Retina World Congress 2026: Rethinking macular hole surgery without gas tamponade

Gas tamponade and strict postoperative positioning have long been considered indispensable in macular hole surgery. A chance clinical observation is now prompting a reexamination of that assumption.

In this Q&A conversation with the Eye Care Network, Siegfried G. Priglinger, MD, FEBO—professor of ophthalmology and head and chair with the Department of Ophthalmology in the University Hospital Ludwig-Maximilians Munich, Germany—discusses the biologic rationale, patient selection considerations, and potential implications for postoperative management of a gas-free, position-free approach to macular hole surgery at Retina World Congress 2026, May 14 to 17 in Fort Lauderdale, Florida.

Note: Transcript edited for clarity and length.

For decades, intraocular gas tamponade and postoperative positioning have been foundational elements of macular hole surgery. What clinical observations or emerging evidence led you to question whether these steps are truly necessary for successful closure?

Siegfried G. Priglinger, MD, FEBO: As is often the case in surgery, the initial observation was partly accidental. In one patient, rapid postoperative gas loss after vitrectomy with an ILM flap created an unintended situation: The ILM flap remained in place, but there was essentially no intraocular air or gas tamponade (personal communication with Marcin Stopa, MD, PhD, FEBO, Poland).

Interestingly, despite the absence of a conventional tamponade, the macular hole still closed successfully. This clinical observation raised the question of whether gas and strict postoperative positioning are always essential for closure, or whether the key factor may instead be the creation of a stable biological scaffold at the level of the macular hole.

This experience encouraged to look more critically at the traditional concept of macular hole surgery and to explore whether, in selected cases, anatomical closure can be achieved without gas tamponade and postoperative positioning.

In the absence of gas or air tamponade, how do you conceptualize the biologic and biomechanical processes that enable macular hole closure, particularly with regard to retinal elasticity, Müller cell response, and vitreoretinal interface dynamics?

Priglinger: We conceptualize this primarily as a hydrodynamic and biomechanical process. Our assumption is that the ILM flap acts as a biological seal over the macular hole, thereby closing the communication between the intraretinal/subretinal space and the vitreous cavity.

Once this communication is sealed, the remaining fluid within the macular hole gap can be resorbed by the retinal pigment epithelium (RPE) pump. This gradually approximates the retinal edges and ultimately leads to closure of the macular hole.

Of course, this concept requires a certain degree of residual retinal elasticity. The retina must still be able to move and adapt once the fluid has been removed. In this model, gas or air tamponade may not necessarily be the decisive factor in every case. In fact, it raises the interesting question of whether gas and air tamponade may themselves work largely through the same mechanism — namely by temporarily sealing the macular hole and allowing the RPE pump to remove the residual fluid until the retinal tissue reapproximates.

The role of Müller cells remains less clear. They may contribute to tissue remodeling and stabilization after closure, but whether they are essential for the initial closure process is still uncertain.

Do you believe this approach is applicable across the spectrum of macular hole presentations, or are there specific morphologic characteristics, chronicity factors, or OCT biomarkers that are critical in determining candidacy?

Priglinger: This is probably one of the most important and still unanswered questions. At this stage, I would not claim that the approach is applicable to the entire spectrum of macular holes.

The key question is: up to which hole size and in which morphologic situations can this technique reliably work? This needs to be clarified in a prospective clinical study. Such a study would also help us to better understand which OCT biomarkers are most relevant for patient selection.

Important factors may include the size of the macular hole, chronicity, retinal elasticity, configuration of the hole edges, and the integrity of the outer retinal layers. However, at present, these criteria still need to be defined more precisely.

If larger studies validate comparable anatomic and functional outcomes without tamponade, how might this reshape postoperative management, patient expectations, and the overall philosophy of minimally disruptive vitreoretinal surgery?

Priglinger: If larger studies confirm comparable anatomical and functional outcomes without gas or air tamponade, this could significantly change postoperative management and patient expectations.

The greatest advantage would clearly be for the patient. First, no face-down positioning would be required, which would make the postoperative period much easier and more comfortable. Second, rehabilitation would be much faster. Patients can often see again already on the first postoperative day, because there is no gas bubble blocking central vision.

This also means fewer practical restrictions:

1. Three-dimensional vision is preserved, participation in daily activities and road traffic may be possible much earlier, and
2. Flying or traveling to higher altitudes would not be restricted in the same way as after gas tamponade.

Another important advantage is for postoperative monitoring. Without gas, the surgeon can assess the macula much earlier and more directly, and can better observe how the macular hole behaves in the immediate postoperative phase.

Overall, this approach fits well with the broader philosophy of minimally disruptive vitreoretinal surgery: achieving the same surgical goal with less burden for the patient, faster recovery, and fewer postoperative limitations.

Siegfried G. Priglinger, MD, FEBO

E: s.priglinger@med.uni-muenchen.de

Siegfried G. Priglinger, MD, FEBO, is professor of ophthalmology and head and chair with the Department of Ophthalmology in the University Hospital Ludwig-Maximilians Munich, Germany. He has no relevant financial disclosures.