Silicone Oil Tamponade to Seal Macular Holes without Position Restrictions Michael H. Goldbaum, MD, 1,2 Brooks W. McCuen, 2nd, MD, 3 Anne M. Hanneken, MD, 4 Stuart K. Burgess, MD, 1 Howard H. Chen, MD 1 Objective: The authors performed a study to determine the effectiveness and safety of silicone oil as a substitute for gas to fill the vitreous cavity to treat macular holes. Design: Multicenter, nonrandomized, interventional trial. Participants: Thirty-seven consecutive patients chose vitrectomy with silicone tamponade instead of gas to treat 40 eyes with stage-2 to stage-4 idiopathic age-related macular holes. Stage-2 holes constituted 40% of the holes, and stage-3 and stage-4 holes made up 60%. Intervention: All eyes were treated with vitrectomy, manual detachment of the posterior vitreous face (not done for stage-4 holes), autologous serum instillation, and silicone fill of the vitreous cavity. After insertion of the oil, the patients resumed normal activity with no restriction of head or eye position except to avoid faceup position. The oil was removed after approximately 6 weeks. Main Outcome Measures: The authors considered the seal of the macular hole and the preoperative and postoperative logarithm of the minimum angle of resolution (logMAR) visions the most significant measures for comparison to other studies. Results: Eighty percent of all holes and 86% of holes not treated previously were sealed with a single silicone tamponade of the vitreous cavity. The logMAR value of visual acuity improved an average of 0.26 (2.6 lines) to 0.61 (20/81) for all eyes and 0.34 (3.4 lines) to 0.52 (20/66) when the macular hole sealed. Completeness of fill of the vitreous cavity with silicone affected seal of the macular hole. Three of eight eyes in which open holes developed after oil removal had less than 90% fill of the vitreous cavity by silicone. Sixty-nine percent of lenses increased opacity one grade or were removed after silicone tamponade. There were no significant adverse effects arising from silicone tamponade. Conclusions: Silicone oil tamponade of macular holes is effective and safe. Silicone may be optimal for the treatment of macular holes in persons who must travel, who cannot maintain facedown positioning, or who have monocular vision. The most important factor in the successful closure of the macular hole was the completeness of fill of the vitreous cavity with silicone oil. Ophthalmology 1998;105:2140 –2148 In 1991, Kelly and Wendel 1 reported that treatment could improve visual function in eyes with full-thickness macular holes. Common to this report and others 2–4 have been surgical detachment of the posterior vitreous in the majority of cases when the vitreous remains attached to the optic nerve and macular region, filling of the vitreous cavity with a long-lasting gas bubble, and strict facedown positioning. In the original report, the retina surrounding the hole was reattached with 58% success. 1 Since then, large series have established 69% to 73% closure of the macular holes. 2,3 Efforts to improve the success rate have included removal of obvious epiretinal membranes near the hole; delamina- tion of the internal-limiting lamina surrounding the hole; probing for occult epiretinal membranes with sharp instru- ments adjacent to the hole; application of autologous serum, transforming growth factor-beta, or autologous platelets over the hole; and photocoagulation. 1,4 –7 Empiric observa- tion led most surgeons to conclude that facedown position- ing, such as 90% for 2 weeks followed by 50% for 2 weeks, 8 improved the success rate. Many patients are un- willing to maintain a facedown position for 2 to 4 weeks or are unable to do so because of physical or medical reasons. The gas fill of the vitreous cavity precludes air travel in depressurized cabins or a gain in altitude of several thou- sand feet in ground transportation, because altitude-induced elevation of pressure in the eye can close retinal and cho- roidal circulation and infarct the retina. Longer duration of intraocular gas tamponade correlates with a higher rate of closure of the macular hole and with greater improvement in visual acuity. 8 The longer-acting gases mean an extended period of restricted travel. Originally received: October 26, 1997. Revision accepted: June 1, 1998. Manuscript no. 97544. 1 Department of Ophthalmology, Shiley Eye Center, University of Cali- fornia, San Diego, California. 2 Ophthalmology Section, Veterans Administration Medical Center, San Diego, California. 3 Department of Ophthalmology, Duke University, Durham, North Caro- lina. 4 San Diego Vitreoretinal Associates, San Diego, California. Presented at the American Academy of Ophthalmology annual meeting, San Francisco, California, October 1997. Address correspondence to Michael H. Goldbaum, MD, Department of Ophthalmology, Shiley Eye Center, University of California, San Diego, La Jolla, CA 92093-0946. 2140