Long-Term Outcomes after Macular Hole

Surgery
Abdelrahman M. Elhusseiny, MD,1,2 Stephen G. Schwartz, MD, MBA,1 Harry W. Flynn Jr., MD,1
William E. Smiddy, MD1

Purpose: To evaluate the structural and visual outcomes after pars plana vitrectomy (PPV) for idiopathic full-
thickness macular hole (MH) with at least 5 years of follow-up information.
Design: Retrospective case series.
Participants: Patients with idiopathic MH who had at least 5 years of follow-up information after PPV.
Methods: Best-corrected visual acuity (BCVA) was recorded preoperatively and, when available, at 1, 2, 3, 5, 8,
and 10 years after surgery. Reestablishment of the postoperative integrity of the ellipsoid zone (EZ) and the external
limiting membrane (ELM) and presence of cystoid spaces were evaluated using spectral-domain (SD) OCT.
Main Outcome Measures: Postoperative BCVA and its correlation with different SD OCT parameters.
Results: Eighty-seven eyes of 80 patients with a mean age at surgery of 68.9
7.03 years were included. The
mean postoperative follow-up was 9.6
4.3 years (median, 9 years; range, 5e22 years). The mean preoperative
BCVA was 0.20
0.14 (range, 0.03e0.66). Postoperative BCVA was improved at all time points compared with
preoperative BCVA (P < 0.05). Improvement in the postoperative BCVA remained stable 10 years after surgery.
Initial successful closure of MH was achieved in 82 eyes (94%). Macular hole reopening occurred in 7 eyes
(8.0%). Eleven eyes (13%) were reoperated: 4 eyes (4.5%) for persistence and 7 eyes (8.0%) for reopening of MH.
Indocyanine green (ICG) stain was used in 22 eyes (25.2%). Among 57 patients (66%) who were phakic before
surgery, 52 eyes (91.2%) underwent cataract extraction after PPV at a mean duration of 32.7
38.5 months
(range, 2e187 months). Postoperative EZ integrity was restored in 52 eyes (60%), ELM integrity was restored in
54 eyes (62%), and cystoid spaces of variable severity were observed in 28 eyes (32%). Preoperative BCVA of 20/
60 or better and postoperative reestablished ELM and EZ integrity were associated significantly with better
postoperative BCVA at different postoperative follow-up visits (P < 0.05).
Conclusions: Visual acuity improvement after MH surgery continued during the first 3 years after PPV and
was maintained thereafter in a substantial fraction of patients, and final BCVA correlated with better preoperative
BCVA and better postoperative OCT parameters. Ophthalmology Retina 2019;-:1e8 ª 2019 by the American
Academy of Ophthalmology

Idiopathic full-thickness macular hole (MH), a common
macular condition causing loss of vision, was reported to be
amenable to surgical management first by Kelly and Wen-
del.1 Although spontaneous closure of MH has been
reported,2,3 and intravitreal ocriplasmin has been reported
to be successful in selected patients,4 surgical intervention
remains the mainstay of treatment.2,5,6 Subsequent studies
have reported improved anatomic and visual success
rates,7e9 perhaps because of internal limiting membrane
(ILM) peeling10 and better case selection. Previous series
characteristically report results up to 1 year after MH
surgery (MHS). Some studies with longer-term follow-up
information have demonstrated that best-corrected visual
acuity (BCVA) can continue to improve even a few years
after surgery,11,12 but results beyond 5 years are limited.
Similarly, although many studies have elucidated anatomic
factors by spectral-domain (SD) OCT associated with
postoperative BCVA improvement, the follow-up duration
for these evaluations also usually has been limited. The
purpose of the current study was to evaluate the anatomic
and visual outcomes of patients who underwent pars plana
vitrectomy (PPV) with ILM peeling for idiopathic MH who
also had a follow-up duration of at least 5 years. Possible
prognostic factors influencing the postoperative visual out-
comes also were studied.
Methods
The institutional review board of the University of Miami Miller
School of Medicine study protocol approval was obtained. The
study and data collection conformed with the principles of the
Declaration of Helsinki. Surgical consent was obtained from all
patients, but informed consent for inclusion in the current study
was waived because the risk to the patient was minimal and
obtaining consent would be impractical.
A retrospective chart review of patients who underwent PPV
for idiopathic MH by 1 surgeon (WES) at Bascom Palmer Eye
Institute was conducted as follows. Patients were identified by

