MANAGEMENT OF MACULAR HOLE, Ophthalmology presentation, eye care in the elderly , macular hole as a consequence of trauma, Vitreoretinal surgical cases, ,

1. EVALUATE AND DISCUSS THE PRINCIPLES OF
MANAGEMENT OF MACULAR HOLE IN A
65YR-OLD RETIRED SCHOOL PRINCIPAL
PRESENTED BY
DR. AVURU CHUKWUNALU JAMES
ON 5TH MAY, 2022

2. OUTLINE
• INTRODUCTION
• BRIEF ANATOMY
• EPIDERMIOLOGY
• ETIOLOGY/ RISK FACTORS
• PATHOPHYSIOLOGY
• CLASSIFICATION
• MANAGEMENT
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• A macular hole is a break in the macular commonly involving the fovea.
• A full thickness macular hole is a defect of the foveal retina involving its full thickness
from the internal limiting membrane (ILM) to the outer segment of the photoreceptor
layer.
• It was first described by Knapp in 1869 in a patient who sustained blunt trauma to the
eye and Subsequent case reports and series in those early days revealed macular
hole to be related to trauma
• However, case series as far back as the 1970s reported that more than 80% of
macular holes are idiopathic and that only less than 10% have associated history of
trauma to the eye

4. INTRODUCTION/BRIEF ANATOMY/PHYSIOLOGY
• Macula is a round area at the
posterior pole temporal to the optic
• 5.5mm in diameter
• Its yellowish color derived from the
presence of xanthophyll pigment
• Comprises of fovea centralis(1.5mm),
foveola(0.35mm) and FAZ(0.4-
0.6mm).

5. FOVEA LAYERS-DIFF FROM RETINA
• Retinal pigment epithelium,
• Photoreceptors (cones only),
• External limiting membrane,
• Outer nuclear layer,
• Outer plexiform (Henle) layer, &
• Internal limiting membrane.

6. SPECIFIC ANATOMIC CONFIGURATION OF THE
FOVEA
• Densest concentration of cones
• A one to one photoreceptor-ganglion cell relationship
• Cones more elongated and slender
• Absence of rods at the foveola
• RPE cells are taller, thinner and deeply pigmented
• Presence of xanthophyll pigment

7. EPIDERMIOLOGY
• Prevalence is approximately 3.3 cases in 1000 in those persons older than 55 year in USA
• Peak incidence of idiopathic macular hole development is in the seventh decade of life,
• Women affected more than men
• Prevalence in India is a reported 0.17%, with a mean age of 67 years.
• Prevalence rate of macular holes is 1.6 out of 1000 elderly Chinese, with a strong female
predilection (Beijing Eye Study)
• It accounts for 4% of retinal diseases in Benin city southern Nigeria, 6.6% in South-South
Nigeria and in Southwestern Nigeria, Macular hole constitutes between 4.2% - 18% of
retinal diseases

9. EPIDERMIOLOGY
• In a study in Ekiti by Iyiade A. Ajayi e’tal, macular hole constituted 0.5% of the number of
new patients with eye disorder and 6.9% of new cases with retinal diseases
• 50% of stage 0 and stage 1 macular holes may resolve spontaneously
• Stage 2 holes progress and worsen in most cases to stage 3 or stage 4
• Incidence of development of an idiopathic full-thickness macular hole in the fellow eye are
approximately 12% in 5yrs
• Rarely, a full-thickness macular hole may spontaneously close with resultant good vision in 0-
10% of cases
• Peak incidence is in the seventh decade of life

10. ETIOLOGY AND RISK FACTORS
• Idiopathic macular hole is the most common presentation
• Risk factors include
• Age
• Female gender
• Myopia : foveal schisis(31% develop FT MH), lamellar holes(4.1% develop FTMH)
• Trauma(6% of contusion eye injuries)
• Ocular inflammation e.g Chronic posterior uveitis
• Ocular surgeries: preceeding Rhegmatogenous RD repair( 1% develop MH

11. PATHOPHYSIOLOGY
• Shrinkage of prefoveal cortical vitreous with persistent adherence of vitreous to the
foveal region results in the causative traction.
• Tangential traction and anterior posterior vitreoretinal traction of the posterior hyaloid
on the parafovea.
• This traction ultimately causes a break or dehiscence to occur at the umbo, the thinnest
and weakest portion of the retina, and subsequent centrifugal movement of the
foveolar tissue
• Trauma-related macular holes have been described to be related to the transmission of
concussive force in a contrecoup manner, which results in the immediate rupture of the
macula at its thinnest point.

