Evaluation and Management of Macular Holes

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Evaluation and Management of Macular Holes - Dr James Beatty

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  • 20/40 to 20/400, 45% loss of 2 lines, 28% loss of three lines, opposite eye 4.6 to 6.5%
  • (foveal center is weak point due to lack of photoreceptor zonular attachments in this area) Adhearent to the ILM, of muller cell cone.
  • Pathogenisis is realated to traction from the vitreous
  • Oval, no or little ffa changes, minimal va watsky and laser neg Partial thickness with overlying retina intact
  • Evaluation and Management of Macular Holes

    1. 1. Evaluation and Management of Macular Holes Focal Points, March 2003
    2. 2. Introduction  Idiopathic (most common)  Nonsurgical trauma  Surgical trauma  Pathological myopia  Retinal vascular disease
    3. 3. Epidemiology and Natural History  2 x more in F than in M  7th to 8th decade  9% due to trauma  1,9% of visually impaired (BES)  Not associated with medical disease or refractive errors  Full thickness = significant visual loss(EDCCS)  Holes will progress in size and stage (EDCCS)
    4. 4. Microscopic Anatomy of the Macula  Macula: 2x ganglion nuclei, ILM  Fovea: no nerve fiber, ganglion cell or inner plexiform layers  Foveola: only cones, Muller cell cone (NB support, vitreous attached)
    5. 5. Pathogenesis  Idiopathic: – Contraction of the prefoveolar vitreous cortex – Foveal pseudocyst formation – Dehiscence of pseudocyst and the Muller cell cone leads to full thickness macular hole – +- Contraction of internal limiting membrane  Traumatic: – ? Unknown
    6. 6. Classification  Stage 1 (a or b) – Perifoveal PVD – Yellow spot (a) or ring (b) – Contraction > split Muller cell cone – Foveal pseudocyst, not full-thickness – Metamorphopsia, VA 20/40 – > Full thickness hole (30%), partial thickness, stay same, 50% show improvement
    7. 7.  Stage 2 – Eccentric or oval full thickness – < 400um – VA 20/50 to 20/80 – 74% progress to stage 3
    8. 8.  Stage 3. – >400um. – Foveal oedema + surrounding neuroretinal rim detachment. – Operculum (ILM, muller cell cone, Henles layer and cone nuclei). – VA 20/100 to 20/400.
    9. 9.  Stage 4 – Full thickness – Complete vitreous seperation (PVD)
    10. 10. Histopathology  Full thickness circular retinal defect at fovea +- an operculum (?Photoreceptors)  100 – 800um  Subretinal fluid, cystoid foveal oedema
    11. 11. Presentation and Diagnosis  Central scotoma, metamorphopsia  Amsler grid  VA (20/80 to 20/100)  Contact lens  FFA (transmission defect)  Optical coherence tomography (Gass hypothesis)  Scanning laser ophthalmoscopy  Watzke-Allen  Laser aiming beam test
    12. 12. Differential Diagnosis  Pseudo-hole (in epiretinal membrane)  Foveal RPE atrophy  CME  Idiopathic central serous chorioretinopathy  Foveal drusen  RPE detachment  Choroidal neovascularization  Lamellar macular lesions
    13. 13. Treatment  PPV/ Delamination of vitreous cortex – Remove tractional forces – Technique using cannula, vitreous cutter
    14. 14.  Delamination of the epiretinal membrane – Especially visible ones – Vitrectomy for macular hole study group (80%, 63%) – Seems reasonable
    15. 15.  Delamination of the internal limiting membrane – Myofibrocytes and fibrous astrocytes in memb. >Hole patency and enlargement – Indocyanine green (ICG) – Controvercy (trauma, light and ICG toxicity)
    16. 16.  Adjuvants  Tamponade of macular hole – Gas or silicone oil – Long acting gas (12-16% C3F8) – Face down positioning (1-2 weeks)/ controversy  Other options (minimal vitrectomy, macular and scleral buckel)
    17. 17. Results of Macular Hole Surgery  Stage 1 lesions (foveal cysts) – Nil surgery – Vitrectomy for prevention macular hole study (30% pts with 20/40 vision progress to full thickness, ? role of enzymatic PVD), no clear benefit for vitrectomy
    18. 18.  Full-thickness macular holes (stage 2-4) – Elevated or flat / open or closed – Elevated/open – failed – Flat/open – VA <20/50 – Flat /closed – VA >20/30
    19. 19. – >VA, >stereopsis, <distortion, <scotoma – Better results with better preop VA, shorter preop duration and more complete ILM peeling – ILM peeling improves VA and eliminates reopening of of holes > than 300um – Current surgery = 90% closure, majority >VA – Also good results without face down positioning – Chronic holes also have an improvement in vision
    20. 20.  Reopened or persistent macular holes. – 2nd vitrectomy (83% closure). – Outpatient fluid gas exchange + lazer of foveal RPE 12/13 and 13/15). – Surgical fluid gas exchange (17/23).
    21. 21.  Macular holes in high myopes – PPV and gas >lower closure rate – Better results with ILM peeling
    22. 22. Complications of Surgery  Retinal detachment (2-11%)  Retinal breaks (5.5%)  Raised IOP (1st week)  RPE (endoillumination /uncommon)  Endophthalmitis (0.1 %)  Late reopening (5 – 9.5%)  Ulnar neuropathy  Cataract
    23. 23. Conclusion  Significant cause of loss in central VA.  Becoming more common.  Increased surgical closure rate (58% to 90%).  Decreased complication rate.  VA and visual function improve in the majority of patients.

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