Macular hole

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Macular hole

  1. 1.  MACULA : Round yellow area at posterior pole 5.5 mm size – 3 mm temporal 1 mm inferior to disc
  2. 2. Fovea - 1.5 mm wide , thin bottom- 22” clivity thick basement margin - prone for macular holes -Henle’s layer-oblique cones Foveola - 0.35 mm wide , thin pit , Densely cones Bowing vitreally- fovea externa Umbo - Tiny depression - Foveal light reflex 0.15 mm - bouquet of cones - narrowed gateau nucleaire
  3. 3.  A dehiscence in the Retina at the location of Fovea.  In Lamellar hole - some layer are intact  Full thickness hole - RPE exposed
  4. 4.  Older female patients  Younger Myopic patients  Post Traumatic  Chronic cystoid macular edema  Associated with Retinal detachment  Inadvertent exposure to laser therapy
  5. 5.  Loss of Central Vision  Central Scotoma  Metamorphospia
  6. 6.  Oblique/anteroposterior traction via a persistent vitreofoveolar attachment following perifoveal vitreous separation.  Tangential vitreoretinal traction.
  7. 7.  Stage O – Premacular hole - Perifoveal vitreous detachment - Loss of foveal depression - Subtle macular topograph changes - Normal visual acuity
  8. 8.  Stage 1a: ‘Impending’ macular hole - flattening of the foveal depression with an underlying yellow spot. - Pseudocyst – a perifoveal vitreoretinal detachment Pathology: inner retinal layers detach from the underlying photoreceptor layer, with the formation of a schisis cavity.
  9. 9.  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 separation Pathology: loss of structural support with centrifugal displacement of photoreceptors.
  10. 10.  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 contraction Pathology: a dehiscence develops in the roof [inner layer]of the schitic cavity, often with persistent vitreofoveolar adhesion.
  11. 11.  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.
  12. 12.  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.
  13. 13.  Fluorescein Angiography Hyperfluorescence -transmission defect (RPE atrophy)  OCT Evaluation of retinal thickness and staging of macular hole.
  14. 14.
  15. 15.  Watzke Allen test On projecting a thin slit beam of light on to the macula ,a broken or thinned out appearance is poistive.  Laser aiming beam test A spot of laser beam of 50 microns when projected on macula has disappeared.
  16. 16.  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
  17. 17.  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 visualization.
  18. 18.  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 of ILM. Special forceps to grasp ILM membrane in a circular fashion around macular hole for 2 disc diameters.
  19. 19.  Cataract formation  Iatrogenic retinal breaks  Rhegmatogenous retinal detachment  Transient rise in Intraocular pressure.
  20. 20.  Following a macular pucker , there is a centripetal pull of the inner sides of epiretinal membrane – resembles Macular hole.
  21. 21.  Partial thickness macular hole where the inner layers of fovea are involved with traction and detached from underlying cellular layers.
  22. 22.    Gass Atlas of Macular diseases by Anita Agarwal American Academy of Ophthalmology , Vol 12 , Retina and Vitreous Kanski ,Clinical Ophthalmology , a Systemic Approach 7 th edition

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