of serum as cheaper and simple alternative as compared to autologous platelet concentrate, transforming growth factor beta, thrombin which require complex segregation procedures.
Kumar A, et al. treated 28 eyes with technique of tapping the macular hole edges and achieved type-1 closure in 20 eyes and type-2 closure in five eyes.
In our case, we demonstrated successful type-1 closure of a large macular hole on spectral domain OCT with combination of tapping macular hole edges and adjuvant serum surgical technique.
Numerous studies are done for large macular holes with inverted flap as the surgical technique but still the learning curve in this technique makes autologous serum a simple, effortless option especially in the hands of the novice vitreo-retina surgeons.
In literature, there are many studies on inverted flap techniques, adjuvant therapy, and tapping macular hole edges used independently for large macular holes.
In our case, we combined tapping the macular hole edges and using autologous serum in the same setting to close a large macular hole.
Finn AP, et al. combined internal limiting membrane flap and autologous plasma concentrate to close a large traumatic macular hole in a paediatric patient.
To our knowledge, this combination technique of tapping the hole edges and autologous serum is not reported so far and needs long-term follow-up and a large prospective randomized study to further confirm the efficacy of this combination technique.
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.
Dr Inderjit Kaur, Dr Nimisha Nagpal and Harjas Singh.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Knapp H. Ueber isolirte zerreissugen der aderhaut in folge von traumen auf dem augapfel. Arch Augenheilkd 1869;1:6-29.
Liggett PE, Skolik DS, Horio B, Saito Y, Alfaro V, Mieler W. Human autologous serum for the treatment of full-thickness macular holes. A preliminary study. Ophthalmology 1995;102:1071-6.
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-9.
Ben Simon GJ, Desatnik H, Alhalel A, Treister G, Moisseiev J. Retrospective analysis of vitrectomy with and without internal limiting membrane peeling for stage 3 and 4 macular hole. Ophthalmic Surg Lasers Imaging 2004;35:109-15.
Glaser BM, Michels RG, Kuppermann BD, Sjaarda RN, Pena RA. Transforming growth factor-beta 2 for the treatment of full-thickness macular holes. A prospective randomized study. Ophthalmology 1992;99:1162-72; discussion 1173.
Hoerauf H, Klüter H, Joachimmeyer E, Roider J, Framme C, Schlenke P, et al
. Results of vitrectomy and the no-touch-technique using autologous adjuvants in macular hole treatment. Int Ophthalmol 2001;24:151-9.
Ezra E, Gregor ZJ. Moorfields macular hole study group report no. 1 surgery for idiopathic full-thickness macular hole two-year results of a randomized clinical trial comparing natural history, vitrectomy and vitrectomy plus autologous serum: Moorfields macular hole study group report no. 1; for the Moorfields macular hole study group. Arch Ophthalmol 2004;122:224-36.
Alpatov S, Shchuko A, Malyshev V. A new method of treating macular holes. Eur J Ophthalmol 2007;17:246-52.
Kumar A, Tinwala SI, Gogia V, Sehra S. Tapping of macular hole edges: The outcomes of a novel technique for large macular holes. Asia Pac J Ophthalmol 2013;2:305-9.
Finn AP, Chen X, Viehland C, Izatt JA, Toth CA, Vajzovic L. Combined internal limiting membrane flap and autologous plasma concentrate to close a large traumatic macular hole in a pediatric patient. Retin Cases Brief Rep 2021;15:107-9.
[Figure 1], [Figure 2], [Figure 3]