When does visual acuity stabilize after macular hole surgery? Five‐year follow‐up of surgery for idiopathic macular hole

Macular hole closure rates of over 90% and improvement in visual acuity (VA) after successful repair have been reported in surgical studies with removal of the internal limiting membrane (ILM), gas tamponade and face-down positioning in previous studies (Karacorlu et al. 2005; Ozdemir et al. 2010; Hu et al. 2016). In this retrospective study, we report 5-year follow-up results of 162 eyes of 146 patients with idiopathic macular hole whose surgery involved removal of the ILM (without dye assistance), 12–14% perfluoropropane tamponade and face-down positioning for about 5 days (Table 1). The differences between preoperative VA and postoperative VA at all subsequent follow-up visits were statistically significant (all, p < 0.001). There was a statistically significant difference in postoperative VA between 1 month and 3 months, between 6 months and 1 year and between 1 year and 2 years (all, p < 0.001). There was no statistically significant difference in best corrected visual acuity (BCVA) 2 years after surgery at subsequent visits. It has been demonstrated that VA continues to improve until 2 years and remains stable afterwards. At 5 years postoperatively, 139 eyes (90%) achieved VA of 20/40 or better. All eyes with VA of 20/40 or better had complete restoration of the external limiting membrane. None of the eyes with VA of 20/25 or better had impairment of the ellipsoid zone. Although anatomical success was achieved in all patients after the first operation, reopening of an initially closed macular hole was observed in three eyes (2%) during follow-up, after a mean of 30.3 ± 21.8 months (range, 6–48 months). Hole closure was obtained after a second vitrectomy in two eyes, but one patient refused additional surgery. Within the first 2 years, 119 eyes (90%) underwent cataract surgery, and cataract surgery was necessitated in the remaining 13 eyes after 2 years. Our successful anatomical and functional outcomes after surgery were comparable to previous published results. At 5 years, macular hole closure had been obtained in 161 eyes (99%) with improvement of VA from 20/80 to 20/32. Recent studies supporting face-down positioning for less than 5 days have reported success rates between 91% and 95.6% (Wu et al. 2011). Improvement in visual acuity after successful repair of macular hole depends on photoreceptor restoration, shown on optical coherence tomography imaging (Mitamura et al. 2013). It has been demonstrated that the retinal layers become restored first at the external limiting membrane, followed by the ellipsoid zone and then the interdigitation zone, and ellipsoid zone reconstruction is considered to be a good prognostic factor for visual rehabilitation after macular hole surgery (Mitamura et al. 2013; Ruiz-Moreno et al. 2013). In our study, at 5 years, similar to previously published reports, none of the eyes had a complete restoration of the ellipsoid zone without a complete restoration of the external limiting membrane or a complete recovery of the interdigitation zone without a complete recovery of the ellipsoid zone. No eyes with VA of 20/25 or better, but all eyes with visual acuity of 20/50 or worse, had impairment of the ellipsoid zone. There was also no statistically significant difference in BCVA 2 years after surgery at subsequent visits. It could be concluded that no restoration of photoreceptor layer was seen in any eyes 2 years after surgery. This study has several strengths. A single surgeon performed the same procedure. The study has one of the longest follow-up periods for macular hole surgery and 5-year follow-up was recorded for all patients. All patients were pseudophakic at the final examination. In conclusion, favourable anatomical success after surgery was obtained in 99% of eyes with an improvement of visual acuity from 20/80 to 20/32 at 5 years postoperatively. It has been demonstrated that visual acuity continues to improve until 2 years and remains stable afterwards.