MACULAR_HOLE presentation dhir hospital bhiwani.pptx

2. MACULAR HOLE
PRESENTER : DR NEELAM ADHIKARI (1ST YEAR RESIDENT )
MODERATOR : DR PUSHKAR DHIR
DHIR HOSPITAL AND POSTGRADUATE INSTITUTE OF OPHTHALMOLOGY

3. Introduction
• Macular hole is a round full-thickness opening in neurosensory retina at the
foveal center
• Causes metamorphopsia and central vision loss
• MHs can resolve, persist stable, or progress to full thickness MH and RD

4. Occurs due to opening of the
central cyst of a cystoid
macular edema , rarely round
Lamellar Macular Hole Macular Pseudoholes
Occurs due to the centripetal
contraction of an ERM ,
verticalization of the edge of the
foveal pit
Macular Hole
Full-thickness opening in
neurosensory retina at the
foveal center

5. History
• Knapp (1869) : First described MH
• Kuhnt (1900) and Coats (1908): Suggested
degenerative origin of MH
• Zeeman (1912) and Lister (1924) :Suggested
vitreoretinal tractional mechanism
• Gass : Proposed a staging system ranging from
impending to full-thickness MH, on the basis of his
biomicroscopic observations
• Kelly and Wendel : The first successful surgery of MH
• Hee et al. : Describe the stages of MH on OCT scans
• It is now one of the most successful vitreoretinal
surgery
J. Donald M. Gass (1928-2005 )
Father of macular diseases
Ryan's Retina E-Book

6. Epidemiology
• Prevalence : 1 in 500 patients ( 1.7 per 1000 in a study in Southern India)
• Bilateral in 11.7% of patients
• Risk Factors :
• Age 65 or older
• Female (2:1)
• MH in fellow eye (10 % involved within 5 years )

7. Etiology :
• Idiopathic or Primary (most common)
• Secondary Macular Hole
High Myopia
Blunt Trauma (ragged and irregular margins)
Post surgical (RRD , Vitrectomy )
• Rare causes :
Central retinal artery occlusion
Nd:YAG laser injury
Proliferative diabetic retinopathy
Severe hypertensive retinopathy
Choroidal neovasculatrisation
Lightening and Electrocution

8. Pathogenesis
• Theories for macular hole formation
Traumatic :blunt force transmitted to macula through sudden globe
compression resulting in foveal rupture
Cystoid : cystic degeneration of macula , these cyst coalescence and form MH
DM /HTN /vein occlusion
Vascular: age related changes in retinal vasculature causing cystoid
degeneration
Vitreous : AP traction cystoid changes MH formation
Mixed : tangential traction + AP traction + hydration
 Shrinkage of prefoveal vitreous cortex leading to anterior traction of
retina
 Middle and inner retina absorbs vitreous fluid at the exposed edge of hole
and expand

10. Muller cell cone
• Muller cell cone provides the resistance of the foveal tissue against mechanical
stress resulting from anteroposterior and tangential tractions
• Involutional changes with age predisposes
• Contain concentrated superficial xanthophyll
Apex : ELM
BASE : umbo and
clivus

11. Symptoms
• Asymptomatic in unilateral cases / incidental finding
• Blurred Vision
• Distorted Vision / Metamorphopsia

12. Classification
Focal VMA < 1.5mm Area of attachment

14. Stage 0 Macular Hole / IVTS: Vitreomacular
Adhesion
• OCT finding of oblique foveal vitreoretinal traction before the appearance of
clinical changes .
• VMA in a fellow eye is stage 0 if other eye has MH

15. Stage 1a: Impending macular hole / IVTS:
vitreomacular traction
• On slit lamp biomicroscopy it appears as flattening of the foveal depression with
an underlying yellow spot (100-200 microns )
• On OCT the inner retinal layers detach from the underlying photoreceptor layer,
often with the formation of a cyst-like schisis cavity. Foveal “pseudocyst,” or
horizontal splitting (schisis)
Differential diagnosis of a
foveal yellow spot includes adult
vitelliform macular
dystrophy, solar and laser
pointer retinopathy, and CMO.
Kanski
https://www.aao.org/bcscsnippetdetail.aspx?i
d=38f5071e-d889-4c2a-8a9d-939ebbb1c326

16. Stage 1b: Occult Macular Hole / IVTS:
Vitreomacular Traction
• On slit lamp biomicroscopy seen as a yellow ring (200-300 microns )
• On OCT there is a break in the outer fovea

