No face-down positioning and broad internal limiting membrane peeling in the surgical repair of idiopathic macular holes

Objective: To demonstrate the efficacy of broad internal limiting membrane (ILM) peeling and 20% sulfur hexafluoride (SF₆) endotamponade with no face-down positioning in the surgical repair of idiopathic macular holes (MHs). Design: Retrospective study. Participants: Sixty-eight idiopathic MH cases in 68 eyes of 65 patients. Methods: All idiopathic MH surgeries by 1 surgeon between March 2009 and December 2012, performed using broad ILM peeling, 20% SF₆, and no face-down positioning, were reviewed. No cases were excluded. Surgeon method included 23-gauge or 25-gauge pars plana vitrectomy with induction of posterior vitreous detachment (if necessary). Indocyanine green dye (0.08 mg/ml in D5W) was injected slowly, allowed to stain for 60 seconds, and then removed. The ILM was broadly peeled to the vascular arcades (approximately 8000 μm in diameter), followed by 2 fluid-air exchanges, separated by 5 minutes, and an air-20% SF₆ exchange. Patients maintained reading position for 3 to 5 days and were followed up at least for 1 month. Exact binomial distributions were used to establish 95% confidence intervals, and the 1-way analysis of variance was used to compare preoperative and postoperative intraocular pressures (IOPs). Main Outcome Measures: Single-procedure MH closure rate, mean postoperative best-corrected visual acuity (BCVA), incidence of cataract, and IOP. Results: Three patients (4.6%) had bilateral MH and 9 patients (13.8%) had recurrent MH (mean duration from previous surgery, 8.3±5.5 years; range, 1-16 years). Twenty-one MH (30.9%) were stage 2, 27 (39.7%) were stage 3, and 20 (29.4%) were stage 4. Five MH had a basal diameter of more than 1000 μm. Mean MH basal diameter was 609.6±226.2 μm. Mean preoperative BCVA was 0.68±0.29 logarithm of the minimum angle of resolution (logMAR) units (Snellen equivalent, 20/95), and mean most recent postoperative BCVA was 0.28±0.18 logMAR units (Snellen equivalent, 20/38). The single-procedure MH closure rate was 100% (95% confidence interval, 95%-100%), and no complications were observed. Conclusions: Macular hole surgery with broad ILM peeling, 20% SF₆ gas, and no face-down positioning is highly effective in the surgical treatment of idiopathic MH with efficacy comparable with methods that use longer-acting gas endotamponade, face-down positioning, or both. In our series, this method eliminated the morbidity associated with postoperative face-down positioning. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.