Surgical management of macular hole

A prospective study of the effect of a unilateral macular hole on sensory and motor binocular function and recovery following successful surgery

AIMS

To examine the effect of a unilateral full thickness macular hole on sensory and motor binocular function and to study recovery after successful surgical closure.

METHODS

Twenty eight consecutive patients undergoing surgery for a unilateral macular hole underwent orthoptic examination, including measurements of Titmus and TNO stereoacuity and motor fusion range before surgery. Twenty three patients had successful anatomical closure. Fifteen of these patients, who had both improved acuity in the operated eye following surgery and were available for further testing, underwent repeat orthoptic assessment 2-7 months after surgery.

RESULTS

In all patients stereoacuity was reduced before surgery, but few patients were subjectively aware of a deficit of depth perception affecting their everyday life. In those patients with improved Snellen acuity after surgery, stereoacuity measured by the Titmus stereotest also improved significantly, but not that measured by the TNO test. Two patients were aware of a subjective improvement in depth perception. Motor fusion was markedly reduced compared to normal before surgery, with only limited recovery after surgery.

CONCLUSION

A unilateral macular hole notably reduced both stereoacuity and motor fusion. Successful closure improved the deficit in stereoacuity associated with the hole when measured by a stereotest using contoured stimuli. The majority of patients were not subjectively aware of the deficit in stereoacuity or its improvement following surgery.

Phacovitrectomy with internal limiting membrane peeling for idiopathic macular hole

BACKGROUND

Progressive nuclear sclerosis is a known complication of macular hole surgery that hinders patients' recovery to their best visual acuity postoperatively. We report the visual outcome, complications and efficacy of combined phacoemulsification, intraocular lens (IOL) insertion and vitrectomy with internal limiting membrane (ILM) peeling for patients with cataract undergoing macular hole surgery.

METHODS

We reviewed the records of 32 consecutive patients (36 eyes) who underwent phacoemulsification with insertion of a polymethylmethacrylate lens into the capsular bag and pars plana vitrectomy with ILM peeling in one session for repair of idiopathic macular hole. Patients were assessed between February 1998 and August 2001.

RESULTS

The mean age of the patients was 70 (range 52 to 83) years, and 25 (78%) were women. The median duration of the holes before surgery was 8.3 months; in 19 eyes (53%) the duration was 6 months or less. Twenty eyes (56%) had stage 3 holes. The preoperative vision was 20/200 or worse in 29 eyes (80%). The mean grade of nuclear sclerosis was 2.4. The average length of follow-up after surgery was 11 (range 1.5 to 37) months. Primary hole closure was achieved in 28 eyes (78%). In five of the remaining eight cases the patient consented to a second procedure, which was successful in four cases, for a final closure rate of 89%. Postoperatively, the visual acuity improved by 2 lines or more in 22 eyes (61%). Of the 32 eyes with final closure, 11 (34%) attained a visual acuity of 20/40 or better, and 25 (78%) had an acuity of 20/100 or better. The most common complication was posterior capsular opacification (27 eyes [75%]), an expected complication when perfluoropropane or other gases are used for tamponade.

INTERPRETATION

The results are comparable to those with standard macular hole surgery. Combined surgery is reliable and safe; the benefits support its use as a routine procedure for patients with cataract undergoing macular hole repair.