Treatment options for macular holes

Special kit greatly reduces previous problems with plasma preparation

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Prof Dr Marta S. Figueroa
In this year’s Kreissig Lecture, Prof Dr Marta S. Figueroa presented her procedural refinement of an advanced surgical approach to the most challenging macular holes in high myopia. Her lecture, entitled “Plasma Rich in Growth Factors for Macular Holes in High Myopia,” was delivered live at the EURETINA 2020 Virtual Meeting. Dr Figueroa, of the Hospital Universitario Ramón y Cajal, Madrid, Spain, is a highly regarded vitreoretinal surgeon and this year’s recipient of the Kreissig Award. The award is given for outstanding contributions in the understanding and treatment of retinal diseases. “The use of autologous adjuvants, such as platelet-concentrate, is not a novelty in the treatment of macular holes. However, despite promising results this technique has not yet been widely adopted by clinicians,” she said. “This is due to profound limitations such as time-consuming preparation of the adjuvants, unpredictable intraocular biologic activity and inconsistent platelet concentration.” However, these limitations can be overcome using a ready-to-use autologous platelet-rich plasma closed system such as the Endoret kit. This offers simpler and faster centrifugation processes and ensures activation of the platelet-rich plasma, leading to the desired product: “plasma rich in growth factors” (PRGF). The procedure is straightforward and efficient: the patient’s blood sample is collected and immediately centrifuged in the Endoret machine. The platelet-rich plasma fraction is collected and then “activated” by Endoret-PRGF activator to obtain PRGF. “PRGF results in quicker, more controlled and more predictable fibrin formation and platelet degranulation, which is what helps close the macular holes,” said Dr Figueroa. “Once the PRGF fluid has been prepared, we perform a fluid-air exchange and release three drops of PRGF over the macula,” she explained as a video of the procedure was shown. Approximately five minutes after injection, fibrin formation becomes visible over the macula of the eye as a whitish membrane. It is this fibrinous fluid that helps close the macular hole. Dr Figueroa described the results of her study, an interventional case series in both treatment-naïve, high-myopic macular holes (Group 1) and persistent, highmyopic macular holes after vitrectomy with ILM peeling (Group 2) treated with PRGF as an adjuvant to the surgery. In both groups, ILM peeling was performed (or extended, as in Group 2), followed by fluid-air exchange. After the addition of PRGF over the macular hole, either C3F8 (Group 1, n=31) or silicone oil (Group 2, N=11) was used as a tamponade, followed by supine positioning for 30 minutes postoperatively and face-down positioning for 15 days. “In the full cohort of patients, the macular hole closed in 90% of the cases. The external limiting membrane in the macular hole region recovered in 69% of cases, and the ellipsoid zone in 48%, with a corresponding improvement in visual acuity from LogMAR 0.82 to 0.54,” she reported. Considering the difficulty of closing this type of high-myopic macular holes, these are impressive results. The PRGF is clearly visible on the postoperative OCT scans as what looks like a hyper-reflective fibrinous membrane located above, within, and, in the retinal detachment cases, under the macular hole. The PRGF disappears several weeks later, upon closure of the macular hole. Dr Figueroa and colleagues also investigated whether PRGF might be useful for macular hole retinal detachment. Starting with highmyopic eyes with macular holes associated with very small, shallow retinal detachments, she and her team then progressed to more challenging cases with large holes and large bullous detachments. Showing a video of the sort of macular hole retinal detachments that tend to keep vitreoretinal surgeons awake at night, Dr Figueroa demonstrates how she aspirates the subretinal fluid through the macular hole and then instils five drops of PRGF over the highly staphylomatous posterior pole. These cases call for silicone oil tamponade. Possible mechanisms of macular hole closure with PRGF include a mechanical mechanism, in which activated PRGF forms a fibrin clot acting as a physical barrier, similar to an ILM flap; and a biological mechanism, in which the trophic factors present in PRGF, may enhance Müller cell activation. A renowned member of the audience, Dr Alistair Laidlaw, asked: “Do you use this technique in holes not associated with myopia?” Dr Figueroa replied that she does, particularly in large, persistent holes. “As shown by the excellent surgical outcomes attained in our series, we believe that the healing capabilities of PRGF are especially useful for macular holes in highly myopic eyes, even in cases of primary surgical failure in which the ILM has already been peeled, as well as in macular hole retinal detachment cases,” she concluded. Marta S. Figueroa: figueroa@servicom2000.com