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.
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
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.
Editor's Notes
20/40 to 20/400, 45% loss of 2 lines, 28% loss of three lines, opposite eye 4.6 to 6.5%
(foveal center is weak point due to lack of photoreceptor zonular attachments in this area) Adhearent to the ILM, of muller cell cone.
Pathogenisis is realated to traction from the vitreous
Oval, no or little ffa changes, minimal va watsky and laser neg Partial thickness with overlying retina intact