Macular Hole Surgery With Inner Limiting Membrane
Peeling, Endodrainage, and Heavy Silicone
ANNELIES SCHURMANS, JOACHIM VAN CALSTER, AND PETER STALMANS
To evaluate the anatomical and functional
outcomes in macular hole (MH) patients who underwent
vitrectomy with inner limiting membrane (ILM) peeling,
endodrainage, and heavy silicone oil (HSO) endotamponade.
A retrospective case series with 54 consecutive
eyes from 53 patients with idiopathic stage 3 or 4 MHs.
Surgery with infracyanine green-assisted
ILM peeling and endodrainage was performed. Patients
who were phakic underwent a simultaneous phacoemul-
siﬁcation. At the end of the operation, a HSO tamponade
was used in all cases. The patient maintained a face-up
position for 24 hours postoperatively. The HSO was
removed two to three months after initial surgery. Opti-
cal coherence tomography was performed preoperatively
and postoperatively to determine the MH stage and the
anatomical closure rate.
The mean follow-up time was 6.6 months
(range, 3.6 to 18.2 months). The overall median dura-
tion between the ﬁrst symptoms and the surgery was four
months (range, two to 37 months). The overall anatom-
ical closure success rate after one surgery was 100%.
The median preoperative visual acuity (VA) was 20/200
(range, 20/40 to 20/600) and increased to 20/50 (range,
20/20 to 20/300) postoperatively. The median increase
in VA was ﬁve lines (mean, 4.8 lines; range, –3 to 12
lines). Of all 54 eyes, 30 (55 %) eyes had a ﬁnal VA of
20/50 or better.
These ﬁndings indicate that surgery
for MH with ILM peeling, endodrainage, and HSO
endotamponade appears to induce a high incidence of
anatomical closure with good visual outcome. (Am J
Ophthalmol 2009;147:495–500. © 2009 by Elsevier
Inc. All rights reserved.)
ACULAR HOLES (MHS) ARE A CAUSE OF DETERI-
orated central vision in the elderly, and they
show a strong female predominance. The prev-
alence of MHs is 3.3 in 1,000. Since the description of pars
plana vitrectomy (PPV) for idiopathic holes by Kelly and
Wendel in 1991,
many new techniques have been devel-
oped to facilitate surgery and improve results. The current
surgical approach consists of a PPV with removal of the
vitreoretinal foveal traction. To improve cell migration for
MH closure after surgery, a smooth template must be
provided. A gas or silicone oil bubble is generally used, but
postoperative positioning is required. This postoperative
face-down positioning is sometimes a challenge for the
patient. Heavy silicone oil (HSO) has been designed to
overcome the disadvantages of silicone oil and gas tam-
ponades because they are heavier-than-water tamponade
agents. Because of their increased density, they provide a
good tamponade of both the inferior and posterior pole in
normal head posturing, making postoperative face-down
positioning no longer necessary.
IN THIS RETROSPECTIVE STUDY, 53 CONSECUTIVE CON-
senting patients (54 eyes) with stage 3 or 4 MHs were
operated on between November 1, 2004 and January 1,
2006. Inclusion criteria were the presence of idiopathic
stage 3 or 4 MHs, as determined by indirect ophthalmos-
copy and optical coherence tomography (OCT) imaging.
Exclusion criteria were preproliferative and proliferative
diabetic retinopathy, age-related macular degeneration,
high myopia, traumatic MH, and previous retinal detach-
ment (RD) surgery. MH size was measured and recorded
with OCT imaging using standard OCT 2 or Stratus OCT
software (Humphrey-Zeiss, San Leandro, California, USA).
Staging of the MH in all patients was done using Gass
classiﬁcation modiﬁed by OCT imaging.
Stage 3 holes have
no retinal tissue on the bottom of the MH and an operculum
with incomplete posterior vitreous detachment (PVD). In
stage 4 MHs, a complete PVD is present.
At present, two types of HSO are available: Oxane HD
(Bausch & Lomb, St Louis, Missouri, USA) and Densiron
68 (Fluoron, Neu-Ulm, Germany). Details of both their
chemical and physical properties are listed in Table 1.
There are publications describing some intraocular inﬂam-
mation and stickiness with the use of OxaneHD,
therefore we obtained Densiron68 HSO.
The surgery was conducted similarly by two surgeons
(P.S. and J.V.C.). Only two eyes (4%) were operated on
See accompanying Editorial on page 381.
Accepted for publication Sep 2, 2008.
From the Department of Ophthalmology, University Hospitals Leuven,
Inquiries to Peter Stalmans, Department of Ophthalmology, University
Hospitals Leuven, Capucijnenvoer 33, B3000 Leuven, Belgium; e-mail:
LL RIGHTS RESERVED