 2019 by the American Academy of Ophthalmology https://doi.org/10.1016/j.oret.2019.09.015 1

Published by Elsevier Inc. ISSN 2468-6530/19
 Ophthalmology Retina Volume -, Number -, Month 2019
searching the electronic medical record (in use since May 2014)
for follow-up examination visits on eyes that appeared on the
surgical logs from 2003 through April 2014 for which a mini-
mum of 5 years follow-up information was recorded. Visits
within 1 year of the anniversary of the surgical date were tabu-
lated as the whole number follow-up year (e.g., 8
1 years was
tabulated as 8 years) for the 5-year visits and after, and within 6
months for the 1-, 2-, and 3-year visits. Best-corrected visual
acuity on a standard Snellen chart was recorded before surgery
and, when available, at 1, 2, 3, 5, 8, and 10 years after surgery.
Fractional Snellen visual acuity values were analyzed and
reported.
Only idiopathic MHs were included in the current study; trau-
matic, myopic, recurrent, persistent, and secondary MHs were
excluded. In addition, patients with history of trauma, any previous
vitreoretinal surgery, retinal break, or intraocular inflammation
were excluded. Diagnosis of MH was confirmed by OCT.
Anatomic success was defined as connection of the MH edges on
both sides on OCT; the flat open configuration was not considered
a closure. External limiting membrane (ELM) and ellipsoid zone
(EZ) integrity were defined as continuity of the corresponding
hyperreflective layers on spectral-domain (SD) OCT as judged by 2
of the authors (WES, RME) who were masked to outcomes.
The surgical technique used in these patients was similar to that
currently used, with the exception that indocyanine green (ICG)
was used more frequently during the (earlier part of the) time frame
during which these cases were performed, skewing current practice
of the authors. Indocyanine green also was used (infrequently)
whenever there was difficulty ensuring ILM peeling. The ICG was
prepared using 0.5 ml diluent and 4.5 ml 5% dextrose in water,
yielding a 0.001% mixture. The ICG was applied for 30 seconds
after performing a partial, temporary airefluid exchange. The
surgical procedure involved a standard 3-port PPV with core vit-
rectomy and removal of the posterior cortical vitreous. Peeling of
the ILM with or without staining was followed by fluideair ex-
change with attention to drying the edges of the MH. Gas (per-
fluoropropane [C3F8] or sulfurhexafluoride [SF6]) was flushed
through the vitreous cavity to provide MH tamponade at the end of
the surgery. The authors historically have used longer-acting gas,
and although it is our impression that shorter-acting gas is used
increasingly, the former is still an admitted bias of the authors. The
2012 survey of the American Society of Retinal Specialists cited
57% of surgeons used SF6 and 41% of surgeons used C3F8 at that
similar time frame.13 All patients were asked to maintain a face-
down position for 1 week after surgery.
Preoperative data collected from the charts included preopera-
tive BCVA, age, gender, past ocular history, and lens status
(phakia or pseudophakia). Surgical details, including intraoperative
use of ICG, type of gas tamponade, and any intraoperative com-
plications, were collected. Postoperative data collected included
BCVA at various follow-up time points (1, 2, 3, 5, 8, and 10 years),
occurrence and interval to cataract extraction (CE) and intraocular
lens (IOL) implantation, persistent or reopening of the MH, in-
terval to any reoperation, occurrence and interval to postoperative
complications such as retinal detachment, and occurrence and in-
terval of other ocular conditions including wet age-related macular
