A Feasible and Reproducible Surgical Approach for Subfoveal Hard Exudates Removal By Intentional Macular Hole Creation in Diabetic Retinopathy.

Abstract

To describe a modified surgical technique for removing subfoveal hard exudates (SFHEs) in diabetic retinopathy through controlled macular hole (MH) creation. Eyes with visual impairment because of SFHE underwent 25-gauge vitrectomy. At the site where internal limiting membrane was locally peeled, subretinal injection of balanced salt solution was performed using a 41-gauge needle and viscous fluid control system to create an intentional MH. Subfoveal hard exudate was removed from the hole, and the MH was closed using an inverted internal limiting membrane flap technique. Anatomical findings and best-corrected visual acuity were evaluated over a 24-month postoperative period. Five eyes of four patients with best-corrected visual acuity less than 20/100 were evaluated. Intentional MHs were created in all eyes by progressively increasing the injection pressure to a maximum of 14 psi. Macular hole closure and SFHE reduction were achieved in all eyes at 1 month postoperatively. At 24 months, all eyes achieved SFHE resolution and sustained best-corrected visual acuity improvement of five or more Early Treatment Diabetic Retinopathy Study lines. One patient with preoperative SFHE accumulation lasting over 6 months developed macular atrophic changes. Viscous fluid control-assisted intentional MH creation and inverted internal limiting membrane flap technique for MH closure provide a technically accessible and reproducible approach for removing vision-threatening SFHE.