management of macular holes surgeries, Nigeria, traumatic macular hole, atrophic.macular hole, primary macular hole macular hole surgery in nigeria, Vitreos an retinal, atrophic holes, traumatic macular holes, myopic Schisis, retinoscisis, parsplana vitrectomy, internal limiting membrane peeling, epiretinal membrane peeling, air fluid exchange, internal limiting membrane staining dye, west african college of surgeons, vitreoretinal surgery, national post graduate medical college of Nogeria, residency training.
2. INTRODUCTION
EPIDEMIOLOGY
PATHOGENESIS
CLASSIFICATION
MANAGEMENT
HISTORY
PHYSICAL EXAMINATION
INVESTIGATION
TREATMENT AND CURRENT TREND IN MH SURGERIES
CONCLUSION
REFERENCES
3. A macular hole is a break in the macular
commonly involving the fovea.
Full thickness macular hole: Internal
limiting membrane (ILM) to the outer
segment of the photoreceptor layer.
First described by knapp in 1869
Case series as at 1970s reported
predominant causes
4.
5. Peak incidence of IDM is in the
seventh decade of life,
Sex
Prevalence
3.3 cases in 1000 in those 55 years
and above in USA
0.17% with a mean age of 67 years
India
1.6 out of 1000 elderly Chinese
4% of retinal diseases in Benin city,
Nigeria
6.6% in South-South Nigeria
4.2% - 18% of retinal diseases in
Southwestern Nigeria
In Ekiti, Ajayi et tal reported MH as
0.5% (new eye cases) and 6.9% of
new cases with retinal diseases,
In Ibadan, Oluleye et al reported
MH as 14.9% of all macular
diseases seen in UCH(2015- 2019)
6. Shrinkage of prefoveal cortical
vitreous
persistent adherence of vitreous to the
foveal
VR Traction :Tangential traction and
anterior posterior vitreoretinal traction
7. Trauma-related MH: transmission of
contusion force in a contrecoup
manner on the macular.
Decreased globe’s anterio-posterior
diameter and equatorial expansion
Immediate rupture of the macula at its
thinnest point.
8. CLASSIFICATION MACULAR HOLE
CLASSIFICATION- GASS
Stage 1(impending Macular hole):
loss of the foveal depression(increased
clinical prominence of xanthophyll
pigment)
Stage 1A: Foveolar detachment with
loss of the foveal contour and a
lipofuscin-colored spot)
Stage 1B: foveal detachment
(lipofuscin-colored ring)
9. Stage 2: Full thickness break < 400µm in size
posterior hyaloid still attached to the fovea
Stage 3: Full thickness break ≥400 µm in size.
A grayish macular rim.
Posterior hyaloid is detached over the fovea
With or without an overlying operculum.
Posterior hyaloid remains attached to the optic disc
10. CLASSIFICATION CONTD
• Stage 4: Full thickness break ≥400
µm in size.
• A grayish macular rim.
• Complete posterior vitreous
detachment and Weiss ring.
11. Vitreomacular adhesion (VMA):
No distortion of the foveal contour
Size of attachment area
Focal if </= 1500 microns
Broad if >1500 microns
12. Vitreomacular traction (VMT):
Distortion of foveal contour present
or intraretinal structural changes
size of attachment area
focal if </= 1500 microns and
broad if >1500 microns
13. Full-thickness macular hole (FTMH)
Size -- horizontal diameter at narrowest
point:
small (≤ 250 μm),
medium (250-400 μm),
large (> 400 μm); 2)
Cause -- primary or secondary;
Presence or absence of VMT
15. Age
Sex
Onset and duration of symptoms
Blurring
Straight lines bent or wavy
Trouble reading small print or
driving
Dark spot
A break/discontinuity in calibre
16. Myopia
Trauma
Ocular inflammation
Ocular surgeries
MH in the other eye or Family
Previous Hysterectomy
Systemic diseases
Treatment sofar
17. Visual acuity: Reported to vary
with stages.
VITAL SIGNS
LID
ANTERIOR SEGMENT
VITREOUS
FUNDUS…….direct and indirect
ophthalmoscope
GRADING OF MACULAR HOLE
18. EXAMINATION:
BIOMICROSCOPIC (SLIT LAMP
+78 D/+90D)
A round excavation with well-defined
borders interrupting the beam of the slit
lamp
An overlying semitranslucent tissue,
representing the pseudo-operculum, may
be seen suspended over the hole.
Surrounding cuff of subretinal fluid
Yellow-white deposits at the base,
19. Amsler grid test:Not specific for macular
hole Watzke-Allen TEST: Performed
on the slit lamp
20. LASER AIMING BEAM TEST
Performed at the slit lamp
A small 50-µm spot size used
Positive test when the patient fails
to detect
21. MICROPERIMETRY
Can be done by using Goldmann
III stimuli (10 cd/m2 luminance)
randomly presented for a duration
of 200 milliseconds on a
1.27 cd/m2 background.
Central 10° from fixation
accessed.
22. Laboratory tests are not indicated
for diagnosis; Determine general
well being of patient and
optimization for surgery.
FBC
FBS
E/U/CR
Ocular imaging and
electrophysical tests
OCT
FFA
FAF
B-SCAN
Multifocal electroretinography
23. OCT; Gold standard test for
confirmation
FFA
24. There is a strong subfoveal
autofluorescence signal in full-
thickness macular holes
Punctate autofluorescence for stage
1
26. MULTIFOCAL
ELECTRORETINOGRAPHY
Provides a topographic map of
electrophysiological activity in the central
retina.
mfERG responses show lower amplitudes in the
fovea in macular hole
Shows loss of retinal function corresponding to
the macular hole.
