Surgical Management of Idiopathic Macular Holes

Idiopathic macular holes have long been considered to be a stable, untreatable condition with little or no chance of spontaneous visual improvement. Within the last few years, surgical intervention has been developed for the management of idiopathic Stage 3 and Stage 4 holes. With pars plana vitrectomy surgery, at least 50% of patients will experience a 2 or more line improvement in visual acuity, and 25% of patients will improve to 20/40 or better. Since the natural history of idiopathic macular holes is extremely poor, all patients with Stage 3 or 4 lesions should be seriously considered for vitreous surgery.

Assessment of Lamellar Macular Hole and Macular Pseudohole With a Combination of En Face and Radial B-scan Optical Coherence Tomography Imaging

PURPOSE

To investigate lamellar macular hole (LMH) and macular pseudohole (MPH) using a combination of en face and radial B-scan OCT.

DESIGN

Retrospective observational case series.

METHODS

Setting: Institutional study.

PATIENT POPULATION

En face and radial B-scan OCT images of 63 eyes of 60 patients diagnosed with LMH or MPH based on an international classification were reviewed.

OBSERVATION PROCEDURES

Cases were classified using en face images based on the presence/absence of epiretinal membrane (ERM), retinal folds, parafoveal epicenter of contractile ERM (PEC-ERM), and retinal cleavage. We compared the en face imaging-based classification system with the international classification system using radial B-scan images. We quantitatively evaluated visual function and macular morphology.

MAIN OUTCOME MEASURES

Characterization of multimodal OCT-based subtypes of LMH and MPH.

RESULTS

All cases showed ERM and were classified into 4 groups. In the first group, which lacked retinal folds and showed significantly lower visual acuity than the other groups, 81% of eyes had degenerative LMH. In the second group, which lacked PEC-ERM and retinal cleavage and showed significantly lower retinal fold depth, all eyes had MPH. The third group, in which 95% of eyes had symmetric tractional LMH, included eyes with retinal cleavage but without PEC-ERM, and this group showed higher circularity of the foveal aperture and cleavage area than the group with both these features, in which all eyes had asymmetric tractional LMH.

CONCLUSIONS

Multimodal OCT enables classification of LMH and MPH based on pathologic conditions. Retinal traction in particular may be useful for determining treatment methods.

A New Method of Treating Macular Holes

Purpose

To evaluate the effect of pars plana vitrectomy (PPV) combined with joining of the hole edges on the closure of full-thickness macular holes.

Methods

In a prospective consecutive clinical trial, standard PPV with internal limiting membrane (ILM) maculorhexis was performed in 25 eyes from 25 patients with stage 3 or 4 idiopathic macular holes (Group A). The retina was massaged gently around the hole from the periphery to the center in order to approximate the edges as closely as possible. The edges of the macular hole were then joined with forceps and gently pressed together. At the end of surgery, air was used for intravitreal tamponade. Patients were required to remain in a face-down position for 1 day postoperatively. For the comparison, a retrospective analysis of outcomes of surgical treatment of 27 eyes of 27 patients with stage 3 to 4 idiopathic macular hole (Group B), whose surgery included standard three-port PPV, followed with ILM peeling, was performed. The closed macular holes were categorized into two patterns based on optical coherence tomography: flat/closed and flat/open.

Results

The overall closure rate was 92±5.4% over a minimum follow-up period of 6 months in Group A, and 86±6.2% in Group B. Best-corrected visual acuity improved from 0.1±0.014 (ranged from 0.02 to 0.5) before surgery to 0.29±0.03 (ranged from 0.2 to 0.7) after surgery in Group A, and from 0.1±0.05 (ranged from 0.05 to 0.4) before surgery to 0.22±0.04 (ranged from 0.05 to 0.4) after surgery in Group B. No significant difference was found in absolute light sensitivity of macula, intraocular pressure, or lens opacification. A common postoperative complication in Group A was retinal pigment epitheliopathy, which developed in 18 cases (72%).

Conclusions

Mechanical joining and compression of the retinal edges during surgery for stage 3 or 4 idiopathic macular holes appears to yield a promising anatomic and functional result. (Eur J Ophthalmol 2007; 17: 246–51)

OCT Angiography Features of a Case of Bilateral Full-Thickness Macular Hole at Different Stages

The authors present the optical coherence tomography angiography features of the deep vascular plexus in a case of bilateral full-thickness macular hole. The right eye is a newly diagnosed, small, full-thickness macular hole, and the left eye is a longstanding, large macular hole.

