http://www.dailymotion.com/video/x16sglm

Advantages:

To exhibit the characteristics of the idiopathic lamellar macular hole (ILMH) that evolves into full thickness macular hole (FTMH) after pars plana vitrectomy (PPV) and peeling of epiretinal membrane (ERM) and internal limiting membrane (ILM) and to discuss the indication and the timing of the surgical treatment.

Methods:

We report two cases of ILMH. Eyes underwent 23 gauge PPV and peeling of ERM and ILM with SF6 tamponade. After surgery, they developed FTMH. In one case we performed PPV by 20 G and tamponade with silicone oil. In the other case we performed PPV with 23 G and tamponade with SF6. The ophthalmological examination, best corrected visual acuity (BCVA), intraocular pressure (IOP), fundus examination were performed at baseline and after surgery. The characteristics of ILMH (diameter, foveal thickness, photoreceptors defect, ERMs type and the presence of antero-posterior and/or tangential tractions) were evaluated before the first surgery by optical coherence tomography (OCT). The post-operative morphological changes were followed by OCT postoperatively.

Effectiveness / Safety:

Preoperative data: Both cases of ILMH associated to a dense ERM without evidence of antero-posterior traction. The OCT showed an intra-retinal split at the level of the outer nuclear layer (ONL). There were not intra-retinal cysts associated with ILMH. Intra-operatively, we noted, in both cases, the adhesion of posterior vitreous cortex. In accordance with the ERMs description reported in literature (Parolini et al.), during the peeling of ERM, the membranes appeared as dense yellow tissue with a fluffy consistency. In the first case, we obtained closure of the macular hole without improvement of vision. In the second case, the macular hole is not closed.

Take home message:

ILMH associated to a dense ERM may be closed by vitrectomy with peeling and BCVA may improve. However, the risk of developing a full thickness macular hole should be taken into account. The depth and the diameter of the intraretinal splitting may be considered the most significant prognostic factors to the development of a FTMH.