Autologous Tenon's Capsule Autograft for Large and Recurrent Full-Thickness Macular Holes

Large, chronic, and recurrent full-thickness macular holes remain challenging to treat despite advances in vitreoretinal surgery. Although pars plana vitrectomy with internal limiting membrane peeling achieves high closure rates in primary macular holes, anatomical success is reduced in very large or recurrent cases. Alternative surgical techniques, including inverted internal limiting membrane flaps, autologous retinal transplantation, and human amniotic membrane grafts, have demonstrated promising results but may be technically demanding or have limited availability. Autologous Tenon's capsule is an easily accessible, biocompatible tissue that may provide an effective scaffold for macular hole closure while avoiding the disadvantages associated with other grafting techniques.

This is a prospective, single-center interventional clinical trial conducted at the Department of Ophthalmology, Zagazig University Hospitals. Fifty eligible adult patients with large (>400 µm), chronic, recurrent, or high-myopic full-thickness macular holes will be enrolled. All participants will undergo standard 23-gauge pars plana vitrectomy. Residual internal limiting membrane will be re-peeled when present, followed by harvesting an autologous Tenon's capsule graft from the superior bulbar conjunctiva. The graft will be trimmed, inserted into the macular hole under perfluorocarbon liquid, and stabilized with 5000-centistoke silicone oil tamponade. Patients will maintain a face-down position for 5 to 7 days after surgery.

Participants will be examined on postoperative day 1, at week 1, and at months 1, 3, and 6. Anatomical closure of the macular hole will be assessed using spectral-domain optical coherence tomography, while functional outcomes will be evaluated by best-corrected visual acuity. Additional assessments include graft position and integration on OCT, intraocular pressure, and the occurrence of postoperative complications such as graft displacement, retinal detachment, or endophthalmitis. The primary outcome is macular hole closure at 3 months, and secondary outcomes include best-corrected visual acuity at 1, 3, and 6 months, graft integration, and postoperative complications.

Inclusion criteria

• Adults aged 18 years or older.
• Large full-thickness macular hole (minimum diameter >400 µm on optical coherence tomography).
• Chronic macular hole (duration >6 months).
• Recurrent or persistent full-thickness macular hole following previous vitrectomy with or without internal limiting membrane peeling.
• High-myopic full-thickness macular hole (axial length >26 mm) without active foveoschisis or retinal detachment.
• No active ocular infection or uncontrolled intraocular inflammation.
• Able and willing to comply with postoperative face-down positioning and scheduled follow-up visits.
• Provided written informed consent.

Exclusion criteria

• Macular hole associated with rhegmatogenous, tractional, exudative, or combined retinal detachment.
• Significant ocular comorbidities that could affect visual outcomes (e.g., advanced glaucoma, proliferative diabetic retinopathy, or severe uveitis).
• Active intraocular infection or inflammation.
• Extensive macular atrophy or scarring (e.g., end-stage myopic degeneration).
• Unhealthy Tenon's capsule or severe conjunctival scarring preventing adequate graft harvest.
• Systemic conditions that preclude vitreoretinal surgery or impair wound healing, including uncontrolled diabetes mellitus or bleeding disorders.