Recovery of photoreceptor layer on spectral-domain optical coherence tomography after vitreous surgery combined with air tamponade in chronic idiopathic macular hole

BACKGROUND AND OBJECTIVE

Studies using sterilized air in chronic idiopathic macular holes show varying success rates, and the impact of a shorter duration of tamponade on photoreceptor layer recovery is not fully elucidated.

PATIENTS AND METHODS

Surgical outcomes of 35 cases (seven in stage 3 and 28 in stage 4) were assessed for best corrected visual acuity and with spectral-domain optical coherence tomography.

RESULTS

The primary closure rate was 91.4%, and the closed cases and unclosed cases were significantly different in the preoperative (P = .042) and postoperative (P = .040) diameter of the photoreceptor layer defect. After surgery, there was a significant improvement in best corrected visual acuity and a decrease in the photoreceptor layer defect. The postoperative logarithm of the minimal angle of resolution was significantly correlated with the preoperative hole diameter (P = .003) and the postoperative diameter of the photoreceptor layer defect (P = .005).

CONCLUSION

Air tamponade is a safe and effective treatment for chronic and severe macular holes, with several spectral-domain optical coherence tomography parameters highly predictive of postoperative visual acuity.

Frequency of vitreomacular interface disease in patients presenting to a tertiary care institution

BACKGROUND AND OBJECTIVE

To evaluate the frequency of vitreomacular interface disease using a recently published optical coherence tomography (OCT) classification and assess which of these patients would qualify for ocriplasmin.

PATIENTS AND METHODS

A retrospective, consecutive case series of patients with macular cyst, hole, or pseudohole (ICD-9 code 362.54) and concurrent OCT imaging was performed. Eyes were classified using OCT as pseudohole, lamellar hole, vitreomacular adhesion (VMA), vitreomacular traction (VMT), and full-thickness macular hole (FTMH). Minimum diameter (MD) of FTMH was measured.

RESULTS

The study included 399 eyes of 331 patients. Of these, 61 eyes (15.3%) had VMA or VMT, 120 (30.0%) had a lamellar hole or pseudohole, and 218 (54.6%) had FTMH. Of eyes with FTMH, 73 were small (< 250 µm MD), 48 were medium (250 to 400 µm MD), and 97 were large (> 400 µm MD). Overall, 68 eyes (17.0%) would be candidates for ocriplasmin therapy.

CONCLUSION

Most patients had FTMH, and 17% would qualify as candidates for ocriplasmin therapy.

Incidence of outer foveal defect after macular hole surgery

PURPOSE

To determine the incidence of outer foveal defects after macular hole surgery and to evaluate the relationship between the defect and visual outcome.

DESIGN

Retrospective, observational case series.

METHODS

A retrospective analysis was performed on 50 eyes from 50 patients who underwent macular hole surgery with a follow-up period of 12 months or more. We evaluated the presence of outer foveal defects using time-domain optical coherence tomography and best-corrected visual acuity at several postoperative time points. The main outcome measures are the incidence of an outer foveal defect and the best-corrected visual acuity.

RESULTS

The incidence of an outer foveal defect at 1, 3, 6, and 12 months after surgery was 49%, 50%, 47%, and 31%, respectively. There were no statistical differences in the postoperative visual acuity between eyes with and without an outer foveal defect at each postoperative time point.

CONCLUSIONS

Outer foveal defects after successful macular hole surgery were observed in approximately half of the eyes during the early postoperative period and one third of the eyes at 12 months postoperatively, suggesting that it takes longer than expected to recover the normal foveal anatomy after surgery. The presence of outer foveal defects did not significantly correlate with the visual outcome.

Spontaneous closure of stage III and IV idiopathic full-thickness macular holes—a two-case report

BACKGROUND

To document and study the spontaneous closure of stage III and IV idiopathic full-thickness macular holes by using both optical coherence tomography (Stratus OCT) and spectral optical coherence tomography (SOCT).

METHODS

A two-center, two-case, observational study of stage III and IV macular holes is presented. OCT and SOCT were performed.

RESULTS

Macular holes spontaneously resolved after 4 to 12 weeks of observation.

CONCLUSION

The spontaneous closure of large idiopathic full-thickness stage III and IV macular holes is possible. We suggest that, as long as no smooth oval shape of the macular hole edges appears on the cross-sectional OCT and SOCT scans, there is still a chance for its spontaneous closure.

