Autologous Neurosensory Retinal Free Flap for Closure of Refractory Myopic Macular Holes.
Macular holes (MHs) in highly myopic patients often develop at a younger age and may be associated with foveoschisis and a posterior retinal detachment (RD) which portend a poorer prognosis. Although recent anatomical success following primary pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peel with gas tamponade have improved to 60% to 100% closure rates are significantly lower if associated with foveoschisis or RD, the MH may attain a flat open configuration even following retinal reattachment, and reopening rates are higher.1,2 Early treatment reports described perifoveolar laser photocoagulation to form chorioretinal adhesions resulting in permanent photoreceptor loss.3 Several procedures are now available for primary repair of myopic MH and MH RD including PPV with ILM peel and gas or silicone oil tamponade, inverted ILM flaps,4,5 episcleral posterior buckling, adjuvant blood components,6 suprachoroidal buckling, and scleral shortening techniques.7 However, options for patients whose MHs fail to close despite initial PPV and ILM peel are limited. Techniques described recently include temporal scleral imbrication,8 autologous ILM flap,5 addition of autologous blood to the autologous ILM flap,9 and autologous anterior or posterior lens capsule flap as a scaffold to plug the MH.10 We describe a new technique involving the use of an autologous neurosensory retinal free flap for closure of refractory myopic MHs with associated foveoschisis and/or RD. This technique involves harvesting an autologous neurosensory retinal free flap and positioning it over the refractory MH to provide a scaffold and plug for hole closure. Surgical Technique A woman in her 50s, with 15 diopter myopia, had undergone a PPV with ILM peel for MH 6 months prior that was complicated by a refractory MH and the development of RD postoperatively. She subsequently underwent a scleral buckle and PPV for RD repair with silicone oil endotamponade. Silicone oil was removed 3 months postoperatively and she had a persistent 1100 mm MH (Figure, inset) with corrected visual acuity of 20/200. The fellow eye had myopic foveoschisis without an MH. Surgery was undertaken using peribulbar anesthesia with 23 gauge vitrectomy (Constellation; Alcon) There was poor staining using indocyanine green in the staphyloma but an adequate peel was confirmed by the ILM remnant in the macula. Additional ILM for use as an autologous flap could not be harvested. As she was pseudophakic with an open posterior capsule following a Yag capsulotomy, no lens capsule could be harvested. A neurosensory retina harvest site was selected superior to the superotemporal arcade. Endolaser barricade was applied in a circular manner around a 2 disc diameter area of retina followed by endodiathermy to blood vessels at the site edges. Using a bimanual approach under chandelier illumination, the edge of the graft was held using forceps and cut using vertical scissors. A 2 disc diameter fullthickness neurosensory retinal free flap was obtained and gently moved toward the MH. Diathermy marks at the edges and pattern of retinal vessels served as anatomical markers to maintain correct orientation of the retinal free flap. Perfluoro n octane heavy liquid (PFC) (Perfluoron; Alcon) was instilled over the retinal flap. Flap edges were gently flattened and it was stretched to lay flat and cover the entirety of the hole (Video) Direct PFC silicone oil (1000 centistokes) exchange was performed. Using active aspiration, a few Video at jamaophthalmology.com
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