Epidemiology and Natural History
2 x more in F than in M
9% due to trauma
1,9% of visually impaired (BES)
Not associated with medical disease or
Full thickness = significant visual loss(EDCCS)
Holes will progress in size and stage (EDCCS)
Microscopic Anatomy of the Macula
Macula: 2x ganglion nuclei, ILM
Fovea: no nerve fiber, ganglion cell or inner
Foveola: only cones, Muller cell cone (NB
support, vitreous attached)
– 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
– ? Unknown
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
– Eccentric or oval full thickness
– < 400um
– VA 20/50 to 20/80
– 74% progress to stage 3
– Foveal oedema + surrounding neuroretinal rim
– Operculum (ILM, muller cell cone, Henles layer and
– VA 20/100 to 20/400.
PPV/ Delamination of vitreous cortex
– Remove tractional forces
– Technique using cannula, vitreous cutter
Delamination of the epiretinal membrane
– Especially visible ones
– Vitrectomy for macular hole study group (80%, 63%)
– Seems reasonable
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)
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
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
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
– >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
Reopened or persistent macular holes.
vitrectomy (83% closure).
– Outpatient fluid gas exchange + lazer of foveal RPE
12/13 and 13/15).
– Surgical fluid gas exchange (17/23).
Macular holes in high myopes
– PPV and gas >lower closure rate
– Better results with ILM peeling
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