|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 1 | Page : 79-80
Comment on Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery
Brijesh Takkar, Indrish Bhatia, Yamini Attiku, Vinod Kumar
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
|Date of Web Publication||16-Feb-2015|
Vitreo-retina Services, Dr. Rajendra Prasad Centre, AIIMS, New Delhi - 110 0 29
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Takkar B, Bhatia I, Attiku Y, Kumar V. Comment on Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery. Indian J Ophthalmol 2015;63:79-80
|How to cite this URL:|
Takkar B, Bhatia I, Attiku Y, Kumar V. Comment on Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery. Indian J Ophthalmol [serial online] 2015 [cited 2020 May 26];63:79-80. Available from: http://www.ijo.in/text.asp?2015/63/1/79/151494
We read with interest the article "repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery " by Rishi et al.  While managing such situations is indeed a challenge, we made few observations.
Optical coherence tomography (OCT) shows presence of "inner retinal dimpling" seen prominently temporal to the fovea after the first procedure. In fact, this dimpling seems to have increased after the repeat macular surgery. Previously named dissociation of optic nerve fiber layer,  these are now considered to be due to an interplay between trauma and healing processes constrained by nerve fiber layer and not because of dissociation of optic nerve fibers.  It is believed that this morphological pattern observed late after inner limiting membrane (ILM) peeling (after 1-3 months) represents traction caused on the Muller cell end plates during the peeling itself and may even represent a successful peel.  In this case, it well corroborates with absence of ILM/ILM re proliferation noted during the second surgery.
The OCT images after the second surgery also show characteristic temporal thinning seen frequently in long-term after ILM peeling.  Retinal thinning represents surgical trauma endured by the macula. Reasons for this asymmetric macular morphology however are not very clear and have been attributed to the resistant nature of nasal macula due to tight packing of nerve fibers. In fact decreased temporal macular nerve fiber layer thickness has been well documented after ILM peeling and thus may be cause of macular thinning.  Furthermore foveal displacement toward the optic disc might be responsible for the stretching and thinning of the retinal parenchyma in the temporal subfield.  Although ILM peel definitely causes architectural changes, until now no detrimental effect on quantitative visual acuity has been proven. 
Finally, as per authors C3F8 gas has been used during the repeat surgery. However fundus picture two weeks after the repeat procedure does not show any gas bubble. Could it be related to wound leak? A similar leak during the first surgery could have been the cause of failure of primary surgery.
| References|| |
Rishi P, Reddy S, Rishi E. Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery. Indian J Ophthalmol 2014;62:363-5.
Tadayoni R, Paques M, Massin P, Mouki-Benani S, Mikol J, Gaudric A. Dissociated optic nerve fiber layer appearance of the fundus after idiopathic epiretinal membrane removal. Ophthalmology 2001;108:2279-83.
Spaide RF. "Dissociated optic nerve fiber layer appearance" after internal limiting membrane removal is inner retinal dimpling. Retina 2012;32:1719-26.
Pichi F, Lembo A, Morara M, Veronese C, Alkabes M, Nucci P, et al.
Early and late inner retinal changes after inner limiting membrane peeling. Int Ophthalmol 2014;34:437-46.
Balducci N, Morara M, Veronese C, Torrazza C, Pichi F, Ciardella AP. Retinal nerve fiber layer thickness modification after internal limiting membrane peeling. Retina 2014;34:655-63.