MACULAR HOLE REPAIR WITH LIMITED NONSUPINE POSITIONING

PURPOSE

To assess the surgical success rates of modern macular hole repair with elimination of face down positioning.

METHODS

A review of data for 72 eyes (from 102 consecutive cases) with idiopathic macular holes treated surgically between 1998 and 2004 was performed. Exclusion criteria consisted of macular hole for >1 year or of unknown duration and macular holes from secondary causes. All patients were evaluated and surgically managed by one surgeon (R.T.).

RESULTS

Average preoperative best spectacle corrected visual acuity (BSCVA) was 20/170 (6/51). Six patients had a grade II hole, 60 patients had a grade III hole, and 6 patients, had a grade IV hole. Anatomical success was achieved in 92% of cases with 1 operation, and the average postoperative BSCVA was 20/46 (6/14). Six patients required additional surgical management to achieve anatomical success with an average postoperative BSCVA of 20/55 (6/16.5). The postoperative BSCVA improved an average of 5.7 lines from baseline.

CONCLUSION

Favorable anatomical and BSCVA outcomes were achieved with the elimination of face down positioning in the postoperative period. Additional benefits are an increase in patient acceptance and compliance and the number of patients eligible for the procedure.

[Current strategies for macular hole surgery in Germany, Austria and Switzerland]

BACKGROUND

Main aim of this study was to determine how macular hole surgery is currently being performed in Germany, Austria and Switzerland.

METHODS

A questionnaire concerning the different aspects of surgery for stage 3 macular hole was developed and sent out to the 380 members of the German Retina Society.

RESULTS

This analysis is based on 129 returned questionnaires from colleagues who perform macular hole surgery. A total of 95% (n=123) of the surgeons routinely perform vitrectomy with posterior vitreous detachment, peeling of epiretinal tissue and internal limiting membrane (ILM) peeling. Some 86% (n=106) stain the ILM, with 80% of these (n=85) using indocyanine green (ICG) in concentrations ranging from 0.005% up to 10%. Fourteen percent of ICG users perform a fluid-air exchange before applying the dye. Platelet concentrate is used by 8% of the surgeons with 97% (n=125) performing a gas tamponade using SF6 (53%), C3F8 (22%), C2F6 (16%) or just air (5%) (multiple answers: 4%). Simultaneous cataract surgery is routinely performed by 8%; by 73% only if there is significant cataract.

CONCLUSIONS

There is common consent on the basic surgical steps, but several surgical details, e.g. ILM staining, are performed in substantially different ways.

Measurement of anterior lens growth after acute primary angle-closure glaucoma

CASE REPORT

We report spontaneous closure of an idiopathic 200 microm stage III macular hole, confirmed by optical coherence tomography, in a 76-year-old woman.

COMMENTS

Spontaneous closure is rare and not well understood. Possible mechanisms are discussed. Delay of surgery is not recommended.

Funktionelle Ergebnisse nach anatomisch erfolgreicher Makulaforamen-Stadium-III/IV-Chirurgie

PURPOSE

To report the functional results after anatomically successful surgery for stage III/IV macular hole.

METHODS

Follow-up examinations (ETDRS charts, Birkhäuser near visual acuity charts, OCT) were carried out in 29 patients 11+/-5 months after surgery for stage III/IV macular hole (hole size >400 microm); in all cases the foveal contour had been restored postoperatively . The surgery performed also included cataract surgery (n=26), vitrectomy, ICG-assisted ILM peeling (in which perfluorcarbon liquid was used to prevent ICG from coming in contact with the retinal pigment epithelium) and tamponade with intraocular gas (n=16) or silicone oil (n=13). Silicone oil had been removed by the time of the follow-up evaluation.

RESULTS

Preoperative mean BCVA was 0.2 (0.64 logMAR+/-0.24) and postoperative BCVA, 0.5 (0.3 logMAR+/-0.19). None of the patients experienced any deterioration in sight; the average improvement in visual acuity was 3.5+/-2 lines. In 70% (n=20) of the patients the postoperative BCVA was > or =0.5. Visual acuity for near sight was 0.45+/-0.2. In 66% (n=19) a visual acuity of > or =0.4 was achieved for close work. The improvement in visual acuity was not related to the kind of endotamponade or to the size of the macular hole. Patients with macular hole diameters of 400-800 microm (n=20) gained 3.5+/-2.,4 lines, while in patients with macular hole diameters of 800-1135 microm the average gain was 3.6+/-1.3 lines.