27. Pseudo-hole due to epimacular
membrane
Lamellar macular hole
Cystoid macular edema
Vitreomacular traction syndrome
29. STAGE O AND STAGE 1
Asymptomatic
No Vitreomacular traction Stage 0
30. Intravitreal ocriplasmin 0.125mg in
0.1ml
MIVI-TRUST clinical trials was a
double-blind study, 652 eyes with
vitreomacular adhesion were
evaluated
58.3% closure rate for holes of less
than 250 µm diameter
31. Removal of vitreous
traction
Removal of scaffold for
myofibroblast, fibrocytes,
RPE proliferation
Intraocular tamponade
Head positioning
In 1991, Kelly and Wendel
Pars plana vitrectomy
Epiretinal membrane removal
Internal limiting membrane (ILM)
peeling
Gas endotamponade
Prone posturing postoperatively
32. Standard 3-port (light source, vitreous
cutter, irrigation/drainage) pars plana
vitrectomy systems (ie, 27 gauge, 25
gauge, 23 gauge)
Non-contact lens e.g Zeiss RESIGHT,
Oculus BIOM
Contact lens e.g DORC flat vitrectomy
lens
The anterior and middle vitreous is
removed
33. Removal of the perimacular traction exerted by
the posterior hyaloid on the macula
Use soft-tipped silicon cannula or the vitrectomy
cutter with the cutter disengaged.
35. REMOVAL
OF INTERNAL LIMITING MEMBRANE
(ILM) AND INVERTED ILM FLAP
Removal by pinch and peel technique
Vital dyes /Stains for ILM
36. SURGICAL TREATMENT:
AUTOLOGOUS
TRANSPLANTATION OF ILM
Involves ILM peeled off to make a free flap
Transplanted and placed inside the macular hole
Failure of standard ILM peeling
Eyes with myopic foveoschisis
Trauma.
Air–fluid exchange performed.
37. AIR-FLUID
EXCHANGE (INTERNAL TAMPONADE-AIR,
GAS, SILICON OIL)
Silicone oil vs Intravitreal gas vs
Air tamponade
Duration of tamponade
Toxicity
Number of surgeries
Anatomic and Visual outcome
38. If visual acuity is good and stable, observe most lamellar holes- no surgery
(Theodossiadis et al)
If visual acuity worsens, surgical intervention is indicated
Pars plana vitrectomy, ERM peeling, and ILM peeling without intraocular
tamponade may be enough ( Michalewska et al)
39. ADJUNCTIVE
AUTOLOGOUS SERUM; Instilled over the macular hole following an air–fluid
exchange to enhance anatomic success.
Helps to remove ICG dye used in surgery
Reduces ICG toxicity
Amniotic membrane graft
Autologous platelet concentrate
Transforming growth factor beta 2
Manipulation of the edges of the macular hole using Tano diamond membrane
scrapper or other instrument to mobilize the edge of the holes towards closure
40. REMOVAL OF INTERNAL
LIMITING MEMBRANE
(ILM) CONTD
The Manchester Large Macular Hole Study showed that the standard ILM peeling was
very effective for macular holes up to 650 microns.
The closure rate of 90% for holes smaller than 650 microns
76% closure rate for holes larger than 650 microns.
Rizzo et al demonstrated a significant difference in hole closure rates for patients with
axial eye lengths of more than 26mm (39% with ILM peeling vs 88% with ILM flap)
Rizzo et al also showed that macular holes of more than 400 microns closure rate (79%
with ILM peeling vs 96% with ILM flap).
CONSIDERATIONS: Dyes retinotoxicity, structural integrity, b-wave recovery
41. CURRENT TREND: FACE-
DOWN POSITIONING
Historically, strict face-down
positioning:recommended for patients for up
to 4 weeks
Further study advocated shorter periods of
face-down positioning such as 1 day
The advent of ILM peeling has encouraged
minimal to no face-down
Tranos et al showed more rapid progression
of cataract formation with less face-down
positioning
Alberti and Ia Cour compared face-
down positioning with nonsupine
positioning
found equivalent macular hole closure
rates and noninferiority of nonsupine
positioning
Hu et al, reported no difference with
positioning for MH < 400 microns.
42. Preoperative visual acuity: most important
Closure rates higher with shorter duration of symptoms: Jaycock et al, Thompson et
al
Macular hole size
ILM peeling
Age of patient
43. Retinal detachments: 2-
14%(development of iatrogenic retinal
breaks following induction of a
posterior vitreous detachment)
Iatrogenic retinal tears
Enlargement of the hole
Macular light toxicity
Postoperative IOP elevation
Cataractogenesis.
Visual field defects
Failure of hole closure/hole
reopening
44. Macular hole is one of the retinal problems that causes loss of central vision
Early presentation and appropriate intervention will guarantee a better
outcome.
Adequate counselling of patients preoperatively that anatomical closure
success rate does not amount to visual success rate is necessary.
45. Kanski J. Clinical Ophthalmology: A Systematic Approach. Nineth Ed. Elsevier Health
Sciences; 2020.macular hole. p. 592-7.
Channa R, Adrienne W. Managing Macular Holes-Common questions associated
with this anomaly are addressed. Retina Today. Jan 2016. [Accessed October 31,
2023]. Available from https://retinatoday.com/articles/2016-jan-feb/managing-
macular-holes
Kean Theng Oh, Macular Hole Treatment & Management: Medscape.Updated: Jan 02,
2020
Omesh P. Gupta et’al, Macular Hole. Eyewiki:Updatedby Christina Y. Weng, MD, MBA
on August 7, 2021. https://eyewiki.aao.org/Macular_Hole#Figure2
Macular holes. N Engl J Med. 2012;367(7):606–615.
Idiopathic Macular Holes, American Academy of ophthalmology: Retna and vitreous,
2016-2017BCSC