Macular Hole Closure Between Two Tamponades: A Case Report

In this case report, we discuss the closure of a macular hole over a perfluorocarbon liquid (PFCL) globule in a silicone oil-filled eye. PFCL is an important adjunct in the armamentarium of a vitreoretinal surgeon. The use of PFCL has changed the management of various retinal pathologies. PFCL has increased the success rates of vitrectomies for retinal detachment associated with giant retinal tear and proliferative vitreoretinopathy. Recent literature has reported the use of PFCL in the management of macular hole with or without concurrent retinal detachment. A 60-year-old woman presented with retinal detachment with macular hole in her right eye. On examination, her vision in the right eye was hand movement close to face (HMCF). The intraocular pressure was 14 mmHg. Anterior segment examination was suggestive of pseudophakia, whereas posterior segment examination revealed a total retinal detachment with a macular hole and multiple retinal breaks. The patient underwent right eye vitrectomy with internal limiting membrane (ILM) peeling with endolaser to the retinal break and silicone oil tamponade (5000 centistokes viscosity, Densiron). Intraoperatively, the ILM peeling of the macula was performed using the countertraction effect of PFCL. Her vision on postoperative day 1 was suggestive of 6/60 on Snellen visual acuity chart. The intraocular pressure in the right eye was 12 mmHg. The anterior segment was normal, and the posterior segment was suggestive of an attached retina with a closed macular hole. On careful examination, the presence of subfoveal PFCL was noted, indicating closure of the macular hole over a PFCL globule. PFCL is helpful in vitreoretinal surgery. It has high specific gravity with low viscosity. It is used to stabilize the retina during the membrane peeling maneuvers in vitreoretinal surgery. ILM peeling around the macular hole with coexistent retinal detachment is performed by placing the PFCL globule on the macula. After the ILM peeling, the PFCL globule is carefully removed. However, during the ILM peeling step, the PFCL globule can sneak in the subretinal space through the macular hole. This occurs due to preexisting retinal detachment and the tractional forces of the ILM. The residual PFCL globule can be missed, as in our case, where the macular hole was found to be closed over the PFCL globule. The subfoveal location of the PFCL globule is associated with toxicity to retinal photoreceptors and is associated with poor prognosis. Meticulous removal of PFCL is necessary during the vitreoretinal surgery. Triamcinolone acetonide adsorbs onto PFCL globule and aid in its removal. The use of PFCL globule as an adjunct during ILM peeling in vitreoretinal surgery for macular hole with concurrent retinal detachment can be associated with subfoveal migration of PFCL and closure of the macular hole over the PFCL globule.