The treatment of macular holes now involves peeling the internal limiting membrane (ILM) as well as vitrectomy and gas tamponade. It has been noted in previous studies that following an ILM peel the morphology of the macula is different. Tadayoni et al. noted numerous arcuate retinal striae along optic nerve fibres and called it ‘dissociated optic nerve fibre layer’ (DONFL). Optical coherence tomography (OCT) has shown that shallow dimples in the optic nerve fibre layer caused the appearance of DONFL. In addition, the temporal retina was found to be significantly thinner, whilst the nasal side was thicker than that in the fellow eye. This asymmetrical parafoveal retinal thickness was thought also to be caused by ILM peeling. This retrospective case study included 27 eyes that underwent macular hole surgery with vitrectomy and ILM peel and analysed the foveal to disc diameter before and after surgery. In addition, OCT images of the macula were also compared before surgery, early postoperatively and 12 months postoperatively. In all eyes included in the study all the post-operative foveal to disc diameters were shorter than preoperative measures. In particular this distance reduced most significantly in those eyes that showed characteristics of DONFL (78%). They conclude that the macula can slip towards the optic disc after ILM peel for macular hole surgery and that DONFL appearances can be seen between 6 to 18 months postoperatively. However, this was a small retrospective case study and it is unclear what clinical impact this may have, as there was no investigation into whether the patients were symptomatic from these changes. Although the anatomical changes are important to note for future fundus examinations in these patients, more research in a larger number of patients should be conducted to determine whether DONFL changes cause any new visual disturbances.

Macular slippage after macular hole surgery with internal limiting membrane peeling.
Nakagomi T, Goto T, Tateno Y, et al.
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Khadijah Basheer

Moorfields Eye Hospital, London, UK.

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