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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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  • 1. 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
  • 2.
    • First described by Knapp (1869) and Noyes (1870)
    • First coined by Ogilve (1900)
    • Initially thought as untreatable.
    • Patho-physiology unknown.
  • 3. 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
  • 4. Theory on Macular hole formation
    • Lister (1924)
    • Stated the importance of the vitreous in the pathogenesis.
  • 5.
    • 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.
  • 6.
    • 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
  • 7. 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
  • 8. 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
  • 9. Gass classification
  • 10.
    • 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
  • 11. Stage 1
  • 12.
    • 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.
  • 13. Stage 2
  • 14.
    • 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
  • 15. Stage 3
  • 16.
    • Stage 4 – full thickness macular hole with a posterior vitreous detachment
  • 17. Stage 4
  • 18.
    • The Watzke-Allen test
      • Slitlamp biomicroscopy
    • The laser aiming beam test.
  • 19. 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?
  • 20.
    • 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
  • 21.
    • 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.
  • 22. 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)
  • 23.
    • 80 cases – phakic
      • 68 - PPV alone
      • 15 - PPV + phaco IOL
    • 11 cases - pseudophakic
    • Tamponade
      • 55 cases - C3F8
      • 36 cases - Silicone oil
  • 24.
    • 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)
  • 25. 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)
  • 26. Observation
    • 100% of patients will claim compliance
      • Face down position
    • Sign of compliance
      • 41/101 (40%)
  • 27. 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)
  • 28. Technical modifications
    • ILM peeling - 91% - 100%
    • No face down requirement - 79%
  • 29. Surgical adjuncts
    • Transforming growth factor
      • 91% vs 53% (Smiddy)
    • Recombinant TGF-beta
      • 78% vs 61% (Thompson)
    • Autologous platelet
      • 94% vs 81% (Paques)
  • 30.
    • “ 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)

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