In vivo imaging of the outer retina after an autologous neurosensory retinal free flap transplantation for a refractory macular hole closure.

[BACKGROUND] There are limited surgical options to successfully close a refractory macular hole. One promising option is an autologous neurosensory retinal free flap transplantation. An autologous neurosensory retinal free flap transplantation places a graft of peripheral autologous retinal tissue into the macular hole and was developed to improve post-surgical outcomes. Here, clinical instrumentation and a high-resolution adaptive optics system imaged the graft and host tissue of a patient whose refractory macular hole was successfully closed with an autologous neurosensory retinal free flap transplantation.

[CASE PRESENTATION] A 71-year-old Hispanic female with bilateral moderate nonproliferative diabetic retinopathy (visual acuity of 20/100 in each eye) underwent an autologous neurosensory retinal free flap transplantation in the right eye only, which successfully closed a large refractory macular hole measuring 4° in diameter. Although somewhat variable, the best-corrected visual acuity improved from 20/100 to 20/70 with a subjective improvement noted by the patient. The eye was examined using (1) fundus photography and (2) clinical optical coherence tomography both presurgery and post surgery and (3) with adaptive optics-optical coherence tomography-scanning laser ophthalmoscopy post surgery. Postsurgical clinical optical coherence tomography imaging revealed restoration of the external limiting membrane within the graft. Adaptive optics-optical coherence tomography imaging provided enhanced lateral and axial resolution and showed a restored inner segment/outer segment junction within the graft. Adaptive optics-optical coherence tomography also revealed the cone outer segment tip layer in the host tissue, highlighting preservation of the microarchitecture and indicating that the host tissue was not negatively impacted by the surgery or the presence of the graft. Further, adaptive optics-scanning laser ophthalmoscopy imaging revealed photoreceptors within the graft and surrounding host tissue, indicating surgical success, graft acceptance and viable host tissue.

[CONCLUSION] Although the exact physiological mechanisms that promote macular hole closure and intraretinal cellular changes after an autologous neurosensory retinal free flap transplantation are unknown, imaging supports the procedure as a reasonable surgical option for refractory macular hole closure. The preserved integrity of the host tissue suggests that the graft does not negatively impact the retina following the surgery. Furthermore, the improvement in the inner segment/outer segment junction and external limiting membrane noted over time within the graft are considered favorable as they relate to the structure and function of the retina.