Refractory Macular Hole with Retinal Detachment Treated with Autologous Retinal Transplantation: A Case Report

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Dear Editor,

Refractory macular hole (MH) associated with retinal detachment (RD) presents a clinical challenge. Although standard interventions such as pars planar vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade are commonly used for MHs, they may not be always effective [1]. In such cases, alternative surgical techniques may be required [2]. Autologous retinal transplantation (ART) has emerged as an alternative method for treating complex MHs, particularly those unresponsive to conventional surgery [3]. This report describes the successful anatomical resolution of a refractory MH associated with RD using ART. Written informed consent was obtained from the patient for the disclosure of the medical details and images.

A 63-year-old female patient presented with an extensive surgical history. Her right eye underwent surgeries in 2007 for RD, in 2013 for epiretinal membrane, in 2014 for MH, and in 2015 for recurrent RD, ultimately resulting in a visual acuity (VA) of finger counting, thereby classifying the eye as legally blind. The left eye also had recurrent retinal issues, beginning with rhegmatogenous RD in 2014, followed by recurrent RD with an associated MH later that year, recurrent RD in 2016, and intraocular lens subluxation requiring intraocular lens scleral fixation in 2017. The left eye remained relatively stable until January 2024, when MH recurred and persisted despite surgery, leading to subsequent endophthalmitis, which was treated with intravitreal antibiotics. In February 2024, another RD occurred and was treated with an additional pars planar vitrectomy. Following these procedures, the VA of her left eye was 20 / 1,000 and due to the low likelihood of vision recovery, she decided against receiving additional treatment (Fig. 1A, 1B). The patient’s high myopia, with an axial length of 27.32 mm in the right eye and 29.90 mm in the left eye, may have contributed to the recurrence of RD and MH in both eyes.

Fig. 1

Sequential (A–D) preoperative, (E–L) intraoperative, and (M–P) postoperative images of the left eye. (A, C, M, O) Optical coherence tomography images. (B, D, N, P) Widefield photography images. (A, B) Preoperative images showing a refractory macular hole (MH) with no signs of retinal detachment (RD), which remained unresponsive to previous interventions. (C, D) Images captured during a routine follow-up, revealing the development of RD alongside the existing MH. (E) Initial view of the retina at the beginning of vitrectomy, showing the presence of an MH and RD. (F) Indocyanine green dye used to identify the internal limiting membrane; however, it was not detected in the targeted area. (G) Single-layer diathermy was applied to the inner boundary, followed by double-layered laser photocoagulation to the outer boundary, forming a circular pattern to mark the harvest area for retinal tissue. (H) Subretinal balanced salt solution injection using a 40-gauge needle to elevate the retina before tissue harvesting. (I) Dissection and harvesting of the indicated autograft retinal tissue from the peripheral retina using scissors. (J) Application of perfluorocarbon liquid to secure the graft in place within the macular area. (K) Placement of the harvested retinal tissue into the MH site using forceps. (L) Final positioning of the retinal autograft covering the MH (arrowheads). (M, N) Images captured 1 week after surgery, showing closure of the MH. Although the images are blurred, they indicate initial improvement. Postoperative images 1 month after surgery, showing successful MH closure with a significant reduction in subretinal fluid, indicating effective reattachment of the retina and improvement in retinal structure.

During a routine follow-up in August 2024, the patient reported further reduced vision of the left eye, which she relied on for daily activities; fundoscopy and optical coherence tomography (OCT) revealed another RD associated with refractory MH, necessitating surgical intervention (Fig. 1C, 1D). During the vitrectomy, a 25-gauge sclerotomy was performed, and the presence of an MH associated with RD was confirmed (Fig. 1E). Surgery was initiated with internal subretinal fluid (SRF) drainage. Indocyanine green dye was injected to stain the ILM and identify any residual ILM for peeling (Fig. 1F). However, no ILM was detected near the posterior pole, necessitating an alternative approach to close the MH. The inner boundary was first marked using diathermy, followed by double-layered laser photocoagulation to the outer boundary, creating a circular outline to define the harvest area (Fig. 1G). Subretinal balanced salt solution injection within the marked boundary using a 40-gauge needle was performed to elevate the retina (Fig. 1H). Retinal tissue was dissected with scissors, then transplanted into the MH site using the forceps, with perfluorocarbon liquid used to secure the graft in place (Fig. 1I–1K). Subsequently, fluid-air exchange and silicone oil injection were performed, and the final autograft position was confirmed (Fig. 1L). One day after surgery, an ocular pressure of 52.5 mmHg was noted; however, this resolved with vitreous tapping and anterior chamber paracentesis. One week after surgery, OCT showed closure of the MH and reduction of SRF (Fig. 1M, 1N). One month postoperatively, the VA of the left eye improved to 20 / 400 and OCT confirmed that the MH had closed with SRF resolution (Fig. 1O, 1P). No other significant intraoperative or postoperative complications were observed.

Overall, although ART is a more invasive procedure with potential complications, it is a viable option in treating refractory MH. Several studies have shown varying degrees of anatomical success with ART. For instance, anatomical closure was reported in 77% of cases after a 12-month follow-up [4]. A recent systematic review reported anatomical success of 94%, with some cases demonstrating significant visual improvement [5]. Similarly, in our case, complete closure of the MH and reduction in SRF was achieved, with the vision improving from 20 / 1,000 to 20 / 400 1 month postoperatively.

In conclusion, this case demonstrates the successful use of ART in managing refractory MH associated with RD. Therefore, ART should be considered as a viable option for cases where traditional methods have failed.

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