Macular hole is a defect in the macula involving its full thickness. It was first described in 1869. Idiopathic macular holes are the most common type and affect people over age 55. Staging of macular holes ranges from stage 1 to 4 based on size and pathology. Symptoms include decreased vision and metamorphopsia. Diagnosis involves examination, OCT, and sometimes FA. Treatment is usually vitrectomy surgery for stages 2-4 to relieve traction on the macula. Prognosis depends on pre-op vision and hole size/duration, with most patients gaining vision after surgery.

1. MACULAR HOLE
Dr samarth mishra

2. INTRODUCTION
• Defect of foveal retina involving its full
thickness from the ILM to the outer segment
of the photoreceptor layer
• Knapp (1869) – 1st described
• Oglive (1900) – 1st coined
• 1970- 80% idiopathic
- 10% trauma

3. DEMOGRAPHIC
• Prev.-worldwide 3.3 / 1000 (>55 yrs)
- India 1.7 / 1000 (>67 yrs)
• F>M
• Fellow eye (12%)
• Risk – CVD, HTN, H/O Hysterectomy

4. ETIOLOGY
• Idiopathic
• Vitreous synersis
• Post. Vitreous separation
• CME
• Trauma
– contusion injury (6% ), accidental laser injury , lightening
• Progressive high myopia (foveal schisis)
– foveal schisis and/or lamellar holes (31%)
• Preceding rhegmatogenous retinal detachment
- successfully repaired rhegmatogenous retinal detachment
(<1%)

5. PATHOGENESIS
• Lister (1924) –vitreous as pathogenesis
• Gass (1988)
– Viteomacular traction theory
Focal shrinkage of foveal vitreous cortex
↓
Intraretinal foveolar cyst formation
↓
Unroofing of the cyst

6. • Tornambe et al (2003)Hydration theory
Post hyaloid traction of fovea
↓
Tear in inner fovea
↓
Seepage of fluid vitreous into spongy layers macula
↓
Cavity in inner retina
↓
Enlargement of hole
↓
Spread to outer retina
↓
Swollen retina remains elevated & retracted

7. • Retinal / choroidal ischaemia theory
– RPE dysfunction & possible intraretinal fluid
accumulation in the fovea
• Involutional retinal thinning

9. GASS STAGING
Stage 1a: ‘Impending’ macular hole
a Signs: yellow spot
b Pathology: Müller cell cone detach from
the underlying photoreceptor layer, with the
formation of a schisis cavity (pseudocyst)
Stage 1b: Occult macular hole
a Signs: a yellow ring (donut-shaped)
b Pathology: photoreceptor layer undergo
centrifugal displacement

10. Stage 2: Small full-thickness hole
a Signs: < 400 µm , central, slightly eccentric
or crescent-shaped.
b Pathology: dehiscence seen in the roof
of the schitic cavity, pseudo-operculum

11. Stage 3: Full-size macular hole
a Signs:
- > 400 µm
- red base with yellow-white dots
- surrounding grey cuff of subretinal fluid
b Pathology: avulsion of the roof of the cyst
with an operculum and persistent parafoveal
attachment of the vitreous cortex.

12. Stage 4: Full-size macular hole with complete
PVD
a Signs: as above
b Pathology:PVD is complete (Weiss ring)

15. CLINICAL FEATURES
• VA
– Depends according to the size, location, and the
stage of the macular hole
– Stage I – metamorphosia ,6/9 to 6/12
– Stage II – small & eccentric 6/9 to 6/12 or central
– Stage III & IV – 6/24 to 2/60

16. DIAGNOSTIC TECHNIQUES
• Direct ophthalmoscopy
– well-defined round or oval lesion in the macula
with yellow-white deposits at the base
– lipofuscin-laden macrophages or nodular
proliferations of the underlying pigment
epithelium with associated eosinophilic material

17. • Biomicroscopic (slit lamp) examination
– A round excavation with well-defined borders interrupting
the beam of the slit lamp can be observed.
– An overlying semitranslucent tissue (pseudo-operculum)
– surrrounding cuff of subretinal fluid
– Cystic changes of the retina at the margins of the hole
– Fine crinkling of the inner retinal surface (ERM)

18. • Watzke-Allen test
– slit lamp using a macular lens and placing a
narrow vertical slit beam through the fovea
– positive test detect a break in the bar of light
• Laser aiming beam test
– a small 50-µm spot size laser aiming beam
– positive test ( fails to detect )

19. • Ocular coherence tomography (OCT)
– detect the presence of a macular hole as well as changes in the surrounding
retina.
– distinguish lamellar holes and cystic lesions of the macula from
macular holes.
– status of the vitreomacular interface can be evaluated
– evaluate the earliest of the stages & association of surrounding cuff of
subretinal fluid.