degeneration and glaucoma development during the entire follow-
up duration. Postoperative integrity of the ELM and EZ and
presence of cystoid spaces were evaluated and recorded using the
last postoperative SD OCT for the patient (median duration, 7
years after surgery). Cystoid spaces were graded as absent (grade
0), barely present (grade 1), mild to moderate (grade 2), or severe
(grade 3). The following factors were evaluated for their influence
on postoperative BCVA: preoperative lens status, preoperative
2
BCVA, use of ICG, type of intraocular gas tamponade used,
postoperative ELM integrity, postoperative EZ integrity, and
presence of cystoid spaces.
Statistical Analysis
Data were entered and encoded using SPSS software version 24
(SPSS, Inc, Chicago, IL). All BCVA values were recorded in
decimals fraction. Data were summarized as mean
standard
deviation. Comparisons between quantitative variables were car-
ried out using the Student t test for 2 variables, the analysis of
variance for 3 or more variables, and the paired t test for comparing
preoperative and postoperative visual acuity follow-ups. All tests
were 2 tailed and considered statistically significant at P < 0.05.
Results
The total number of MH surgeries performed during the case
acquisition interval was 614, but only 87 eyes were included in
the study after excluding secondary MH cases and those with
follow-up information less of than 5 years’ duration. The study
included 87 eyes of 80 patients with a mean age of 68.9
7.0
years (range, 52e93 years) at the time of MHS. The mean
postoperative follow-up examination duration was 9.6
4.3 years
(median, 9 years; range, 5e22 years when a few first eyes were
included); 25 eyes (29%) had at least 10 years follow-up in-
formation. The study cohort involved MHS in 44 left eyes
(51%) and in 67 eyes of women (77%). Indocyanine green was
used to assist ILM peeling in 22 eyes (25.2%). Intraoperative
gas tamponade used was C3F8 in 72 eyes (83%) and SF6 in 15
eyes (17%).
Anatomic success occurred in 82 eyes (94%) after the first
surgery. Five eyes (5.7%) showed persistent MH after initial MHS;
4 underwent reoperation, but final MH closure was achieved in
only 1 eye. The MH reopened in 7 eyes (8.0%) at a mean duration
of 18.13
17.08 months after the first surgery; all underwent
reoperation, and the MH was closed in 5 eyes. Among the 11 eyes
(13% of the study cohort) that underwent reoperation, the mean
postoperative BCVA after the second surgery was 0.23
0.18.
The mean BCVA for the entire cohort improved from
0.20
0.13 before surgery to 0.39
0.23 at 1 year after surgery,
0.43
0.26 at 2 years after surgery, 0.47
0.29 at 3 years after
surgery, 0.50
0.26 at 5 years after surgery, 0.53
0.28 at 8 years
after surgery, and 0.61
0.27 at 10 years after surgery (P  0.001;
Fig 1). Improvement was evident when comparing BCVA at 1 year
with that at 2 years (P ¼ 0.021), when comparing BCVA
improvement from 2 years to 3 years (P ¼ 0.002), and when
comparing BCVA at 3 years to that at 8 years (P ¼ 0.005;
Table 1) but not when comparing BCVA at 3 years with that at
5 years (P ¼ 0.68). Best-corrected visual acuity also was
improved when comparing year 5 with year 8 results (P ¼ 0.002)
but was not improved when comparing BCVA results from 8 years
with those from 10 years (P ¼ 0.07).
A subgroup analysis of the pseudophakic eyes also was eval-
uated to dissect out any effect of cataract removal on BCVA.
Progressive visual improvement generally was demonstrated when
analyzing the subgroup of pseudophakic patients, regardless of
whether cataract surgery occurred before or after MHS (Table 2;
Fig 2). Improvements tended to occur in almost a biphasic
 Elhusseiny et al 
Long-Term Outcomes after Macular Hole Surgery

