The Manchester Large Macular Hole Study: Is it Time to Reclassify Large Macular Holes?

PURPOSE: To evaluate anatomic and functional outcomes of full-thickness macular holes (FTMH) larger than 400 mu m following vitrectomy, internal limiting membrane peel, gas tamponade, and face-down posturing. DESIGN: A retrospective interventional case series. METHODS: A total of 258 consecutive eyes with FTMH larger than 400 mu m were enrolled at the Manchester Royal Eye Hospital study over a 5-year period from 2012 to 2017. All eyes underwent pars plana vitrectomy, ILM peel, and gas tamponade. Anatomic success rates were measured. A correlation between macular hole size and closure was evaluated. RESULTS: A total of 258 eyes were analyzed. The anatomic closure rate was 89.92%. When divided into quartiles, the closure rate of FTMH was 98% (64/65) in the 400-477 mu m quartile, 91% (59/65) in the 478558 mu m quartile, 94% (60/64) in the 559-649 mu m quartile, and 76% (49/64) in the 650-1416 mu m quartile. Using receiver operating characteristic and area under the curve analysis, the maximum sensitivity and specificity was obtained with a cutoff <= 630 mu m (sensitivity 76.7%, specificity 69.2%) giving a Youden index (J) of 0.46. One hundred and forty-six eyes (56.6%) improved by 0.3 logMAR units from their preoperative best-corrected visual acuity at 3 months following surgery. CONCLUSION: This study shows that standard FTMH surgical repair has very high success rate up to 650 mu m. It may suggest that there is a need for a reclassification of large FTMH, and new surgical techniques such as internal limiting membrane flaps should be reserved for macular holes larger than 650 mu m. (C) 2018 Elsevier Inc. All rights reserved.