20. • Fluorescein angiography (FA)
– differentiating macular holes from CME and CNV
– Full-thickness stage 3 holes- granular hyperfluorescent window
associated with the overlying pigment layer changes

21. • B Scan USG
Stage I – retinal suface irregularity
- perifoveal PVD
- VMT
- pseudooperculum
Stage II – I + partial foveal PVD
Stage III – double hump irregularity
- echodense operculm
- partial PVD attached to OD
Stage IV – double hump
- echodense operculum
- complete PVD with weiss ring

22. • Amsler grid
– small central scotomas
– bowing of the lines and micropsia
• Microperimetry and multifocal ERG
– loss of retinal function corresponding to the
macular hole with subsequent recovery of
function following surgical repair of the hole.

23. DIFFERENTIAL DIAGNOSIS
• Pseudohole
• Foveal RPE atrophy
• CME
• Idiopathic CSR
• Foveal drusen
• RPE detachment
• CNV
• Lamellar macular lesions

24. MANAGEMENT
• NO MEDICAL t/t
• Autologous plasmin
– Idiopathic and traumatic macular holes
– Intravitreal injection of plasmin
– October 2012, ocriplasmin (Jetrea) was approved by
the USFDA for the treatment of vitreomacular
adhesion
– Recombinant proteolytic enzyme
– MIVI-TRUST study group
– Activity against fibronectin and laminin
– Randomized, double-blind study, 652 eyes with
vitreomacular adhesion were treated with an
intravitreal injection of ocriplasmin
– 40.6% of treated eyes compared to 10.6% in the
placebo group ]

25. SURGICAL CARE
• Indications
– stage 2 or higher full-thickness macular hole
– Stage 1 holes and lamellar holes are managed
conservatively
• Contraindications
– Coexisting choroidal rupture
– Traumatic RPE rupture
– Chronic cystoid macular edema
– Optic nerve disorders

26. • Gonver & Machemer (1982)- 1st
recommended surg. Procedure
• Kelly & Wendel (1991)
– 1st demonstrated
– 58% ASR & 42% VI of 2 lines
– Mechanism is relief of traction, stimulation of
fibroglial proliferation
• Time of surgery
– Best <1yr
– Chronic holes (1-5yrs) esp if fellow eye has
progressive macular / ON pathology

27. PROCEDURE
1. PPV / Delamination of cortical vitreous
– standard 3-port (ie, 25 gauge, 23 gauge, 20 gauge)
– Anterior and middle vitreous is removed
– Relieved either by removing perimacular vitreous
/ combining it with complete PVD
– Soft tipped silicon cannula / vitrectomy cutter
– Fish –strike sign / bending of silicon cannula

28. 2. Delamination of ILM & ERM
– Stained by DYE (ICG, Tryphan blue, Brilliant blue G)
ICG – stains good
- possibility of renal toxicity
- safety measure reduces toxicity (0.5 mg/ml
dose, fast surg., slow injection, use of 20G, VINCE
brush)
Triamcinolone acetonide – facilitate peeling of ILM

30. 3. Adjuvant
– Bovine TGF-b, recombinant TGFb, autologous
serum, plasmin
– “chemovitrectomy”

31. 4. Tamponade of hole
– nonexpansile concentration of a long-acting gas is
exchanged for air
– perfluoropropane or sulfur hexafluoride
– Silicone oil has also been used as an internal
tamponade for patients with difficulty positioning
or altitude restrictions
– Interfacial tension is the mechanism

32. 5. Face-down positioning
• Strict face-down positioning had been
recommended for patients for up to 4 weeks

34. COMPLICATIONS
• Cataract (75%)
• Late macular hole reopening(2-10%)
• RD (3%)
• Retinal breaks (5.5%)
• Raised IOP (1stwk)
• Endophthalmitis(<1%)
• Ulnar neuropathy
• VF defects

35. PROGNOSIS
• Depends on:
– Preop VA & duration
– Preop minimum hole diameter & base diameter
– Larger size & longer duration outcome is adversly
affected

37. PROGNOSIS

38. • Visual prognosis depends on the type of
closure
– U-pattern : normal foveal contour
– V-pattern : steep foveal contour
– W-pattern : foveal defect of neurosensory retina
U>V>W

39. REOPERATION
• Failed primary surg.
– 1-15% cases
-↓use of adjuvents, ILM peel
• Late reopening
– 2-10% cases
– ↑axial length, pseudophakia, ERM
• Procedure –
– Rpt PPV
– PPV+ILM peel
– PPV+ILM peel + DYE
– Operate FAE with laser to RPE
– Use longer acting gas
– Stress on face down position
– Silicon oil tamponade

40. CURRENT T/T STATAGIES
• Almost all macular holes can achieve success
• ILM peel improves hole closure (85-95%)
• ILM peel slows visual recovery
• Use of dye staining facilitates complete peel
• Prone positioning duration decreased with ILM peel
• 1Wk gas adequate in most eyes
• Long term (5 yrs) results excellent 60% with6/12
• Morizane et al ( 10 patients with refractory macular
holes ) with autologous transplantation of ILM
• PHACOVITRECTOMY

41. CONCLUSION
• Significant cause of loss in central VA
• Becoming more common
• Increased surgical closure rate (58% -90%)
• Decreased complication rate
• VA & VF improve in majority of pts.