Current Approaches in the Management of Complicated Macular Holes

Kelly and Wendel reported the first successful intervention for idiopathic full-thickness macular holes in 1991. Since then, pars plana vitrectomy and internal limiting membrane peeling have become the standard treatment approach, with >90% hole closure rates. However, the results were not satisfactory in cases of complicated macular holes, including large, recurrent, refractory, and myopic macular holes. To date, several surgical approaches, including the inverted internal limiting membrane flap technique, autologous retinal transplantation, the human amniotic membrane plug, and the autologous Tenon's capsule plug, have been described by various authors to improve the anatomical and functional outcomes of challenging cases. Although these techniques have significantly increased hole closure rates, each technique has its own strengths and weaknesses. Currently, there is no consensus among vitreoretinal surgeons on a single ideal technique for treating challenging macular holes. In this review, the inventors of each innovative surgical technique will discuss the indications, pros and cons, complications, and anticipated future applications.