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Macular hole
 

Macular hole

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basic macular hole lecture designed for beginning ophthalmololgy residents

basic macular hole lecture designed for beginning ophthalmololgy residents

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    Macular hole Macular hole Presentation Transcript

    • Macular hole Narciso F. Atienza, Jr. MD, DPBO Michael Shea Vitreo-Retina Fellow, University of Toronto St. Michael’s Hospital (2002-2004) Chief Retina Service: Cardinal Santos Medical Center
      • First described by Knapp (1869) and Noyes (1870)
      • First coined by Ogilve (1900)
      • Initially thought as untreatable.
      • Patho-physiology unknown.
    • Factors inciting macular hole formation
      • Vitreous syneresis
      • Posterior vitreous separation
      • Cystoid macular edema
              • Previous ocular surgery
        • Inflammatory process
      • Traumatic blunt ocular injury
        • Accidental laser injury
        • Lightning
        • Electrical shock
      • High Myopia
    • Theory on Macular hole formation
      • Lister (1924)
      • Stated the importance of the vitreous in the pathogenesis.
      • Tangential traction on the macula
        • Remnant posterior vitreous membrane on the macula with contractile cells.
      • Focal shrinkage of foveal vitreous cortex
      • Tractional elevation of the Henle’s nerve fiber layer.
      • Intraretinal foveolar cyst formation.
      • “ Unroofing” of the cyst.
      Gass JDM. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol 1988: 106:629-639.
      • Hydration theory
        • Together with peri-foveal traction, hydration of the edges of the hole causes the bridge to expand, increasing the size of the hole.
      Tornambe, P. Macular Hole Genesis: The Hydration Theory. Retina: 23 (3) June 2003 421-424
    • Other theories in macular hole formation
      • Retinal/choroidal ischemia theory
        • Affected by RPE dysfunction and possible intraretinal fluid accumulation in the fovea
      • Involutional retinal thinning
    • Incidence and Risk factors (?)
      • Incidence
        • 0.05%
        • Female predominance
        • Lack of Estrogen use
        • Bilateral in 3 to 22%
      • Risk factors
        • History of glaucoma
        • Increased plasma fibrinogen
    • Gass classification
      • Stage 1 - localized shrinkage of prefoveal cortical vitreous, tractional shallow detachment of the foveola (loss of the normal foveolar depression and light reflex), retinal striae, Lack of Watzke sign.
        • Stage 1A - small yellow spot (250-300 mm)
        • Stage 1B - foveal detachment progresses, a yellow halo forms
    • Stage 1
      • Stage 2 - minute holes form near the center of the detached fovea. This is not an inevitable process. In 50% of cases, the vitreofoveal attachment spontaneously separates.
      • Followed by restoration of the normal foveal depression and improved visual acuity.
    • Stage 2
      • Stage 3 – full thickness macular hole greater than 450 um in size, with no posterior vitreous separation.
      • Most common presentation in the clinics
        • Yellow deposits at the level of the retinal pigment epithelium
        • Cuff of subretinal fluid
        • Operculum
        • Cystoid macular edema
        • Positive Watzke’s sign
    • Stage 3
      • Stage 4 – full thickness macular hole with a posterior vitreous detachment
    • Stage 4
      • The Watzke-Allen test
        • Slitlamp biomicroscopy
      • The laser aiming beam test.
    • Questions asked
      • (1) Is it possible to reattach the retina around the macular hole?
      • (2) If it is reattached, will the patient's central vision improve?
      • Vitrectomy and fluid/gas exchange
      Kelly, EK, and Wendel, RT. Vitreous surgery for idiopathic macular holes: results of a pilot study, Arch Ophthalmol 109:654, 1991
      • In 30 (58%) of 52 patients, successful reattachment of the detached macula.
      • In 22 (73%) of the 30 patients in whom the macula was successfully reattached, there was an improvement in visual acuity of two lines or better.
      • In the 22 patients in whom reattachment of the macular hole was not obtained, there was no significant improvement in visual acuity.
    • Personal experience
      • 91 cases macular hole surgery (since 7/2004)
      • 76 patients
      • 62 female vs 14 male patients
      • 15 patients (bilateral)
      • VA (CF 4 feet - 20/60)
      • 80 cases – phakic
        • 68 - PPV alone
        • 15 - PPV + phaco IOL
      • 11 cases - pseudophakic
      • Tamponade
        • 55 cases - C3F8
        • 36 cases - Silicone oil
      • 80 patients (90%) - successful hole closure in one surgery
        • 71 patients- improvement in BCVA (more than 2 lines)
      • 6 cases - did not close
        • 2 cases had re-operation (closed after 2nd surgery)
    • Conclusions
      • Importance of compliance
        • (Face down positioning)
      • Combined surgery
        • Does not affect closure rate
      • Tamponade
        • No direct relationship between gas and oil (too small for comparison)
    • Observation
      • 100% of patients will claim compliance
        • Face down position
      • Sign of compliance
        • 41/101 (40%)
    • Post-operative course
      • 15 developed cataract within 2 years (3 months - 2 years)
      • No retinal detachments
      • 3 cases of high IOP
      • Failure to close
        • 6 cases (1 case still had ILM, 4 cases patients did not position)
    • Technical modifications
      • ILM peeling - 91% - 100%
      • No face down requirement - 79%
    • Surgical adjuncts
      • Transforming growth factor
        • 91% vs 53% (Smiddy)
      • Recombinant TGF-beta
        • 78% vs 61% (Thompson)
      • Autologous platelet
        • 94% vs 81% (Paques)
      • “ If you don’t have complications, then you haven’t operated enough”
      Dr. Michael Shea 1st Fellow of Charles Schepens 1st Retina Surgeon in Canada (U of Toronto)