Macular hole


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basic macular hole lecture designed for beginning ophthalmololgy residents

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Macular hole

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