17. Stage 2: Small Full-Thickness Hole / IVTS:
Small or Medium FTMH with VMT
• Hole < 400 micron in diameter at its narrowest point with persistent
vitreofoveolar adhesion
• Based on the horizontally
measured linear width at the
narrowest point of the hole,
they had been classified into
 Small ≤250 µm
 Medium >250 µm and
≤400 µm
 Large (>400 µm)

18. Stage 3: Full-size Macular Hole / IVTS:
Medium or Large FTMH with VMT
• Hole > 400 micron in diameter with a red base in which yellow– white dots may
be seen
• Grey cuff of subretinal fluid and an overlying pseudo-operculum( glial tissue and
condensed vitreous cortex) may be visible

19. Stage 4: Full-size Macular Hole with Complete PVD
IVTS: small, medium or large FTMH without VMT
• The clinical appearance is indistinguishable from stage 3
• Complete PVD often suggested (but not confirmed) by the presence of a Weiss
ring
• Associated ERM can be seen

20. Investigation
• Amsler grid : Central distortion , scotoma
• The Watzke–Allen test : Narrow slit beam is
projected over the centre of the hole using a
fundus contact lens, patient with a macular
hole will report that the beam is thinned or
broken
• Laser aiming beam test
• OCT
• Fundus Autofluorescence (FAF) :
Hyperfluorescent foveolar spot in stages 3 and
4, punctate fluorescence in stage 2.
• Fluorescein Angiography : Shows an early
window defect due to xanthophyll
displacement and RPE atrophy. Late frames
show the surrounding subretinal fluid as a
hyperfluorescent halo

21. Management
• Observe :
50% of stage 1 holes resolve spontaneously
10% of full-thickness holes also close
spontaneously
• Pharmacological vitreolysis : Ocriplasmin suitable
for small earlier-stage holes
• Surgery : Superior results are usually achieved in
smaller lesions present for under 6 months
PPV : Pars Plana Vitrectomy , induction of PVD
and removal of perifoveal vitreous
Peeling of the ILM facilitated by vital dye
staining
Gas tamponade : C3F8 ,SF6

22. Intravitreal Ocriplasmin
• Single dose of 0.125mg in 0.1ml
• Protease ( breaks down the fibronectin and laminin ) that
essentially performs pharmacolytic vitreolysis
• Indication :
VMT in patients with no evidence of an epiretinal
membrane
Stage II FTMH with a diameter of 400micron or less
Presence of severe symptoms
• Side Effects :
Photopsia
Lens subluxation or phacodonesis
Color Blindness
Retinal tear or retinal detachment
Reduction in visual acuity

23. Prognosis
• Hole is closed in up to 90% of cases
• Visual improvement occurs over the course of months in 80–90% of eyes
• Final visual acuity of 6/12 or better in approximately 65%
• Minimum linear diameter predicted surgical prognosis most accurately
• Good prognosis in younger people , less duration of symptoms
• More vitreomacular traction preoperatively gave better results

24. Prognosis
• Hole form factor (HFF) : Ratio of left arm
length and right arm length to the base
diameter of macular hole . Higher
HFF preoperatively was associated
with better postoperative functional
outcomes (0.9)
• Macular hole index (MHI) : Ratio of hole
height to base diameter . ≥0.5 MHI predict
better postoperative outcomes

25. • Diameter hole index (DHI) : Ratio of
minimum diameter of MH to base
diameter and is an indicator of
extent of tangential traction.
• Tractional hole index (THI) : Ratio of
maximal height of MH to minimum
diameter and is an indicator of AP
traction .
• Higher THI values (>1.41) and low
DHI values (<0.50) had the best
post-op VA recovery

26. Various Types of Closed MH
• Type 1 closure : No neurosensory retinal defect
• Type 2 closure : Foveal neurosensory retinal defect
+nt
• U-type (normal foveal contour)—the RPE covered by
a smooth surface
• V-type (steep foveal contour)—RPE covered with
moderately backscattering layers with a notch
• W-type (foveal defect of neurosensory retina)—
terminating of sensory retinal layers leading to
exposure of retinal pigment epithelium to the surface
https://www.intechopen.com/chapters/63008

27. References
• Kanski
• https://doi.org/10.1155/2019/3467381
• https://www.intechopen.com/chapters/63008
• http://dx.doi.org/10.7869/djo.617
• https://doi.org/10.1186/s12886-021-02164-2
• https://link.springer.com/article/10.1007/s10792-020-01477-3