Secondary Macular Hole Associated with Branch Artery Occlusion Treated with Inverted Flap Technique by Maria del Mar Prieto del Cura, Muxima Acebes Garcia, Maria Jose Crespo Carballes, Spain



Currently, pars plana vitrectomy (PPV) combined with peeling of the internal limiting membrane (ILM) is used as a standard procedure for treatment of a macular hole (MH). Since idiopathic MHs are caused by tangential traction of the posterior hyaloid membrane and by anterior posterior vitreomacular traction, surgical removal of the tractional force is beneficial for the restoration of normal macular anatomy. In contrast, the underlying cause of secondary MH associated with retinal edema is thought to be inflammation. We report a case of secondary MH associated with macular edema in a patient with a branch retinal artery occlusion that supplies blood to the superior area of the macula. We postulated that internal limiting membrane (ILM) peeling for decompression of macular edema in cases of retinal artery occlusion would facilitate egress of blood and extracellular fluid out of the inner retinal layers, leading to reduction of macular edema and improvement in visual acuity.

Case Report:

A 63 year old female presented vision loss with a central scotoma in the left eye of one month duration. She was diabetic and hypertensive of 7 years duration under good control. On examination, best corrected visual acuity was 20/20, in the right eye, and 20/80, in the left. Her anterior segment examination was within normal limits. Applanation tonometry was 19 mmHg in both eyes. A dilated fundus examination in the left eye revealed a macular hole with subretinal fluid at the end of a branch retinal artery occlusion that supplies blood to the superior area of the macula and visualisation of the peripheral retina exclude pathology such as retinal tears and other vascular lesions. An optical coherence tomography revealed a large hole with a full-thickness defect of 552 μm in width and vitreomacular adhesion in the left eye, the classic œanvil-shaped deformity of the edges of the retina is noted due to intraretinal edema. A 23 gauge pars plana vitrectomy with Visualization System was performed, free filtered triamcinolone acetonide was injected into the vitreous cavity to delineate the posterior hyaloid face and facilitate inducing posterior vitreous detachment (PVD), after that step, a vitrectomy was done. The internal limiting membrane was stained with a membraneblue-dual® solution and an ILM circumference of approximately 2 disc-diameters around a circle whose centre was the MH was peeled off, the peripheral piece of ILM was trimmed, whereas the central part of ILM was left in place, half of the remaining ILM circle over the macula was peeling with an ILM forceps and left attached to the edge, these free semicircle ILM flap was fold covering the fovea. We performed a modified technique described by Shin et al. wherein a small amount of perfluorocarbon (PFC) help to the free semicircle ILM attached to the edge remain over the macula to keep the inverted ILM flap in position, in order to stabilize it in the fluid-air exchange followed by followed by air-gas tamponade (SF6) exchange. The patient maintained prone positioning postoperatively. Two months postoperatively, the optical coherence tomography (OCT) showed closure of the MH, with improved restoration of the external limiting membrane and the ellipsoid zone, normalization of the foveal contour, and improvement in vision to 20/32.


The development of an MH related to CRVO has been previously reported but rarely associated with a branch retinal artery occlusion (BRAO). Despite the differences in MH closure between idiopathic MH and secondary MH associated with retinal edema, both of them share common features that may provide clues to better therapeutic strategies in MH associated with inflammation. We suggested that a single-layer ILM flap would be more physiological, providing a more regular structure for glial proliferation and less inflammation than a multilayered ILM.



Maria del Mar Prieto del Cura, Muxima Acebes Garcia, Maria Jose Crespo Carballes
The University Hospital Infanta Leonor
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