13. GASS MACULAR HOLE CLASSIFICATION (CLINICAL
OBSERVATIONS ON EVOLUTION)
• Stage 1(impending Macular hole): loss of the
foveal depression(increased clinical prominence of
xanthophyll pigment)
• Stage 1A: There is foveolar detachment (loss
of the foveal contour and a lipofuscin-colored
spot)
• Stage 1B: foveal detachment (lipofuscin-
colored ring)

14. GASS CLASSIFICATION
• 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 denotes a cuff of
subretinal fluid. Posterior hyaloid is detached
over the fovea with or without an overlying
operculum. The posterior hyaloid remains
attached to the optic disc

15. GASS MACULAR HOLE CLASSIFICATION (CLINICAL
OBSERVATIONS ON EVOLUTION)
• Stage 4: Full thickness break
≥400 µm in size. A grayish
macular rim denotes a cuff of
subretinal fluid. Has complete
posterior vitreous detachment and
Weiss ring.

16. CLASSIFICATION SCHEME OF VITREOMACULAR
TRACTION AND MACULAR HOLES(BASED ON OCT
FINDINGS)
• Vitreomacular adhesion (VMA): No distortion of the foveal contour; size of attachment area
between hyaloid and retina defined as
• focal if </= 1500 microns and
• broad if >1500 microns
• Vitreomacular traction (VMT): Distortion of foveal contour present or intraretinal structural changes
in the absence of a full-thickness macular hole; size of attachment area between hyaloid and retina
defined as
• focal if </= 1500 microns and
• broad if >1500 microns

17. CLASSIFICATION SCHEME OF VITREOMACULAR TRACTION AND
MACULAR HOLES(BASED ON OCT FINDINGS)
• Full-thickness macular hole (FTMH): Full-thickness defect from the internal limiting membrane
to the retinal pigment epithelium.
• Described 3 factors:
• 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

18. MANAGEMENT
• HISTORY
• EXAMINATION
• INVESTIGATION
• TREATMENT

19. HISTORY
• AGE: More >60yrs
• SEX; > females than males
• Onset and Duration of symptoms

20. HISTORY CONTD
• Blurred and distorted vision.
• Straight lines may look wavy or bowed
• Trouble reading small print or driving
• The appearance of a dark spot across the middle of the field of
view
• A decrease in the ability to see fine details when a person is
looking directly at an object
• A break/discontinuity or decrease in calibre at the centre of a
thin object

21. HISTORY CONTD
• Myopia
• Trauma
• Previous eye surgeries
• Ocular inflammation e.g Chronic posterior uveitis
• Hypertension and other cardiovascular diseases
• Previous Hysterectomy
• Treatment sofar

22. PHYSICAL EXAMINATION: VISUAL ACUITY
• Visual acuity: varies according to the size,
location, and the stage of the macular hole.
• Patients with small, eccentric holes may retain
excellent visual acuity in the range of 20/25 to
20/40
• Less than full thickness can have very good
visual acuity in the range of 20/30 to 20/50
• Well developed or full thickness, the usual range
of visual acuity is from 20/80 to 20/400
• STAGE 1:Visual acuity usually
better than 20/50
• STAGE 2: Visual acuity is in the
20/50 - 20/80 range
• STAGE 3: Mean visual acuity :
20/200

23. PHYSICAL EXAMINATION
• VITAL SIGNS
• LID
• ANTERIOR SEGMENT
• VITREOUS
• FUNDUS…….direct and indirect ophthalmoscope
• GRADING OF MACULAR HOLE