no statistically significant difference in the postoperative BCVA

based on type of intraocular gas tamponade used, whether SF6 or
C3F8.
Reestablishment of ELM integrity was identified by post-
operative SD OCT in 54 eyes (62.1%), reestablishment of EZ
integrity was identified in 52 eyes (59.8%), and cystoid spaces
were present after surgery in 28 eyes (32.1%). Patients with
postoperative ELM integrity showed better postoperative BCVA
when compared with those with disrupted ELM at 1, 2, 3, 5, 8
(P < 0.001), and 10 years after surgery (P ¼ 0.002; Table 5).
Patients with postoperative EZ integrity showed better
postoperative BCVA when compared with those with disrupted
EZ at 1, 2, 3, 5, 8 (all P < 0.001), and 10 years after surgery
(P ¼ 0.002; Table 6). Absence of cystoid spaces (grade 0) was
associated with better BCVA at 5 years (P ¼ 0.02) and 8 years
Figure 1. Box-and-whisker plot showing decimal best-corrected visual (P ¼ 0.05) when compared with patients with mild to moderate
acuity (BCVA) before surgery and at different follow-up time points. cystoid spaces.
P value is compared with the baseline BCVA. Circle refers to outlier.
Three eyes (3.4%) demonstrated rhegmatogenous retinal
n ¼ number of eyes with data at that time point.
detachment at 2 months, 3 years, and 10 years after MH surgery
and underwent repair: 2 eyes with scleral buckle, PPV, and gas
fashion, 1 in the first year after CE and IOL implantation, but again (C3F8) injection, and 1 eye with fluidegas exchange and cryopexy
in comparisons later in the course of treatment.
Fifty-seven (66%) eyes were phakic at the time of initial MHS. Table 1. Comparison between Mean Best-Corrected Visual Acu-
Cataract extraction and IOL implantation were performed in 52 of ity in Decimals at Different Follow-up Time Points (Full Cohort)
these eyes (91%) at a mean duration of 32.7
38.5 months (range,
2e187 months) after MHS. Subgroup analysis based on the pre- Best-Corrected Visual Acuity Mean ± Standard Deviation P Value
operative lens status (phakic or pseudophakic) did not yield any At 1 yr compared with 2, 3, 5, 8, and 10 yrs
differences in the mean postoperative BCVA between eyes that At 1 yr (n ¼ 76) 0.39
0.24 0.021
were phakic before surgery compared with pseudophakic eyes at At 2 yrs (n ¼ 76) 0.42
0.25
any postoperative follow-up visit except at 8 years, with better At 1 yr (n ¼ 73) 0.4
0.24 0.001
mean postoperative BCVA among the group of phakic eyes before At 3 yrs (n ¼ 73) 0.47
0.29
At 1 yr (n ¼ 72) 0.41
0.24 <0.001
surgery (P ¼ 0.036)
At 5 yrs (n ¼ 72) 0.5
0.26
Stratifying eyes according to preoperative BCVA (group 1, At 1 yr (n ¼ 63) 0.4
0.24 <0.001
<20/60; group 2, >20/60) showed that the percent magnitude of At 8 yrs (n ¼ 63) 0.54
0.28
visual improvement from the baseline to 1-year visit was higher in At 1 yr (n ¼ 36) 0.44
0.25 <0.001
patients with preoperative BCVA of worse than 20/60 compared At 10 yrs (n ¼ 36) 0.62
0.26
with those with preoperative BCVA of 20/60 or better; however, At 2 yrs compared with 3, 5, 8, and 10 yrs
At 2 yrs (n ¼ 73) 0.43
0.26 0.002
no difference was found in the percent magnitude of visual
At 3 yrs (n ¼ 73) 0.47
0.29
improvement during the rest of the follow-up intervals between At 2 yrs (n ¼ 70) 0.44
0.25 0.005
both preoperative BCVA groups (Table 3). We also assessed the At 5 yrs (n ¼ 70) 0.49
0.27
possibility of whether the study eye seemed to measure better At 2 yrs (n ¼ 57) 0.43
0.25 <0.001
BCVA (possibly artifactitiously) when the fellow eye was poor At 8 yrs (n ¼ 57) 0.55
0.28
but found no such trend. At 2 yrs (n ¼ 32) 0.48
0.25 <0.001
Preoperative visual acuity influenced the postoperative BCVA At 10 yrs (n ¼ 32) 0.64
0.25
At 3 yrs compared with 5, 8, and 10 yrs
outcomes. Patients with preoperative BCVA of 20/60 or better At 3 yrs (n ¼ 70) 0.48
0.29 0.684
showed a better mean postoperative BCVA compared with those At 5 yrs (n ¼ 70) 0.49
0.27
with preoperative BCVA worse than 20/60 at 1 year (0.49
0.26 At 3 yrs (n ¼ 55) 0.48
0.3 0.005
compared with 0.36
0.22; P < 0.001), 2 years (0.56
27 At 8 yrs (n ¼ 55) 0.56
0.27
compared with 0.37
0.23; P ¼ 0.003), 3 years (0.64
0.26 At 3 yrs (n ¼ 32) 0.54
0.27 0.008
compared with 0.41
0.27; P ¼ 0.02), 5 years (0.67
0.25 At 10 yrs (n ¼ 32) 0.64
0.25
At 5 yrs compared with 8 and 10 yrs
compared with 0.44
0.24; P ¼ 0.001), and 8 years (0.69
0.26
At 5 yrs (n ¼ 57) 0.51
0.26 0.002
compared with 0.48
0.26; P ¼ 0.007), but not at 10 years At 8 yrs (n ¼ 57) 0.58
0.26
(0.71
0.25 compared with 0.57
0.27; P ¼ 0.163; Table 4). At 5 yrs (n ¼ 34) 0.57
0.22 0.004
The mean BCVA in eyes in which ICG was not used during At 10 yrs (n ¼ 34) 0.67
0.22
surgery was better than BCVA in eyes in which ICG was used at 1 At 8 yrs compared with 10 yrs
year (0.42
0.22 compared with 0.27
0.23; P ¼ 0.01), 3 years At 8 yrs (n ¼ 35) 0.57
0.24 0.07
At 10 yrs (n ¼ 35) 0.61
0.27
(0.51
0.28 compared with 0.32
0.29; P ¼ 0.017), 5 years
(0.54
0.26 compared with 0.38
0.24; P ¼ 0.021), and 8 years
(0.57
0.28 compared with 0.41
0.26; P ¼ 0.038), but not at 10 n ¼ number of eyes.
years (0.64
0.29 compared with 0.52
0.26; P ¼ 0.25). There was Boldface indicates P values below the level of statistical significance.

