A dehiscence in the Retina at the location of
In Lamellar hole - some layer are intact
Full thickness hole - RPE exposed
Older female patients
Younger Myopic patients
Chronic cystoid macular edema
Associated with Retinal detachment
Inadvertent exposure to laser therapy
Loss of Central Vision
Oblique/anteroposterior traction via a persistent
vitreofoveolar attachment following perifoveal vitreous
Tangential vitreoretinal traction.
Stage O – Premacular hole
- Perifoveal vitreous detachment
- Loss of foveal depression
- Subtle macular topograph changes
- Normal visual acuity
Stage 1a: ‘Impending’ macular hole
- flattening of the foveal depression with an underlying
- Pseudocyst – a perifoveal vitreoretinal detachment
Pathology: inner retinal layers detach from the
underlying photoreceptor layer, with the formation of
a schisis cavity.
Stage 1b: Occult macular hole
Signs: a yellow ring with metamorphopsia or a mild
decrease in visual acuity.
- Progression of pseudocyst to outer foveal layer
Pathology: loss of structural support with centrifugal
displacement of photoreceptors.
Stage 2: Small /Early full-thickness hole
Signs: full-thickness hole < 400 µm in diameter
The defect may be central, eccentric or crescent-shaped.
Pseudo operculum – prefoveal cortical vitreous
Pathology: a dehiscence develops in the roof [inner
layer]of the schitic cavity, often with persistent
Stage 3: Full-size /Established macular hole
Signs: full-thickness hole > 400 µm in diameter
red base with yellow-white dots seen.
Surrounding grey cuff of subretinal fluid
Pathology: Avulsion of the roof of the cyst with an
operculum and persistent parafoveal and optic disc
attachment of the vitreous cortex.
Stage 4: Full-size macular hole with complete PVD
Pathology: the posterior vitreous is completely
detached, often suggested by the presence of a Weiss ring.
Hyperfluorescence -transmission defect (RPE
Evaluation of retinal thickness and staging of macular
Watzke Allen test
On projecting a thin slit beam of light on to the
macula ,a broken or thinned out appearance is
Laser aiming beam test
A spot of laser beam of 50 microns when projected on
macula has disappeared.
Surgery not recommended in stage 1 50 % chance
of spontaneous resolution .
Stage 3 and 4 with visual acuity < 6/18 require surgery
Contraindications for surgery
- Coexisting choroidal rupture
- Traumatic RPE rupture
- Chronic Cystoid macular edema
- Optic nerve disorders
Pars Plana Vitrectomy
Anaesthesia is local or general .
Conjunctival peritomy is done.
Three sclerotomies in superotemporal ,superonasal and
inferotemporal at 3.5 mm from limbus .
Induction of Posterior vitreous detachment by suction of cutter
, suction cannula or forceps close to disc.
Use of intravitreal triamcinolone acetonide for improving
Internal gas tamponade :
A non expansile mixture of C3F8 and air is used and
patient lie down in prone for 14 hours for first 10 days .
Internal Limiting Membrane (ILM) Peeling :
Stains like trypan blue , Brilliant blue , ICG
, Triamcinolone acetonide to improve visualization
Special forceps to grasp ILM membrane in a circular
fashion around macular hole for 2 disc diameters.