24. EXAMINATION: DIRECT OPHTHALMOSCOPY
• A full-thickness macular hole is
characterized by a well-defined round or
oval lesion in the macula with yellow-
white deposits at the base (Yellow dots
probably represent lipofuscin-laden
macrophages or nodular proliferations of
the underlying pigment epithelium with
associated eosinophilic material)

25. EXAMINATION: BIOMICROSCOPIC (SLIT LAMP)
• 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

26. MICROPERIMETRY
• Can be done by using Goldmann
III stimuli (10 cd/m2) randomly
presented for a duration of 200
milliseconds on a
1.27 cd/m2 background.
• Central 10° from fixation
accessed.

27. AMSLER GRID TEST
• Not specific for macular hole
• Small central scotomas caused by full-
thickness macular holes
• Difficult to plot because of the poor
fixation in the affected eye
• Bowing of the lines and micropsia could be
seen due to the surrounding area of retinal
edema and intraretinal cysts

28. WATZKE-ALLEN TEST
• Performed at the slit lamp
• Using a macular lens over the eye
• Place a narrow vertical slit beam through the
fovea
• Positive test is elicited when patient detect a
break in the bar of light that is perceived
• Narrowing or distortion of the bar of light is
not diagnostic of full-thickness macular holes
and should be interpreted with caution

29. LASER AIMING BEAM TEST
• Performed at the slit lamp
• Using a macular lens over the eye
• A small 50-µm spot size laser aiming beam is placed within the macular
lesion.
• A positive test is obtained when the patient fails to detect the aiming beam
when it is placed within the lesion but is able to detect it once it is placed
onto normal retina.

30. INVESTIGATIONS-LABORATORY/BODY IMAGING
• No laboratory tests are indicated for diagnosis but may indicated for
uptimization of patient and ensuring general well being
• FBC
• FBS
• E/U/CR
• ABDOMINAL SCAN
• ECG/ECHOCARDIGRAPHY

31. INVESTIGATIONS: FLUORESCEIN ANGIOGRAPHY
• Hyperfluorescence pattern consistent with a
transmission defect due to loss of xanthophyll at base
of the Macular hole.
• A granular hyperfluorescent window associated with
the overlying pigment layer changes
• No leakage or accumulation of dye is observed as
opposed to other lesions
• Study not usually necessary for diagnosis or
management

32. INVESTIGATION: OPTICAL COHERENCE
TOMOGRAPHY(OCT)
• High-resolution OCT image can allow
evaluation of the macula in cross-section
and three-dimensionally.
• Gold standard in the diagnosis and
treatment
• Helpful in detecting subtle macular holes
as well as staging obvious ones

33. B-SCAN ULTRASONOGRAPHY
• Helpful in elucidating the
relationship of the macula to the
vitreous
• May be helpful in staging the
disease

34. MULTIFOCAL ELECTRORETINOGRAPHY
• Multifocal electroretinography is a noninvasive method that objectively
measures visual function by selecting multiple retinal locations around
macular area to provide a topographic map of electrophysiological activity
in the central retina
• mfERG responses show lower amplitudes in the fovea in macular hole
• N1 is generated by photoreceptors in the outer retinal layer and P1 is
generated by Müller and bipolar cells
• Shows loss of retinal function corresponding to the macular hole

35. FUNDUS AUTOFLORESCENCE IN MACULAR HOLE
• There is a strong subfoveal
autofluorescence signal in full-
thickness macular holes
• Punctate autofluorescence for
stage 1

36. DIFFERENTIAL DIAGNOSIS
• Pseudohole due to epimacular membrane
• Cystoid macular edema
• Lamellar macular hole
• Vitreomacular traction syndrome

