This document summarizes evaluation and management of macular holes. It describes the epidemiology, pathogenesis, classification, diagnosis, treatment and outcomes of macular hole surgery. Key points include: macular holes are more common in females over 70; stage 3 holes have the worst vision; surgery involves vitrectomy to remove traction and seal the hole with gas or oil; post-op vision improves in 90% of cases with closure rates over 90% when internal limiting membrane is peeled. Complications are low but include retinal detachment and reopening in some cases.

1. Evaluation and Management of
Macular Holes
Focal Points, March
2003

2. Introduction
 Idiopathic (most common)
 Nonsurgical trauma
 Surgical trauma
 Pathological myopia
 Retinal vascular disease

3. Epidemiology and Natural History
 2 x more in F than in M
 7th
to 8th
decade
 9% due to trauma
 1,9% of visually impaired (BES)
 Not associated with medical disease or
refractive errors
 Full thickness = significant visual loss(EDCCS)
 Holes will progress in size and stage (EDCCS)

4. Microscopic Anatomy of the Macula
 Macula: 2x ganglion nuclei, ILM
 Fovea: no nerve fiber, ganglion cell or inner
plexiform layers
 Foveola: only cones, Muller cell cone (NB
support, vitreous attached)

5. Pathogenesis
 Idiopathic:
– 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
 Traumatic:
– ? Unknown

6. Classification
 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

7.  Stage 2
– Eccentric or oval full thickness
– < 400um
– VA 20/50 to 20/80
– 74% progress to stage 3

8.  Stage 3.
– >400um.
– Foveal oedema + surrounding neuroretinal rim
detachment.
– Operculum (ILM, muller cell cone, Henles layer and
cone nuclei).
– VA 20/100 to 20/400.

9.  Stage 4
– Full thickness
– Complete vitreous seperation (PVD)

10. Histopathology
 Full thickness circular retinal defect at fovea +-
an operculum (?Photoreceptors)
 100 – 800um
 Subretinal fluid, cystoid foveal oedema

11. Presentation and Diagnosis
 Central scotoma, metamorphopsia
 Amsler grid
 VA (20/80 to 20/100)
 Contact lens
 FFA (transmission defect)
 Optical coherence tomography (Gass hypothesis)
 Scanning laser ophthalmoscopy
 Watzke-Allen
 Laser aiming beam test

12. Differential Diagnosis
 Pseudo-hole (in epiretinal membrane)
 Foveal RPE atrophy
 CME
 Idiopathic central serous chorioretinopathy
 Foveal drusen
 RPE detachment
 Choroidal neovascularization
 Lamellar macular lesions

13. Treatment
 PPV/ Delamination of vitreous cortex
– Remove tractional forces
– Technique using cannula, vitreous cutter

14.  Delamination of the epiretinal membrane
– Especially visible ones
– Vitrectomy for macular hole study group (80%, 63%)
– Seems reasonable

15.  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)

16.  Adjuvants
 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
scleral buckel)

17. 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
vitrectomy

18.  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

19. – >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

20.  Reopened or persistent macular holes.
– 2nd
vitrectomy (83% closure).
– Outpatient fluid gas exchange + lazer of foveal RPE
12/13 and 13/15).
– Surgical fluid gas exchange (17/23).

21.  Macular holes in high myopes
– PPV and gas >lower closure rate
– Better results with ILM peeling

22. Complications of Surgery
 Retinal detachment (2-11%)
 Retinal breaks (5.5%)
 Raised IOP (1st
week)
 RPE (endoillumination /uncommon)
 Endophthalmitis (0.1 %)
 Late reopening (5 – 9.5%)
 Ulnar neuropathy
 Cataract

23. Conclusion
 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
of patients.