"Choosing wisely": Intravitreal gas injection as first-line treatment for macular hole-a clinical case perspective

Purpose: To evaluate the potency and security of Pneumatic Vitreolysis (PVL) as the primary treatment for Full-Thickness Macular Holes (FTMHs) and provide insights into patient selection criteria and procedural outcomes. Patients and methods: A retrospective analysis of three clinical cases presenting with FTMHs treated initially with PVL was conducted. Cases were evaluated for anatomical and functional outcomes through comprehensive ophthalmic examination and optical coherence tomography (OCT) imaging. Patient demographics, pre-operative characteristics, procedural details, and post-operative outcomes were documented. Results: PVL demonstrated favorable outcomes in two out of three cases, with complete closure of FTMHs and restoration of visual acuity. One case exhibited significant reduction but required subsequent pars plana vitrectomy (PPV) for closure. No intraoperative complications were noted. Factors such as active vitreomacular traction (VMT), head down position and smaller MH sizes appeared to positively correlate with successful closure following PVL. Thorough pre-procedural assessment of retinal periphery and OCT evaluation of MH characteristics aided in patient selection and treatment planning. Conclusion: PVL emerges as a promising initial treatment option for select FTMH cases, particularly those with active VMT and smaller MH sizes. Its less invasive nature and favorable outcomes make it a valuable alternative to traditional surgical interventions. Patient selection based on pre-operative characteristics, including VMT status and MH size, is crucial for optimizing treatment success. Further research and long-term studies are warranted to refine patient selection criteria, procedural techniques, and outcomes assessment in PVL for FTMHs.