3
 Ophthalmology Retina Volume -, Number -, Month 2019

Table 2. Comparison between Best-Corrected Visual Acuity in

Decimals at Different Follow-up Visits in Pseudophakic Patients

Best-Corrected Mean ± Standard

Visual Acuity Deviation P Value
Patients pseudophakic before surgery compared with those who were
pseudophakic at 1, 2, 3, 5, and 8 yrs (n ¼ 29)
Before surgery 0.18
0.14 <0.001
At 1 yr 0.41
0.24
At 1 yr 0.41
0.24 0.163
At 2 yrs 0.39
0.24
At 2 yrs 0.39
0.25 0.222
At 3 yrs 0.41
0.25
At 3 yrs 0.43
0.24 0.809
At 5 yrs 0.42
0.26
At 5 yrs 0.43
0.24 0.007
At 8 yrs 0.51
0.28
Patients pseudophakic at 1 yr compared with those
who were pseudophakic at 2, 3, 5, 8, and 10 yrs (n ¼ 39)
At 1 yr 0.43
0.23 0.679
At 2 yrs 0.44
0.24 Figure 2. Box-and-whisker plot showing decimal best-corrected visual
At 2 yrs 0.44
0.24 0.022 acuity (BCVA) before surgery and at different follow-up time points in the
At 3 yrs 0.48
0.26 baseline pseudophakic patients.
At 3 yrs 0.49
0.25 0.797
At 5 yrs 0.5
0.27 injection. The edema improved, but the BCVA remained 20/100
At 5 yrs 0.52
0.26 0.002
At 8 yrs 0.6
0.28
compared with 20/60 after MHS.
At 8 yrs 0.6
0.23 0.142
At 10 yrs 0.65
0.24
Patients pseudophakic at 2 yrs compared with those who were Discussion
pseudophakic at 3, 5, 8, and 10 yrs (n ¼ 52)
At 2 yrs 0.45
0.24 0.001
At 3 yrs 0.51
0.27 The current study cohort of 87 eyes with a mean post-
At 3 yrs 0.52
0.26 0.835 operative follow-up duration of 9.6 years represents the
At 5 yrs 0.51
0.26 longest-term results of structural and visual outcomes of
At 5 yrs 0.53
0.25 0.003 MHS. The BCVA seemed to continue to improve for at least
At 8 yrs 0.59
0.27 the first 3 years and was at least stable thereafter, even after
At 8 yrs 0.61
0.22 0.043
At 10 yrs 0.67
0.24
excluding possible effects of CE. As in other studies, the
Patients pseudophakic at 3 yrs compared with those who were preoperative BCVA was associated with better post-
pseudophakic at 5, 8, and 10 yrs (n ¼ 59) operative BCVA, but poorer preoperative BCVA showed a
At 3 yrs 0.53
0.26 0.826 larger percent magnitude of early improvement. The
At 5 yrs 0.52
0.26 reestablishment of EZ and ELM integrity was associated
At 5 yrs 0.54
0.25 0.005 with better postoperative BCVA.
At 8 yrs 0.6
0.26
At 8 yrs 0.62
0.22 0.075
Most studies have evaluated visual improvement for
At 10 yrs 0.67
0.23 approximately 1 year, whereas 3 have reported results to
Patients pseudophakic at 5 yrs compared with those who were approximately 5 years after MHS.11,12,14 Leonard et al11
pseudophakic at 8 and 10 yrs (n ¼ 65) reported continued BCVA improvement from 20/125
At 5 yrs 0.55
0.25 0.022 before surgery to 20/50 at 12 months and 20/30 at 36
At 8 yrs 0.6
0.25 months after surgery. Longer-term visual outcome (me-
At 8 yrs 0.61
0.21 0.057
At 10 yrs 0.67
0.23
dian, 91 months) was evaluated by Scott et al,12 who
reported 77% of 74 eyes gaining 3 lines or more at the
final follow-up visit compared with preoperative BCVA.
n ¼ number of eyes.
Boldface indicates P values below the level of statistical significance.
A prospective noncomparative study conducted by Har-
itoglou et al15 in 64 patients (median follow-up, 61 months)
showed visual improvement from a median of 20/100 before
surgery to 20/32 after surgery without any cases of MH
only, achieving postoperative BCVA of 20/40, 20/30, and 20/20, reopening or epiretinal membrane formation. The continued
respectively. Two eyes demonstrated wet age-related macular improvement in BCVA in these studies as well as the cur-
degeneration after 2 and 3 MH surgeries, respectively; both rent study suggests slowly progressive improvement of
received intravitreal bevacizumab injections and achieved BCVA macular and photoreceptor functions over several years, at
of 2/200 and 20/200 at the final follow-up visit. One eye demon- least in a substantial subset of postoperative MH patients, a
strated cystoid macular edema after CE and IOL implantation for finding that may offer some encouragement to patients and
which the patient received a single intravitreal triamcinolone surgeons.

