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INTRODUCTION: Macular holes are breaks in the retinal tissue at the center of the macula, affecting central vision. The standard treatment involves vitrectomy with membrane peeling and gas tamponade. However, for larger or chronic holes, alternative techniques like autologous retinal graft have emerged. This meta-analysis evaluates the efficacy and safety of retinal transplantation in managing large macular holes. METHODS: We conducted a systematic review and meta-analysis following PRISMA guidelines. The study was prospectively registered in PROSPERO (CRD42024504801). We searched PubMed, Web of Science, Cochrane, and Embase databases for observational studies including individuals with large macular holes with or without retinal detachments and retinal transplantation as the main therapy. We used a random-effects model to compute the mean difference with 95% confidence intervals and performed statistical analysis using R software. RESULTS: We conducted a comprehensive analysis of 19 studies involving 322 patients diagnosed with various types of macular holes (MHs). These included cohorts with refractory MH, high myopia associated with MH, primary MH, and MH with retinal detachment (RD). The findings were promising, revealing an overall closure rate of 94% of cases (95% CI 88-98, I2 = 20%). Moreover, there was a significant improvement in postoperative visual acuity across all subgroups, averaging 0.45 (95% CI 0.33-0.58 ; I2 = 72%; p < 0.01) overall. However, complications occurred with an overall incidence rate of 15% (95% CI 7-25; I2 = 59%). CONCLUSION: ART for large MH shows promising results, including significant improvements in visual acuity and a high rate of MH closure with low complication risks overall and for subgroups.
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Macular holes (MHs), including atraumatic idiopathic and refractory MHs, affect central vision acuity due to full-thickness defects in the retinal tissue. The existing controversy regarding the pathophysiology and management of MHs has significantly improved with the implementation of internal limiting membrane (ILM) surgical techniques and improved MH closure rates. Thus, to determine the effect of ILM techniques on large idiopathic and refractory MH management, the present study systematically reviewed 5910 original research articles extracted from online literature databases, including PubMed, Cochrane, Google Scholar, and Embase, following the PRISMA guidelines. The primary outcome measures were MH closure rate and postoperative visual acuity. A total of 23 randomized controlled trials (RCTs) with adequate patient information and information on the effect of ILM peeling, inverted ILM flaps, autologous retinal transplantation (ART), and ILM insertion techniques on large idiopathic and refractory MH patients were retrieved and analyzed using RevMan software (version 5.3) provided by the Cochrane Collaboration. Statistical risk of bias analysis was also conducted on the selected sources using RoB2, which showed a low risk of bias in the included studies. A meta-analysis indicated that the inverted ILM flap technique had a significantly greater MH closure rate for primary MH than the other treatment methods (OR = 3. 22, 95% CI 1.34-7.43; p = 0.01). Furthermore, the findings showed that the inverted ILM flap group had significantly better postoperative visual acuity than did the other treatment options for patients with idiopathic MH (WMD = - 0.13; 95% CI = 0.22-0.09; p = 0.0002). The ILM peeling technique had the second highest statistical significance for MH closure rates in patients with idiopathic MH (OR = 2. 72, 95% CI: 1.26-6.32; p = 0.016). In refractory MHs, autologous retinal transplant (ART) and multilayer ILM plug (MIP) techniques improve the closure rate and visual function; human amniotic membrane grafting (hAMG) provides a high degree of anatomical outcomes but disappointing visual results. This study demonstrated the reliability and effectiveness of ILM techniques in improving the functional and anatomical outcomes of large idiopathic and refractory MH surgery. These findings will help clinicians choose the appropriate treatment technique for patients with idiopathic and refractory MH.
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The purpose of this case report is to describe a chandelier-assisted bimanual autologous retinal transplantation (ART) with air tamponade technique for the treatment of a large macular hole (MH). A patient with a primary chronic large MH, who underwent chandelier-assisted bimanual ART with the use of air tamponade is described. The MH diameter was 888 µm. Changes in best-corrected visual acuity (BCVA) were measured postoperatively; clinical pictures and optical coherence tomography were analyzed. Baseline preoperative BCVA was 20/400. Closure of the MH was achieved. At 7 months, post-surgery BCVA improved to 20/50. Optical coherence tomography examinations showed the integration of the autologous transplant with the adjacent macular tissue and continuity preservation of the ellipsoid layer. In conclusion, chandelier-assisted bimanual ART with air tamponade technique was effective in achieving complete MH closure and long-term visual improvement.
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La retinopatía diabética, la degeneración macular relacionada con la edad y la retinitis pigmentosason las enfermedades retinianas más frecuentes en todo el mundo. A pesar de no contar consuficientes estudios que demuestren resultados funcionales positivos en cuanto a recuperar lafunción visual, el uso de células madre y células progenitoras retinianas y el trasplante de retinafetal parecen bastante promisorios. Hasta el momento no se han podido obtener resultadospositivos sobre la funcionalidad de las células trasplantadas, pero sí se ha demostrado que elprocedimiento para transferir el tejido retiniano es seguro y confiable. Aún no se ha intentadoen seres humanos el trasplante de células progenitoras retinianas, pero dicho trasplante ha dadoresultados satisfactorios en modelos múridos. Los estudios con células progenitoras retinianashan logrado demostrar en modelos múridos que se activan y expresan los fotorreceptores. Existenalgunas barreras de disponibilidad para el uso de células progenitoras retinianas, que se debensuperar con el fin de adelantar estudios que permitan aumentar las posibilidades de integracióny diferenciación de dichas células hacia fotorreceptores.
Retinal tissue transplantation and retinal progenitor cells: A therapeutic promise for patients with retinal diseaseWorldwide, diabetic retinopathy, age-related macular degeneration, and retinitis pigmentosahave the highest incidence rate among retinal diseases. Despite the lack of enough trialsdemonstrating positive functional results on eyesight recovery, the use of stem cells, retinalprogenitor cells, and fetal retinal tissue transplantation seem very promising. So far positiveresults on the functionality of the transplanted cells have not been obtained. However, the safetyand reliability of the procedure to transfer retinal tissue have been demonstrated. Transplantationof retinal progenitor cells has not been tried on human beings, but there have been satisfactory results with it in murine models. Trials with retinalprogenitor cells have demonstrated activation andexpression of photoreceptors in murine models. Somebarriers of availability exist for the use of retinalprogenitor cells that must be overcome in order tocarry out studies to increase the possibility of theirintegration and differentiation towards photoreceptors.