CLOSE study offers updated surgical classification for treating large full-thickness macular holes


According to investigators, a new proposed classification for large and extra-large full-thickness macular holes is based on the surgical results achieved with different surgical techniques

A new proposed classification for large and extra-large full-thickness macular holes (MHs) is based on the surgical results achieved with different surgical techniques,1 according to Flavio A. Rezende, MD, PhD, and colleagues.

Rezende is from the Centre Universitaire d’Ophtalmologie, Maisonneuve-Rosemont Hospital, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Est-de-l’Île-de-Montréal, University of Montreal in Montreal, Quebec, Canada.

The investigators pointed out that while good surgical results are obtained with small and medium-sized macular holes.

“It is important to determine the hole diameters at which the success rates of conventional surgery begin to decline,” they said.

Notably, the success rates fall off when MHs exceed 500 microns, with steeper reductions associated with holes of 630 microns and greater.

The CLOSE Study Group sought to increase the knowledge about the treatment outcomes after MH surgery based on different surgical techniques with the goal of proposing an updated classification for large MHs and other spectral-domain (SD)-optical coherence tomography (OCT) parameters.

“The new classification presented is based on data that compared visual outcomes and closure rates for MHs exceeding 400 microns that were treated with some of the newer adjunctive techniques,” Rezende said. “This classification is designed to help surgeons in the decision-making process to obtain the best anatomic and functional results for both primary and refractory (persistent or recurrent) MHs and general ophthalmologists to be aware of significant improvement in surgical outcomes of previously untreatable MHs.”

The primary objective was to compare the anatomic and functional results achieved with different surgical techniques among different sized MHs. For each technique, the MH closure rate and improvements in the best-corrected visual acuity (BCVA) were compared according to the preoperative minimal linear MH diameter. The secondary objective was creation of a new surgical classification for large MHs based on the review of these studies and SD-OCT biomarkers.

The investigators evaluated data published by the CLOSE Study Group members and from the literature. The surgeries evaluated included internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART).

The literature search gathered data from 1135 eyes. The various techniques had been performed in the following numbers of eyes: ILM peeling (n = 683), ILM flap (n = 233), macular hydrodissection (n = 64), hAM (n = 59), and ART (n = 96).

The investigators found that ILM peeling had the best results with large full-thickness MHs of 535 microns or smaller (closure rate, 96.8%); the adjusted mean BCVA was 0.49 logarithm of the minimum angle of resolution (logMAR), with a statistical difference among groups.

For large full-thickness MHs ranging from 535 to 799 microns, the ILM flap technique had better results (closure rate, 99.0%); the adjusted mean BCVA was 0.67 logMAR, which also was significant.

For larger full-thickness MHs of 800 microns or larger, more invasive techniques are required. Use of hAM, macular hydrodissection, and ART achieved higher closure rates of 100%, 83.3%, and 90.5% respectively; the adjusted mean BCVAs varied from 0.76 to 0.89. The differences in the closure rates did not reach significance likely because the numbers of cases were small.

“The CLOSE Study Group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research,” the investigators concluded. “This new classification demonstrated that large and extra large MHs holes can be treated highly successfully with ILM peeling and ILM flap techniques, respectively.”

Moreover, they advise additional studies of larger and giant MHs to determine which technique is better suited for each hole size and characteristics.


1. Rezende FA, Ferreira BG, Rampakakis E, et al. Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group. Int J Retin Vitr. 2023; published online Jan 30;

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