Treatment of Stage 2 Macular Hole by Intravitreous Injection of Expansile Gas and Induction of Posterior Vitreous Detachment

Purpose: To demonstrate the morphological and functional outcomes of intravitreous injection of an expansile gas bubble for the treatment of stage 2 macular holes. Design: Prospective interventional case series. Participants: Twenty eyes of 20 consecutive patients with unilateral stage 2 macular holes. Methods: The patients underwent intravitreous sulfur hexafluoride injection, followed by postoperative facedown positioning for 3 to 5 days. The patients were observed per protocol schedule with complete ophthalmological examination, including determination of corrected visual acuity (VA), slit-lamp biomicroscopic examination, funduscopic examination, and optical coherence tomography (OCT). Follow-up was greater than 12 months for all patients (mean, 19.5). Main Outcome Measures: Posterior vitreous detachment, anatomical closure of the hole, VA, and hole diameter as measured by OCT. Results: Detachment of the posterior vitreous at the macula was achieved in 19 of 20 eyes (95%). Ten cases (50%) had anatomical closure of the hole with intravitreous gas injection alone. The remaining 10 cases (50%) achieved anatomical closure of the hole after subsequent vitreous surgery. There was a significant difference in hole diameter (P = 0.004) and in pretreatment vision (P = 4.5×10^-5) in patients for whom gas alone resulted in hole closure and those proceeding to vitreous surgery. Hole closure by gas injection alone was achieved in 7 of 7 eyes (100%) with pretreatment vision better than 20/40 and in 6 of 7 eyes (86%) when the hole was smaller than 200 μm. There were no major complications in this series of patients. Successfully treated macular holes remained closed at all follow-up points during the study period. Conclusion: An intravitreous injection of an expansile concentration of the inert sulfur hexafluoride gas alone frequently induces detachment of the posterior vitreous in the aged eye. Anatomical closure of the hole without major complications is more likely in smaller holes with better pretreatment vision. This technique may have clinical application for stage 2 holes in selected cases. A number of potential advantages including decreased morbidity and a potential cost savings may result from successful utilization of this procedure.