4
 Elhusseiny et al 
Long-Term Outcomes after Macular Hole Surgery

Table 3. Percentage (Magnitude) of Postoperative Visual Improvement between 2 Groups Based on Mean Preoperative Best-Corrected
Visual Acuity at Different Follow-up Visits: Group 1 Included Preoperative Best-Corrected Visual Acuity of 20/60 or Better and Group 2
Included Preoperative Best-Corrected Visual Acuity of Less Than 20/60

Percentage of Visual Improvement Preoperative Best-Corrected % of Best-Corrected Visual Acuity

at Different Visits Visual Acuity Improvement, Mean ± Standard Deviation P Value
Before surgery to 1 yr 20/60 or better (n ¼ 21) 35.08
84.2 <0.001
Less than 20/60 (n ¼ 60) 225.23
225.85
1 yr to 2 yrs 20/60 or better (n ¼ 21) 20.9
27.6 0.741
Less than 20/60 (n ¼ 53) 16.1
63.6
2 to 3 yrs 20/60 or better (n ¼ 20) 18
23.8 0.275
Less than 20/60 (n ¼ 51) 8.9
33.5
3 to 5 yrs 20/60 or better (n ¼ 20) 9.6
38.6 0.525
Less than 20/60 (n ¼ 48) 21.9
81.6
5 to 8 yrs 20/60 or better (n ¼ 17) 7.6
26.3 0.308
Less than 20/60 (n ¼ 38) 24.9
66.7
8 to 10 yrs 20/60 or better (n ¼ 11) 1.06
12.5 0.519
Less than 20/60 (n ¼ 23) 9.17
40.02

n ¼ number of eyes.
Boldface indicates P values below the level of statistical significance.

Brooks10 reported a 100% success rates in the ILM
peeling group compared with 61% in the non-ILM peeling
group. The current series (which involved ILM peeling)
found primary anatomic success in 94%, which is in the
range of most recent reports. Kazmierczak et al16 and
Haritoglou et al15 corroborated the beneficial role of ILM
peeling in achieving higher rates of primary successful
MH closure with lower rates of reproliferating epiretinal
membrane (1.1%) and MH reopening rates (10.3%) even
several years after PPV.
Progressive nuclear sclerotic cataract development after
MHS necessitates CE and IOL implantation in the vast
majority of phakic eyes (52 of 57 in the current study) The
reopening rate of a previously surgically closed MH has
been reported to range from 0% to 20%, with conflicting
data in the literature regarding the association between
cataract surgery and MH reopening.15,17,18 Although MH
reopening occurred in 7 eyes (8.0%) in the current series,
a temporal relationship to cataract surgery was not
observed in any case.
Indocyanine green was the first dye introduced to
improve the visualization of the ILM to facilitate its
peeling.19 It has been reported that the MH closure rate
using ICG staining of the ILM is slightly higher
(91.2% with compared with 73.5% without).20 However,
retinal toxicity of ICG has been demonstrated infrequently
in both in vivo and in vitro studies; hence, the current
authors generally have tried to avoid its use, especially as
manifested later in the current series.21 The current study
demonstrated poorer postoperative BCVA at all follow-up