37. TREATMENT
• General measures
• Medical treatment
• Surgical treatment

38. FOLLOW UP FOR SPONTANEOUS CLOSURE
• STAGE 0 AND STAGE 1
• Assymptomatic
• No Vitreomacular traction

39. CHEMICAL VITRECTOMY
• Intravitreal ocriplasmin 0.125mg in 0.1ml is used and approved in 2012 by US FDA
• Ocriplasmin is a 27 kilodalton serine protease that demonstrated activity against
fibronectin and laminin and essentially performs pharmacolytic vitreolysis
• Separates the hyaloid from the underlying retina
• MIVI-TRUST clinical trials was a double-blind study, 652 eyes with vitreomacular
adhesion were evaluated this at day 28 post injection, eyes receiving ocriplasmin
exhibited greater release of the vitreoretinal attachment in 26.5% vs. 10.1% p < 0.001
while closure of macular hole (40.6% vs. 10.6%, p < 0.001) in ocriplasmin vs control
respectively .58.3% closure rate for holes of less than 250 µm diameter

40. CHEMICAL VITRECTOMY CONTINUED
• A 2018 study suggests slightly higher closure rates for full-thickness
macular hole following ocriplasmin use.
• 6 patients with vitreomacular traction and a full-thickness macular hole
• By 24 weeks’ of follow-up, four of the six full-thickness macular holes had
closed
• Ocriplasmin has the potential to cause retinal toxicity from its use.

41. SURGICAL TREATMENT-HISTORICAL EVOLUTION
• Once full thicknessmacular holehas developed, the potential for spontaneous resolution
is low.
• Treatment for stage 2 or higher
• In 1982, Gonvers and Machemer were the first to recommend vitrectomy, intravitreal
gas, and prone positioning for retinal detachments secondary to macular holes.
• Kelly and Wendel reported that vision might be stabilized or even improved if it were
possible to surgically relieve tangential traction on the macula, reduce the cystic
changes, and reattach the cuff of detached retina surrounding the macular hole.

42. SURGICAL TREATMENT-HISTORICAL EVOLUTION
CONTD
• In 1991, Kelly and Wendel demonstrated that vitrectomy, removal of cortical
vitreous and epiretinal membranes, and strict face-down gas tamponade could
successfully treat full-thickness macular holes.
• Results of their initial report were a 58% anatomic success rate and visual
improvement of 2 or more lines in 42% of eyes.
• A succeeding report showed a 73% anatomic success rate and 55% of patients
improving 2 or more lines of visual acuity.
• Present anatomic success rates range from 82-100% depending on the series.

43. SURGICAL TREATMENT: VITRECTOMY
• Standard 3-port (light source, vitreous
cutter, irrigation/drainage) pars plana
vitrectomy preferably smaller gauge
vitrectomy systems (ie, 27 gauge, 25
gauge, 23 gauge)…transconjunctival
vitrectomy systems
• The anterior and middle vitreous is
removed

44. SURGICAL TREATMENT: REMOVAL OF
PERIMACULAR TRACTION(INDUCTION OF PVD)
• Removal of the perimacular traction.
• The traction exerted by the posterior hyaloid on the
macula should be relieved by either removing just the
perimacular vitreous or combining it with the induction
of a complete posterior vitreous detachment.
• Use of a soft-tipped silicon cannula or the vitrectomy
cutter with the cutter disengaged
• A "fish-strike sign" or bending of the silicon cannula
shows posterior hyaloid has been engaged
• Released from the underlying retina and removed with
the vitrectomy cutter.

45. SURGICAL TREATMENT: REMOVAL OF INTERNAL
LIMITING MEMBRANE (ILM)
• Removal is also associated with a reduced risk of subsequent reopening
of the macular hole
• ILM peeling can be accomplished via a "rhexis“ using very fine forceps
to peel the ILM from the underlying retina
• Use of vital dyes such as indocyanine green, trypan blue, brilliant blue
G (TissueBlue) to stain the ILM makes it easier to visualize the ILM.
• Triamcinolone acetonide can be used to assist with visualization of the
ILM for peeling.
• Inverted” ILM flap” was first described in 2010 and beneficial for
large macular holes and macular holes in patients with high
myopia ( have a low rate of closure with standard ILM peeling
techniques).

46. SURGICAL TREATMENT: 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).

47. SURGICAL TREATMENT; EPIRETINAL
MEMBRANES REMOVAL
• Epiretinal membranes, if present, also
should be removed. Techniques in
completing this procedure vary from
surgeon to surgeon
• Techniques for this procedure varies
among different surgeons.

