Full-Thickness Macular Hole Surgery: A Comparison of Ten Techniques

Vitreoretinal Surgery for Full-Thickness Macular Hole: A Comparative Study of Ten Techniques

This study compares ten modern vitreoretinal surgical techniques for full-thickness macular hole repair. Participants will be randomly assigned to one of the surgical approaches during pars plana vitrectomy, using stratified randomization based on macular hole size to ensure balanced groups. The main goal is to determine which technique provides the highest anatomical closure rate on optical coherence tomography (OCT) and the best visual outcomes. Follow-up visits are scheduled at Day 7, Month 1, and Year 1 after surgery to assess OCT findings, visual acuity, safety outcomes, and the need for reoperation.

Full-thickness macular hole is a vision-threatening condition that is commonly treated with pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling. While standard approaches achieve high closure rates in many cases, outcomes may vary depending on macular hole size and OCT morphology, and advanced surgical strategies (e.g., different ILM flap configurations, adjunctive biologic augmentation, hydrodissection, or grafting techniques) are increasingly used in clinical practice.

This single-center, randomized, parallel-group interventional study will compare ten PPV-based surgical techniques for full-thickness macular hole repair. Eligible participants will include adults with full-thickness macular hole across a broad range of minimum linear diameter (MLD), including MLD <250 µm. After eligibility confirmation and informed consent, participants will be randomized to one of the ten procedure groups. Randomization will be stratified by macular hole size into five predefined MLD strata to ensure balanced distribution of hole sizes across all intervention groups. Postoperative care and follow-up procedures will be standardized across groups according to the study protocol.

Follow-up visits are scheduled at Day 7, Month 1, and Year 1 after surgery and will include clinical examinations and OCT imaging. The primary endpoint is anatomical macular hole closure on OCT at the prespecified primary time point. Secondary endpoints include best-corrected visual acuity (BCVA), OCT-based morphologic recovery parameters, intraoperative and postoperative complication rates, reoperation rates, and adverse event information through Year 1. The study aims to generate evidence to guide selection of surgical technique based on macular hole morphometric and clinical characteristics while maintaining patient safety.

Inclusion Criteria:

Adults aged ≥18 years.

Full-thickness macular hole (FTMH) eligible for pars plana vitrectomy (PPV).

Symptom duration ≤12 months.

Clear ocular media sufficient for high-quality OCT imaging.

No prior pars plana vitrectomy in the study eye.

No severe foveal atrophy on OCT.

Able and willing to comply with postoperative positioning and follow-up visits.

Written informed consent provided.

Exclusion Criteria:

A. Etiology-Related / Secondary Macular Holes:

Traumatic macular hole.

High myopia with posterior staphyloma (axial length >28 mm and/or spherical equivalent ≤-8.0 D).

Diabetic tractional retinal detachment (TRD) or significant tractional maculopathy.

Retinal vascular occlusion-related macular hole.

Uveitis-related macular hole.

Advanced age-related macular degeneration (AMD) with foveal atrophy.

B. Prior Interventions:

Any prior pars plana vitrectomy in the study eye.

C. Ocular Conditions That May Affect Outcomes or Safety:

Active or recent ocular infection or inflammation (e.g., uveitis, endophthalmitis, keratitis).

Uncontrolled glaucoma (intraocular pressure >28 mmHg despite treatment).

Media opacity precluding adequate OCT (e.g., dense cataract or corneal opacity).

Geographic atrophy involving the fovea.