Table 4. Mean Postoperative Best-Corrected Visual Acuity between 2 Groups Based on Mean Preoperative Best-Corrected Visual Acuity
at Different Follow-up Visits: Group 1 Included Preoperative Best-Corrected Visual Acuity of 20/60 or Better and Group 2 Included
Preoperative Best-Corrected Visual Acuity of Less Than 20/60

Postoperative Best-Corrected
Visual Acuity at Different Visits Preoperative Best-Corrected Visual Acuity Mean ± Standard Deviation P Value
1 yr 20/60 or better (n ¼ 21) 0.49
0.26 0.042
Less than 20/60 (n ¼ 60) 0.36
0.22
2 yrs 20/60 or better (n ¼ 21) 0.56
0.27 0.003
Less than 20/60 (n ¼ 53) 0.37
0.23
3 yrs 20/60 or better (n ¼ 20) 0.64
0.26 0.002
Less than 20/60 (n ¼ 51) 0.41
0.27
5 yrs 20/60 or better (n ¼ 20) 0.67
0.25 0.001
Less than 20/60 (n ¼ 52) 0.44
0.24
8 yrs 20/60 or better (n ¼ 18) 0.69
0.26 0.007
Less than 20/60 (n ¼ 44) 0.48
0.26
10 yrs 20/60 or better (n ¼ 12) 0.71
0.25 0.163
Less than 20/60 (n ¼ 25) 0.57
0.27

n ¼ number of eyes.
Boldface indicates P values below the level of statistical significance.

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 Ophthalmology Retina Volume -, Number -, Month 2019

Table 5. Correlation between Re-establishment of External Limiting Membrane Integrity and Postoperative Best-Corrected Visual Acuity
in Decimals at Different Follow-up Time Points

Best-Corrected Visual Acuity External Limiting Membrane Integrity Mean ± Standard Deviation P Value
1 yr Disrupted (n ¼ 28) 0.26
0.17 <0.001
Intact (n ¼ 52) 0.46
0.24
2 yrs Disrupted (n ¼ 26) 0.26
0.18 <0.001
Intact (n ¼ 46) 0.51
0.25
3 yrs Disrupted (n ¼ 23) 0.28
0.22 <0.001
Intact (n ¼ 46) 0.57
0.28
5 yrs Disrupted (n ¼ 21) 0.29
0.22 <0.001
Intact (n ¼ 50) 0.59
0.23
8 yrs Disrupted (n ¼ 17) 0.24
0.19 <0.001
Intact (n ¼ 45) 0.64
0.23
10 yrs Disrupted (n ¼ 8) 0.33
0.31 0.002
Intact (n ¼ 27) 0.67
0.22

n ¼ number of eyes.
Boldface indicates P values below the level of statistical significance.

time points for eyes in which ICG was used (P < 0.05), but
this may reflect cases in which ILM peeling may indicate
other covariates such as longer peeling or more adherent
ILM.
Many studies have reported elegantly various features of
the preoperative MH and postoperative configuration using
OCT.10,22e26 In general, the outer retinal structures (EZ,
ELM, cone outer segments) correlate to better visual acuity,
but even these rigorously performed studies have subtle,
even arcane, discrepancies. The current study was designed
to evaluate these parameters in a way that would be ascer-
tained more readily and applied by the clinician in the office.
The findings generally corroborated the previously reported
findings from more rigorous studies that reestablishment of
outer retinal structures (EZ, ELM) was associated with
better final BCVA.
Limitations of the current study are its retrospective
nature and, possibly, in the temporally retrospective
manner in which the cohort was collected.27 This
ascertainment mechanism was chosen to exploit the
capability of the (relatively recently adopted) electronic
medical record. The OCT features were not evaluated
as rigorously as in other studies designed specifically to
do so because the aforementioned study design would
only be compounded even within the study cohort
because many of the preoperative OCT were not
retrievable or were obtained during the time-domain
OCT era.
In conclusion, the current study demonstrated sus-
tained long-term visual improvement after MHS
continuing for the first 3 years after surgery and at least
remaining stable thereafter. These results support and
extend previously published evidence of the beneficial
effect of ILM peeling in achieving higher rates of MH
closure with lower reopening rates with acceptably low
complication rates. Better postoperative vision was
associated with restoration of outer retinal layer
morphologic features.