48. SURGICAL TREATMENT: AIR-FLUID EXCHANGE
(INTERNAL TAMPONADE)
• Total air-fluid exchange is performed
• Aimed to desiccate the vitreous cavity
• A nonexpansile concentration of a long-acting gas can be used
• Sterile air and varying concentrations of perfluoropropane or sulfur hexafluoride have been used
• Longer period of internal tamponade equated to a higher success rate (duration of the gas
bubble)
• Silicone oil can be used as an internal tamponade for patients with difficulty positioning or
altitude restrictions

49. SURGICAL TREATMENT: AIR-FLUID EXCHANGE
(INTERNAL TAMPONADE)
• Use of silicone oil necessitates a second
subsequent surgery to remove the oil(usually 2-6
months post-op).
• visual results are poorer with silicon oil when
compared to gas tamponade and may be due to
silicone oil toxicity at the level of the
photoreceptors and RPE.
• Rate of single operation macular hole closure
higher in gas tamponade than silicone oil
tamponade

50. SURGICAL TREATMENT: 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 and
found equivalent macular hole closure rates
and noninferiority of nonsupine positioning

51. SURGICAL TREATMENT: AUTOLOGOUS
TRANSPLANTATION OF ILM
• Eyes that did not respond to initial surgery with standard ILM
peeling
• Eyes with myopic foveoschisis
• Trauma
• A small piece of the internal limiting membrane was peeled
off to make a free flap
• Then transplanted and placed inside the macular hole under
perfluorocarbon liquids
• Air–fluid exchange was performed and SF6 gas was
injected at a non-expansile concentration.

52. SURGICAL ADJUNCTIVE AGENT-AUTOLOGOUS
SERUM
• An intraoperative adjunctive agent,
• Used to be instilled over the macular hole following an air–fluid exchange to enhance
anatomic success.
• Found to help remove ICG dye used in surgery by significantly shortening the period
of residual retinal ICG staining
• Probably reduce ICG toxicity
• Poor outcome(no difference in anatomic or visual outcome) of treatment on trial

53. COMPLICATIONS
• 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.

54. COMPLICATIONS CONTD
• Visual field defects : due to dehydration of the nerve fiber layer.
• Reduced by shorter surgical times
• Lower air flow
• Oblique placement of infusion cannulas caused by beveled incisions of
smaller gauge vitrectomies.
• Failure of hole closure/hole reopening

55. GENERAL CONCERN ON HEALTH AT 65YRS/
OPTIMIZATION
• REFRACTION
• CONCERN FOR COST OF TREATMENT
• COEXISTING CATARACT AT 65YRS OR PSEUDOPHAKIA
• MOBILITY CONCERN
• FREQUENT HOSPITAL VISIT
• FOLLOW UP

56. GENERAL PROGNOSTIC FACTORS FOR
SUCCESSFUL TREATMENT
• Preoperative visual acuity: most important….Better VA correlates with higher rates
of anatomical closure and visual gain.
• Cosure rates higher with shorter duration of symptoms(better visual outcomes).
Hole duration of greater than 9 months(poorer outcome)
• Macular hole size larger than 400 microns(poorer outcome)
• No ILM peeling( poorer outcome)
• Older age of patient(Poorer outcome)

57. CONCLUSION
• Macular hole is one of the retinal problems that causes loss of central
vision
• Early presentation, proper staging and use of appropriate technology and
skills commensurate with the stage of macuar hole will guarantee a better
outcome,
• Counselling of patients that anatomical closure success rate does not
amount to Visual success rate is necessary.

58. REFERENCES
• Kean Theng Oh, Macular Hole Treatment & Management: Medscape.Updated: Jan 02,
2020
• Omesh P. Gupta et’al, Macular Hole. Eyewii: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
• Kanski J. Clinical Ophthalmology: A Systematic Approach. Nineth Ed. Elsevier Health Sciences;
2020.macular hole. p. 592-7.

59. THANK YOU