Autologous retinal transplantation: 5 things to know about this new procedure
In 2016, Tamer Mahmoud, MD, PhD invented autologous retinal transplantation (ART) for the treatment of large refractory myopic macular holes (MH).1
Dr Philip Storey of Austin Retina Associates recently performed the first ART in Central Texas on a patient who had previously undergone 3 traditional macular hole surgeries that failed to close her macular hole.
“The future is bright for autologous retinal transplantation. Recalcitrant macular holes can be quite challenging to treat,” said Dr Storey. “Now that we have strong data that shows ART can result in excellent visual outcomes, ART is likely to be more widely adopted.”
Below, Dr Storey answers questions about how this procedure is performed, who may benefit from it, and more.
1. What is an ART?
Dr Storey: An ART is used to close MH, usually when the MH is large or has failed with standard surgical techniques. During an ART, a surgeon makes a free flap of tissue by cutting a circle in the peripheral retina, outside of a patient’s central vision. The surgeon moves the free flap from the outside of the retina to the macula, over the central portion of vision. The surgeon then inserts a heavy liquid called PFO. The PFO is left in the eye for 1-2 weeks and is then removed.
2. Who are the ideal candidates for this procedure?
Dr Storey: Our standard technique of closing MH is usually quite successful. We close the hole with 1 surgery in over 95% of cases involving small to medium MHs. However, in cases of large MH or patients who have already received surgery for the MH but it remains open, our success rates are much lower. ART is usually performed for MH >1000 microns or for patients with refractory MH’s.
3. How is ART is performed?
Dr Storey: A MH can be diagnosed by physical exam and by optical coherence tomography (OCT). OCT can be used to precisely measure the size of the MH or to monitor whether a MH completely closes. Surgery is performed with pars plana vitrectomy in which the gel of the eye is completely removed. A dye is usually injected into the eye and the internal limiting membrane (a normally occurring membrane of the retina) is peeled as this can help close the MH. A small circular area of retina is then cut and transplanted from the peripheral of the retina to the center of the macula covering the macular hole. The transplant site is then lasered so that the retina does not detach. Once the transplant is carefully placed over the MH, a heavy liquid—PFO—is injected into the eye and the eye is sutured closed. A patient is usually required to lay flat on their back for up to a week. The PFO is removed 1-2 weeks after surgery and the retinal transplant can then be followed with physical exam and OCT.
4. What skill set is required for a retina surgeon to perform this procedure?
Dr Storey: A retina surgeon must be well trained in vitreoretinal surgery to perform a retinal transplant. In the hands of a well-trained retina surgeon, an autologous retinal transplant is not a technically challenging procedure; the procedural approach is similar to many of our common surgeries.
5. What are the typical outcomes for patients undergoing ART?
Dr Storey: The first large study of outcomes of ART was recently published.2
In this study, outcomes of 130 eyes undergoing ART were evaluated. Overall, 89% of macular holes closed with ART and visual acuity improved at least 3 lines in 43% of patients. The authors concluded that patients undergoing ART for large primary and refractory MH achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.
The procedure appears safe with a similar risk profile to other vitreoretinal surgeries.
Reference
1. Grewal DS, Mahmoud TH. Autologous neurosensory retinal free flap for closure of refractory myopic macular holes. JAMA Ophthalmol. 2016;134(2):229–230. doi:10.1001/jamaophthalmol.2015.5237
2. Moysidis SN, Koulisis N, Adrean SD, et al. Autologous retinal transplantation for primary and refractory macular holes and macular hole retinal detachments: The Global Consortium. Ophthalmol. 2021;128(5):672-685. doi: 10.1016/j.ophtha.2020.10.007. Epub 2020 Oct 10. PMID: 33045315.
Dr Storey is an affiliate faculty member at the University of Texas Dell Medical School. He has authored and co-authored over 50 publications and book chapters, which have received over 440 research citations by his peers. Dr. Storey serves as a reviewer for several top journals including Ophthalmology and Retina: The Journal of Retinal and Vitreous Diseases.