Table 6. Correlation between Re-establishment of Ellipsoid Zone Integrity and Postoperative Best-Corrected Visual Acuity in Decimals at
Different Follow-up Time Points

Best-Corrected Visual Acuity Ellipsoid Zone Integrity Mean ± Standard Deviation P Value
1 yr Disrupted (n ¼ 30) 0.25
0.15 <0.001
Intact (n ¼ 50) 0.48
0.24
2 yrs Disrupted (n ¼ 28) 0.25
0.18 <0.001
Intact (n ¼ 44) 0.53
0.25
3 yrs Disrupted (n ¼ 25) 0.29
0.25 <0.001
Intact (n ¼ 44) 0.58
0.27
5 yrs Disrupted (n ¼ 23) 0.31
0.21 <0.001
Intact (n ¼ 48) 0.59
0.23
8 yrs Disrupted (n ¼ 20) 0.27
0.19 <0.001
Intact (n ¼ 42) 0.65
0.23
10 yrs Disrupted (n ¼ 10) 0.37
0.29 0.002
Intact (n ¼ 25) 0.69
0.22

n ¼ number of eyes.
Boldface indicates P values below the level of statistical significance.

6
 Elhusseiny et al 
Long-Term Outcomes after Macular Hole Surgery
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Footnotes and Financial Disclosures
Originally received: July 10, 2019.
Final revision: September 16, 2019.
Accepted: September 25, 2019.
Available online: ---. Manuscript no. ORET_2019_37.
1
Department of Ophthalmology, Bascom Palmer Eye Institute, University
of Miami Miller School of Medicine, Miami, Florida.
2
Department of Ophthalmology, Kasr Al-Ainy School of Medicine, Cairo
University, Cairo, Egypt.
Financial Disclosure(s):
The author(s) have made the following disclosure(s): S.G.S.: Financial
support - Welch Allyn.
Supported in part by the National Institutes of Health, Bethesda, Maryland
(Center Core grant no.: P30EY014801); and Research to Prevent Blindness,
Inc, New York, New York (unrestricted grant to the University of Miami).
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HUMAN SUBJECTS: Human subjects were included in this study. The
human ethics committees at the University of Miami Miller School of
Medicine approved the study. All research adhered to the tenets of the
Declaration of Helsinki. Surgical consent was obtained from all patients,
but informed consent for inclusion in the current study was waived because
the risk to the patient was minimal, and obtaining consent would be
impractical.
No animal subjects were included in this study.
Author Contributions:
Conception and design: Elhusseiny, Schwartz, Smiddy
Analysis and interpretation: Elhusseiny, Schwartz, Flynn, Smiddy
Data collection: Elhusseiny, Smiddy
Obtained funding: N/A
7
 Ophthalmology Retina Volume -, Number -, Month 2019
Overall responsibility: Elhusseiny, Schwartz, Flynn, Smiddy PPV ¼ pars plana vitrectomy; SD ¼ spectral-domain;
Abbreviations and Acronyms: SF6 ¼ sulfurhexafluoride.
BCVA ¼ best-corrected visual acuity; CE ¼ cataract extraction; Correspondence:
C3F8 ¼ perfluoropropane; ELM ¼ external limiting membrane; William E. Smiddy, MD, Department of Ophthalmology, Bascom Palmer
EZ ¼ ellipsoid zone; ICG ¼ indocyanine green; ILM ¼ internal limiting Eye Institute, University of Miami Miller School of Medicine, 900 NW
membrane; MH ¼ macular hole; MHS ¼ macular hole surgery; 17th Street, Miami, FL 33136. E-mail: wsmiddy@med.miami.edu.