Intravitreal gas injection for macular hole with localized retinal detachment in highly myopic patients - Reply
Journal
Acta Ophthalmologica
Journal Volume
89
Journal Issue
4
Pages
e380-e381
Date Issued
2011
Author(s)
Abstract
Editor, We appreciate Dr Georgalas and associates (2010) for raising several important issues about the treatment of macular hole with retinal detachment (MHRD) in highly myopic patients. First of all, we agree that patients with peripheral vitreo-retinal degeneration in the lesion eyes are not good candidates for gas injection as reasoned by Georgalas and associates. In fact, we believe pneumatic retinopexy is contraindicated for treating any type of rhegmatogenous retinal detachment in eyes with any lattice degeneration in the attached area because of the high incidence of new breaks formed at the degeneration sites. In this series, we had thoroughly checked the peripheral retina before the operation in all our patients, and all patients enrolled in this study had no lattice degeneration or retinal breaks in the periphery. We apologize for not clearly stating this criterion in the patients and methods section. The vitreo–retinal relationship is complex in high myopic eyes, with frequent presence of vitreous schisis exerting traction to the retina in various directions and at different sites. Even with complete posterior vitreous detachment (PVD), the eye may not be free from localized peripheral vitreo-retinal adhesion, and the chance of break formation from gas escaping into retro-hyaloid space causing retinal traction, the postulated mechanism of pneumopexy-related new break formation (Holz & Mieler 2003; Yam et al. 2008), may not be too different compared to those cases with no vitreous detachment or partial posterior vitreous detachment. In our study, we observed that 2 patients suffered from rhegmatogenous retinal detachment from peripheral breaks after gas injection; one had no PVD (patient 1) and the other had complete PVD (patient 19). We found, however, failure to reattach the retina in such cases may not jeopardize or affect subsequent treatment and prognosis to the same extent as it may do in the more common types of rhegmatogenous retinal detachment. In our study, gas injection could not achieve macular hole closure in any case. However, even with vitrectomy and internal limiting membrane peeling, low closure rate of macular hole was still observed, as in a study by Ichibe et al. (2003) (10% of hole closure). Besides, the visual recovery is limited despite anatomic success. A recent prospective study showed final visual prognosis had no difference between gas injection and vitrectomy in treating macular hole-related retinal detachment in high myopia (Li et al. 2009). The retinal reattachment rate after single gas injection was 59.8% at 12 months in that study, which also enrolled patients with more extensive retinal detachment. Considering that intravitreal gas injection is a relatively simple procedure with reasonable long-term success rate and that its failure would not affect the final outcome by more aggressive treatment, we maintain that this modality is an appropriate first-line treatment option for localized MHRD whether PVD is present or not. Thorough pre- and postoperative fundus examination can help to exclude and identify the high-risk patients of iatrogenic retinal break and to increase the safety of the procedure.
SDGs
Type
letter