Full-Thickness Macular Hole

Published on 10/05/2015 by admin

Filed under Opthalmology

Last modified 22/04/2025

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10.2

Full-Thickness Macular Hole

Introduction:

A macular hole is a full-thickness defect in the neurosensory retina occurring at the macular center, usually associated with a central scotoma and decreased vision. Macular holes can be primary (formerly referred to as ‘idiopathic’), resulting from vitreomacular traction (VMT) in the course of anomalous posterior vitreous detachment. Primary macular holes are more common in women, most often seen in the sixth or seventh decade of life. Primary macular holes may be bilateral in 10–20% of cases. Secondary macular holes are due to forces other than VMT. They can be traumatic, associated with posterior staphylomas in severe myopia, epiretinal membrane, cystoid macular edema, or rarely associated with solar retinopathy.

Clinical Features:

Classic symptoms are acute unilateral decreased vision and occasional metamorphopsia. An impending macular hole may be seen as a loss of the normal fovelar depression with a yellow spot or ring in the center of the macula. A full-thickness macular hole (FTMH) is seen as a well demarcated, round red spot in the center of the macula surrounded by a grey halo that represents a cuff of subretinal fluid around the hole (Fig. 10.2.1) An operculum may be seen above the hole. Yellowish deposits may be seen within the hole.

Figure 10.2.1 Fundus photograph of a full-thickness macular hole. The picture to the left shows an acute hole, whereas the one on the right shows a chronic hole with retinal pigment epithelium changes at the margin.

Macular holes were classified according to their clinical findings. However, with OCT data available, this classification system is now in flux. This is described in some detail below.

OCT features of macular holes include a full-thickness defect in the neurosensory retina (Figs 10.2.2 to 10.2.4). There may be cysts in the neurosensory retina surrounding the area of the hole. A cuff of subretinal fluid may be seen around the defect in the retina. The vitreous may be attached to the hole with vitreomacular traction or there may be an operculum seen in the posterior vitreous on OCT scanning. Chronic macular holes may show loss of the cuff of subretinal fluid. There may also be RPE atrophy seen in chronic holes.

Figure 10.2.2 OCT scan through an acute macular hole showing intraretinal cysts, a cuff of subretinal fluid and an operculum . Note that the vitreous is detached from the fovea.

Figure 10.2.3 A large sized macular hole with the calipers showing a measurement of over 600 µm.

Figure 10.2.4 One week and one month post-vitrectomy for macular hole closure. Note the small area of subretinal elevation that decreases with time with restoration of the ELM and a small area of disruption in the IS–OS/ellipsoid layer. Various studies have shown that disruption in the ELM, IS–OS/ellipsoid layer, as well as the length of disruption of the cone outer segment tips correlates with level of post-operative visual acuity.

OCT-based macular hole classification is informed by the size of the hole and the status of the vitreomacular interface:

▶ Stage 0 macular hole: On OCT, this is an eye with VMA which has a FTMH in the contralateral eye. The risk of progression to a full-thickness hole in the eye with VMA may be close to 40%.

▶ Stage 1 macular hole: This is an eye with vitreomacular traction.

▶ Stage 2, 3 and 4 macular holes per Gass’s classification are now re-classified as small, medium or large macular holes with (stage 4) or without (stage 2 and 3) release of the vitreomacular adhesion.

FTMHs are now better classified according to their aperture size on OCT scanning as measured by the caliper function of the OCT scanner:

▶ Small FTMH – aperture size less than or equal to 250 µm

▶ Medium-sized FTMH – aperture size between 250 µm and 400 µm

▶ Large FTMH – aperture size greater than 400 µm

FTMH may further be sub-classified by presence or absence of ongoing VMT.

Ancillary Testing:

The diagnosis of a macular hole is made on examination and OCT scanning. Additional tests are usually not warranted

Management:

For stage 0 and 1 macular holes, the management is as described in the VMA/VMT section (Chapter 10.1). FTMHs are typically treated surgically, with excellent prognosis for closure and visual recovery for small and intermediate sized holes. Chronic (>2 years) holes show slightly lower closure rate with surgery, but the visual results are significantly less than acute FTMH. Small and medium-sized FTMH can be treated with intravitreal ocriplasmin with closure rates of approximately 50%.