GOCOMMENTS
Full Thickness Macular Hole

A macular hole is a retinal break commonly involving the fovea. Patients with macular holes typically present over the age of 60 and females are more frequently affected.

A careful history should be obtained to investigate for any of the risk factors mentioned above. Different findings can be observed depending the stage of the macular hole. Residual cortical vitreous, retinal glial, and retinal pigment epithelial cells are often found on the retinal surface. They are thought to cause tangential traction on the fovea. Cystoid edema in the outer plexiform and inner nuclear layers and thinning of the photoreceptor layer can also be observed.

It has been hypothesized that macular holes are caused by tangential traction as well as anterior posterior traction of the posterior hyaloids on the parafovea. Macular holes are noted as a complication of a posterior vitreous detachment (PVD) at its earliest stages.

 

Natural FundusNatural Fundus   Fundus with macular holeFundus with macular hole

Full Thickness Macular HoleFull Thickness Macular Hole   Full Thickness Macular Hole with Retinal DetachmentFull Thickness Macular Hole with Retinal Detachment

 

Symptoms of Full Thickness Macular Hole

Depending on the stage of the macular hole, a subfoveal lipofuscin-color spot or ring can be noted. In more advanced cases, a partial or full thickness macular break is observed.

Diagnosis of Full Thickness Macular Hole

This is a clinical diagnosis based on history and clinical exam, including slit lamp and dilated fundus examination. Careful examination of the fellow eye is also recommended given that macular holes are bilateral in up to 30% of patients. Special attention should be paid to the vitreoretinal interface, involutional macular thinning, and retinal pigment epithelial window defects because these are risk factors for macular hole development in the fellow eye. Patients without a PVD in the fellow eye have an intermediate risk (~15%) of developing a macular hole, whereas patients with a PVD are at low risk for developing a macular hole.

However, OCT is the gold standard in the diagnosis and management of this disorder. This high-resolution image can allow evaluation of the macula in cross section and three-dimensionally. OCT can be helpful detecting subtle macular holes as well as staging obvious ones.

OCT can also help guide management. Some cases of macular holes there is an associated epiretinal membrane that can be difficult to determine clinically. OCT can be used the aid in prognosis of the fellow eye. Patients with a full-thickness macular hole in one eye and foveal abnormalities consistent with a stage 1 macular hole in the fellow eye have a high risk progression in the fellow eye. In surgical cases, evaluation of each scan can elucidate the best approach for removal of the internal limiting membrane.

 

 

Natural OCTNatural OCT  OCT with macular holeOCT with macular hole

 

General treatment of Full Thickness Macular Hole

Surgery involves a pars plana vitrectomy procedure with tamponade. This can be done with or without peeling of the internal limiting membrane. A number of different instruments can be used to facilitate removal including intraocular forceps, pick, diamond dusted instruments, as well as other instruments.

Surgical technique has been debated for many years. While most vitreoretinal surgeons agree that tamponade is important, the type of tamponade and duration of postoperative positioning is debated. The importance of peeling the internal limiting membrane with or without staining has also been debated.

Surgical follow up of Full Thickness Macular Hole

The follow up is similar for most eyes following pars plana vitrectomy surgery. It is important that patients understand the importance of postoperative positioning (with the face down, known as bubble position). While the duration of positioning has been debated, most vitreoretinal surgeons advise positioning to improve the rate of hole closure. Visual acuity improvement does not occur immediately in some patients. This is highly dependant on preoperative characteristics, duration of the macular hole, as well as other factors.

 

Head positionHead position

Bubble positionBubble position

Complications of Full Thickness Macular Hole

The complications are similar to all eyes undergoing pars plana vitrectomy. In particular, these patients are at a higher risk for retinal tear and detachment. The vitreous is the most adherent to the optic nerve, macula, and ora. Macular holes are caused by an abnormal adherence of the vitreous to the parafoveal area. This abnormal adherence may also be present at the ora and result in retinal tears or detachment during vitrectomy. All cases of macular surgery also include complications such as intraoperative macular trauma and light toxicity.

Success Rates

Retinal detachment
Final restoration → 98,7%!

Μacular hole, final
restoration → 100%!

Epiretinal Membrane → Final Restoration 100%!
Lameral Hole → research in progress, results will be presented soon

 

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