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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 106-108

A neoteric approach for treatment of persistent macular hole using human amniotic membrane

1 Department of Vitreo Retina, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
2 Department of Vitreo Retina, Netralayam, Kolkata, West Bengal, India

Date of Submission31-Mar-2022
Date of Acceptance05-Sep-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Rupak Roy
Aditya Birla Sankara Nethralaya, 147, Mukundapur, E. M. Bypass, Kolkata - 700 099, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_828_22

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Treatment of persistent macular holes is a challenge. Various techniques have been devised to reduce the surgical failure rate. We present a case of persistent macular hole treated with human amniotic membrane (hAM). We performed primary 23 Gauge pars plana vitrectomy surgery with internal limiting membrane peeling and perfluoropropane (C3F8) gas. Two weeks postoperatively, spectral domain optical coherence tomography (SDOCT) showed an open macular hole. A secondary surgery using hAM plug as scaffold and C3F8 gas was performed. Three weeks postoperative follow-up SDOCT showed anatomical closure of the macular hole. This suggests that hAM can be an effective substrate for persistent macular holes.

Keywords: Human amniotic membrane, macular hole, spectral domain optical coherence tomography, vitrectomy

How to cite this article:
Gorhe S, Eswaran BV, Chattree S, Goel N, D'souza Z, Saurabh K, Roy R. A neoteric approach for treatment of persistent macular hole using human amniotic membrane. Indian J Ophthalmol Case Rep 2023;3:106-8

How to cite this URL:
Gorhe S, Eswaran BV, Chattree S, Goel N, D'souza Z, Saurabh K, Roy R. A neoteric approach for treatment of persistent macular hole using human amniotic membrane. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:106-8. Available from: https://www.ijoreports.in/text.asp?2023/3/1/106/368224

Macular hole (MH) is defined as a partial- or full-thickness defect in neurosensory retina in the center of macula.[1] Pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling with gas tamponade has been the standard surgical treatment for MH. The rate of persistence of MH after primary surgery is reported to be 8%–44%.[2] Several factors responsible for nonclosure of MH include poor patient compliance in maintaining prone position, insufficient gas tamponade, persistence of tangential and anteroposterior traction, larger hole diameter, chronicity, previously failed surgery, and so on.[3],[4] This has led to various modifications in MH surgery, such as inverted ILM flap technique, autologous ILM transplantation, lens capsule flap transplantation, autologous retinal transplantation (ART), adjuvant autologous platelet concentrate, induction of macular detachment with subretinal blebs, and others.[5]

Human amniotic membrane (hAM) tissue has been used widely in various ophthalmological procedures such as ocular surface reconstruction, tectonic support in small corneal perforations, limbal cell transplantation, socket reconstruction, retinal breaks, and so on.[6] The hAM has many advantages such as being easily available, transparent, nonimmunogenic, and cosmetically acceptable.[6] In vitro studies have shown that the hAM can provide a substrate for proliferation of retinal pigment epithelial (RPE) cells, and thus cause anatomical closure of MH.[7] Rizzo et al.[8] found significant improvement in MH closure with the use of hAM for recurrent MHs and retinal breaks. Caporossi et al.[9] demonstrated 100% closure rate with hAM and improvement in best-corrected visual acuity (BCVA) in cases of failed MH surgery.

We report a case of successful closure of persistent MH using hAM transplantation technique.

  Case Report Top

A 53-year-old female presented with the complaint of gradual painless diminution of vision in left eye since 1 year. On examination, BCVA in right eye was logMAR 0.2, near vision logMAR 0.5 and in left eye was logMAR 1, near vision logMAR 0.9, with early cataractous changes in both eyes. On dilated fundus examination with +20 D lens, right eye showed few RPE alterations at the macula. Left eye revealed a full-thickness defect in retina at the center of macula, suggestive of MH. Minimum hole diameter was 658 μm and the MH height was 504 μm, as measured with the inbuilt calliper tool on spectral domain optical coherence tomography (SDOCT) (Heidelberg SPECTRALIS HRA–OCT). The patient underwent vitrectomy with ILM peeling with the inverted flap technique using 14% perfluoropropane (C3F8) as tamponade under peribulbar anesthesia. Patient was advised strict prone position for 12–14 h/day for 2 weeks. On the first postoperative day, the inverted flap was in situ and the patient was maintaining prone position as advised. Two weeks postoperative SDOCT showed persistent MH with minimum hole diameter of 626 μm and MH height of 523 μm. Hence, the hAM plug technique was attempted under peribulbar anesthesia. The hAM plug was cut from its patch, inserted into the vitreous cavity via 23 Gauge sclerotomy port, and trimmed to the required size using vitrectomy scissors. The hAM plug was positioned and inserted into the MH using ILM forceps. The chorion layer of amniotic membrane faces the RPE (sticky side down). The graft was placed in the MH without the edge of graft being inserted below the MH edges. Fluid–air exchange was performed. Small amount of viscoelastic substance was instilled over the graft to prevent its displacement. Then, 14% C3F8 gas was exchanged with air to act as endotamponade. Sclerotomies were self-sealing. Patient was advised strict prone position for 2 weeks. On the first postoperative day examination, the hAM graft was in situ. Three weeks postoperatively, the BCVA for distant vision was logMAR 1.0, near vision was logMAR 0.9, with SDOCT showing reattachment of margins and anatomical closure of MH.

