COORDINATED BY ABDHISH R. BHAVSAR, MD
Abdhish R. Bhavsar, MD, is an attending retina surgeon at the Phillips Eye Institute, Director of Clinical Research at the Retina Center, P.A., in Minneapolis, MN., and adjunct assistant professor at the University of Minnesota. He also serves as state chair of the Minnesota Diabetes Eye Exam Initiative. E-mail him about Face Off at firstname.lastname@example.org.
Welcome to Face Off, a column that will explore controversial topics in the diagnosis and management of retinal diseases. Several topics will be covered in each issue with one retina specialist voicing one line of thought in favor of the treatment or surgery and another retina specialist voicing an opposing line of thought. The column will be a nice exercise in exploring pro- and con- aspects of treatment decisions that we face on a daily basis. This column should be interpreted in the spirit of a debate society. We hope that you will find the column interesting, entertaining and educational.
In this issue we address 3 macular hole surgery topics: face down positioning, internal limiting membrane (ILM) dissection during surgery, and short-acting (SF6) vs. long-acting (C3F8) gas for surgery.
Face-Down Position after Macular Hole Repair Surgery
IN FAVOR OF
Maurice Gutierrez Syrquin, MD: In our practice, Bruce Taylor, MD, Richard Winslow, MD, Gregory Kozielec, MD, and I are all 1-week face-down positioning proponents. We feel our success rates are higher with this regimen. Both SF6 and C3F8 gas are suitable, but the SF6 allows for quicker visual rehabilitation. Having made these comments, I am reminded of a patient I operated on who went from 20/400 to 20/20. I said to him "Aren't you glad you kept your head down for 1 week?" He replied with a smile on his face, "Do you really want to know the truth Dr. Syrquin? I never positioned." I therefore feel we need more prospective studies to both help answer these questions and practice evidence based medicine.
Paul E. Tornambe MD: The reasons for face- down posturing after macular hole surgery appear to be historical for there are no data to prove face-down positioning is indispensable to the goal of closing a macular hole. The bubble's purpose is to isolate the hole from vitreous fluid to permit healing of the inner retinal defect, or 'divot', which was created when the vitreous pulled away from the perifoveal region. So long as the bubble is 'on the trouble' for 3 to 5 days, the hole will close. If the vitreous cavity is filled with a 20% SF6 bubble, the bubble will 'waterproof' the macular hole for that period of time with upright positioning. I never use face-down positioning in pseudophakic patients, and in those phakic patients over 60 who do not wish to spend a week face down, I advise cataract surgery 2 weeks before (or at the time) of macular hole surgery. All these patients will develop a cataract within a year, so it makes sense to take the cataract out first to avoid face-down misery. I have used this technique for a decade and my success rate is in the 95%+ range. It works!
Internal Limiting Membrane Dissection during Macular Hole Repair Surgery
IN FAVOR OF
Neil E. Kelly, MD: The success rate of hole closure is higher with internal limiting membrane (ILM) dissection. Visual results are not compromised and the surgeon and patient do not have to return to the OR. The patient does not have to assume a prone position for another week, and most importantly, the surgeon does not have to tell the patient, "I'm sorry, it did not work."
Alan R. Margherio, MD: The necessity of ILM peeling for acute macular holes remains a controversial subject. The majority of recent publications would have us believe that ILM peeling is necessary in order to achieve high closure rates. However, in acute cases (less than 1 year duration) of stage 2 and 3 holes, I have not peeled the ILM in nearly 10 years. If the surgeon creates a complete posterior vitreous detachment in these cases, ILM peeling is redundant. Of course, patient compliance with face down positioning is critical. I reserve ILM peeling for chronic holes, failed holes and re-opened holes.
Short-Acting vs. Long-Acting Gas for Macular Hole Surgery
IN FAVOR OF
Howard D. Gilbert, MD: Twenty-five percent to 28% F6 gas is sufficient to close macular holes in 97% of cases or even more in the hands of many surgeons. With a complete gas/fluid exchange in the OR, this gas will keep the macular tamponade in the sitting position for 5 to 7 days. SF6 would be expected to be less likely to cause air cataract than longer acting gases if patients are allowed up (i.e., not face down) after 3 to 5 days, which is now quite commonplace. Visual recovery for the patient is enhanced by gases that clear more quickly as long as the macular hole stays closed (which indeed is the case with SF6). For physicians who prefer a full week or even 10 days of face down positioning, 25% to 28% SF6 will still create a large enough and long lasting enough bubble to do so.
Everett Ai, MD: Simply put, both long-acting and short-acting intraocular gases can result in anatomically successful macular hole surgery. One important variable remains: that of patient compliance with head positioning. In this regard, there is a "learning curve" in patient selection, similar to that encountered in the early days of pneumatic retinopexy. Less compliant macular hole patients will benefit from long-acting intraocular gases, just as less compliant retinal detachment patients benefit from larger volumes of long-acting gases.