Pathogenesis of macular hole recurrence and its prevention by internal limiting membrane peeling

Purpose: To determine the pathogenesis of macular hole recurrence after vitreous surgery and to evaluate internal limiting membrane (ILM) peeling to prevent recurrence. Methods: We conducted a retrospective, nonrandomized, comparative trial in which we performed pars plana vitrectomy with intravitreal gas injection on 161 consecutive eyes with macular holes without ILM peeling between September 1993 and June 1996 and on 150 consecutive eyes with ILM peeling between July 1999 and January 2003. Closure and reopening rates with and without ILM peeling were compared, and the evolution of recurrence was evaluated. Results: The macular holes closed in 85% of eyes without ILM peeling and in 94% of eyes with ILM peeling during the initial surgery. During mean follow-ups of 25 months and 30 months with and without ILM peel:, g, respectively, macular holes reopened in 6 eyes (4%) without ILM peeling; the macular holes did not reopen in any eye in which the ILM was peeled. Reopening first occurred 6 months to 48 months after the initial surgery and was associated with an epiretinal membrane (ERM) around the macular hole. The macular holes in four eyes closed permanently after repeated removal of a perifoveal ERM. The holes in the remaining two eyes closed permanently after ILM peeling after reopening occurred six and three times. Conclusions: Macular holes reopen because of tangential contraction of the ERM postoperatively. ILM peeling prevents macular hole reopening by inhibiting recurrence of the ERM.