[Figure 1] shows the intraoperative placement of hAM in the MH. [Figure 2] shows the left eye SDOCT at baseline (a), after the first surgery (b) and after the second surgery (c).
Figure 1: Intraoperative photos of the surgical technique using hAM plug for persistent macular hole. (a) The hAM inside the vitreous cavity. (b) Trimming of the hAM plug according to the macular hole size using vitrectomy scissors and its insertion under the edges of macular hole with ILM forceps. (c) The hAM plug placed inside the macular hole. (d) Fluid–gas exchange performed away from the graft to avoid its displacement. hAM = human amniotic membrane, ILM = internal limiting membrane

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Figure 2: Pre and post operative outcomes on Spectral Domain Optical Coherence Tomography (SDOCT) of the patient who underwent hAM plug surgical technique for persistent macular hole. (a) Preoperative SDOCT showing an idiopathic full-thickness macular hole. (b) Two weeks postoperative SDOCT image after vitrectomy with ILM peeling shows persistent macular hole. (c) Three weeks postoperative SDOCT image showing closure of macular hole with the hAM plug. hAM = human amniotic membrane, ILM = internal limiting membrane, SDOCT = spectral domain optical coherence tomography

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  Discussion Top

Various new techniques and use of adjuvants such as free ILM flap, retinal autograft, and lens capsular flap have been described for the treatment of persistent MH.[5] These techniques have achieved 100% closure anatomical rate; however, they are difficult to perform, have longer duration, and are associated with complications such as retinal detachment and vitreous hemorrhage.

Caporossi et al.[9] have demonstrated complete anatomical closure of failed MH in high myopics using hAM with silicone oil and C3F8 gas as endotamponading agents at 1 month follow-up. Rizzo et al.[8] have demonstrated complete MH closure with the neurosensory retina totally overfilling the hAM plug in all cases of hAM MH transplantation after 1 week. Yadav et al.[10] used hAM in primary surgery for MHs and achieved anatomical closure in all the 10 cases.

In our case, complete anatomical closure of persistent MH at 3 weeks postoperatively was achieved with the use of hAM. It has advantages like being easily available, nonimmunogenic, and sizable according to the dimensions of MH. The hAM also provides support to RPE and promotes its integration into the subretinal space.[7] Procuring an adequate size ILM free flap, autologous retinal patch, or capsular flap are more difficult procedures; the limitations of these techniques are longer duration of surgeries and associated intraoperative and postoperative complications.

  Conclusion Top

We can conclude that the hAM is a safe and effective substrate in the treatment of persistent MHs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Majumdar S, Tripathy K. Macular Hole. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.  Back to cited text no. 1
Tam ALC, Yan P, Gan NY, Lam W-C. The current surgical management of large, recurrent, or persistent macular holes. Retina Phila Pa 2018;38:1263–75.  Back to cited text no. 2
Kumagai K, Furukawa M, Ogino N, Larson E. Incidence and factors related to macular hole reopening. Am J Ophthalmol 2010;149:127–32.  Back to cited text no. 3
Chow DR, Chaudhary KM. Optical coherence tomography-based positioning regimen for macular hole surgery. Retina Phila Pa 2015;35:899–907.  Back to cited text no. 4
Cao JL, Kaiser PK. Surgical management of recurrent and persistent macular holes: A practical approach. Ophthalmol Ther 2021;10:1137–53.  Back to cited text no. 5
Sridhar U, Tripathy K. Amniotic Membrane Graft. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.  Back to cited text no. 6
Capeáns C, Piñeiro A, Pardo M, Sueiro-López C, Blanco MJ, Domínguez F, et al. Amniotic membrane as support for human retinal pigment epithelium (RPE) cell growth. Acta Ophthalmol Scand 2003;81:271–7.  Back to cited text no. 7
Rizzo S, Caporossi T, Tartaro R, Finocchio L, Franco F, Barca F, et al. A human amniotic membrane plug to promote retinal breaks repair and recurrent macular hole closure. Retina Phila Pa 2019;39(Suppl 1):S95–103.  Back to cited text no. 8
Caporossi T, Pacini B, Bacherini D, Barca F, Faraldi F, Rizzo S. Human amniotic membrane plug to promote failed macular hole closure. Sci Rep 2020;10:18264.  Back to cited text no. 9
Yadav NK, Venkatesh R, Thomas S, Pereira A, Shetty KB. Novel method of plugging the hole: anatomical and functional outcomes of human amniotic membrane-assisted macular hole surgery. J Curr Ophthalmol 2020;32:361–7.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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