**24. Adjuvants with ILM techniques**

#### **24.1 Autologous blood**

Autologous gluconated blood has been used with inverted ILM flaps as a macular bandage, and one study showed initial surgical success in all patients with MH > 500 without gas tamponade or postoperative positioning [118].

#### **24.2 Heavy fluids**

Per-fluro-octane (PFO) has been applied to the MH to stabilise the free or inverted ILM flap in the correct position until the end of the fluid-air exchange [119–121]. PFO could also help flatten the retina whilst the ILM flap is being created by providing a degree of counteraction. Due to its vapour pressure, a small bubble of residual PFO can be removed by evaporation instead of using irrigation, thus reducing the risk of flap displacement [92, 122].

### **24.3 Viscoelastic**

Viscoelastic can facilitate macular hole surgery in a variety of ways. When used before ILM peeling it reduces the toxicity of the dye to the retina. When applied over the ILM flap it can act to reduce the displacement of the flap and keep it in the correct position. It can also act as a binder to stabilise the flap. The functions of adhesive viscoelastic (Viscoat, Alcon) were investigated in a study by Song [123]. Viscoelastic was injected into the MH and then ILM was stained with ICG. The ILM below the hole was removed but the ILM above the hole was used to create an inverted flap. Supplemental viscoelastic was then injected into the surface of the inverted ILM flap prior to the fluid air exchange. This technique resulted in anatomical and functional recovery in highly myopic patients with large MHs.

#### **25. Summary**

There are many techniques available for the treatment of macular holes. The authors preferred technique for small to medium-sized macular holes is combined phaco-vitrectomy with 360-degree ILM peel without face down posture but with the patient avoiding lying on his or her back for 1 week. Face-down posturing is reserved for larger holes. With small holes and good vision, a period of observation is an option as these holes can spontaneously improve and so avoid surgery.

With the many techniques available it is possible to postulate a flowchart for patient treatment.

Recent, small Stage 2 MH's may be managed by PPV and gas tamponade although a short period of observation is an option as some can spontaneously improve and avoid surgery.

MH <400 μm with ERM, PPV with ILM peel is suggested.

MH >400 μm or chronic, inverted ILM flap is preferable.

MH >700 μm, primary ART (Autologous neurosensory retinal transplant).

Refractory holes where ILM has been peeled or difficult ILM flap, consider a free ILM flap or hinged ILM flap. If ILM is not available ART, human amniotic membrane graft and lens capsule are all options depending on the availability of tissue and surgical experience (**Figure 18**).

**Figure 18.** *Macular hole surgery suggested approach.*

### **Author details**

Sergio Scalia<sup>1</sup> \*, Peter Reginald Simcock<sup>2</sup> , Simone Scalia<sup>3</sup> , Daniela Angela Randazzo<sup>1</sup> and Maria Rosaria Sanfilippo<sup>1</sup>


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