CONCLUSIONS

Anatomically successful macular hole stage III/IV surgery with ICG-assisted ILM peeling and protection of the retinal pigment epithelium from contact with ICG by perfluorcarbon liquid can yield good functional results.

Treatment of stage 2 macular hole by intravitreous injection of expansile gas and induction of posterior vitreous detachment

PURPOSE

To demonstrate the morphological and functional outcomes of intravitreous injection of an expansile gas bubble for the treatment of stage 2 macular holes.

DESIGN

Prospective interventional case series.

PARTICIPANTS

Twenty eyes of 20 consecutive patients with unilateral stage 2 macular holes.

METHODS

The patients underwent intravitreous sulfur hexafluoride injection, followed by postoperative facedown positioning for 3 to 5 days. The patients were observed per protocol schedule with complete ophthalmological examination, including determination of corrected visual acuity (VA), slit-lamp biomicroscopic examination, funduscopic examination, and optical coherence tomography (OCT). Follow-up was greater than 12 months for all patients (mean, 19.5).

MAIN OUTCOME MEASURES

Posterior vitreous detachment, anatomical closure of the hole, VA, and hole diameter as measured by OCT.

RESULTS

Detachment of the posterior vitreous at the macula was achieved in 19 of 20 eyes (95%). Ten cases (50%) had anatomical closure of the hole with intravitreous gas injection alone. The remaining 10 cases (50%) achieved anatomical closure of the hole after subsequent vitreous surgery. There was a significant difference in hole diameter (P = 0.004) and in pretreatment vision (P = 4.5x10(-5)) in patients for whom gas alone resulted in hole closure and those proceeding to vitreous surgery. Hole closure by gas injection alone was achieved in 7 of 7 eyes (100%) with pretreatment vision better than 20/40 and in 6 of 7 eyes (86%) when the hole was smaller than 200 mum. There were no major complications in this series of patients. Successfully treated macular holes remained closed at all follow-up points during the study period.

CONCLUSION

An intravitreous injection of an expansile concentration of the inert sulfur hexafluoride gas alone frequently induces detachment of the posterior vitreous in the aged eye. Anatomical closure of the hole without major complications is more likely in smaller holes with better pretreatment vision. This technique may have clinical application for stage 2 holes in selected cases. A number of potential advantages including decreased morbidity and a potential cost savings may result from successful utilization of this procedure.

Ultrastructure of the vitreomacular interface in full-thickness idiopathic macular holes: a consecutive analysis of 100 cases

PURPOSE

To evaluate the ultrastructure of the vitreoretinal interface in stage III and stage IV idiopathic macular holes.

DESIGN

A consecutive observational case series, laboratory investigation.

METHODS

Pars plana vitrectomy with en-bloc removal of the internal limiting membrane (ILM) and epimacular tissue was performed by one surgeon in 80 eyes with stage III macular holes and in 20 eyes with stage IV macular holes. In total, 218 specimens were processed for light and transmission electron microscopy.

RESULTS

Fibrocellular proliferation at the vitreal side of the ILM was found in 57 cases. Native vitreous collagen (NVC) was attached to the ILM in 36 eyes. The presence of NVC was considerably more frequent in eyes with stage IV (70%) than in eyes with stage III macular holes (26%). Mono- and multilayered cellular membranes were seen more frequently in stage IV macular holes. NVC, if present, was always associated with fibrocellular proliferation. In 39 eyes with stage III and in four eyes with stage IV macular holes, the ILM was devoid of any cells and collagen.

CONCLUSIONS

Fibrocellular proliferation appears to be a secondary event instead of a primary feature in macular hole development. The severity of fibrocellular proliferation is associated with the presence of NVC. Incomplete vitreoretinal separation may contribute to the development of epimacular membranes in eyes with idiopathic macular holes. Remnants of the vitreous cortex remain more often attached to the ILM in eyes with spontaneous posterior vitreous detachment (PVD) than in eyes with surgical PVD induction.

Clinicopathologic correlation of stage 2 macular hole

PURPOSE

To provide histopathologic correlation of the appearance of a stage 2 macular hole.

METHODS

A 79-year-old woman presented with a recent onset of mildly decreased vision in the right eye. With slit-lamp biomicroscopic examination and fundus photography, she was diagnosed as having a stage 2 macular hole. Her vision remained stable thereafter without intervention for 15 months. She died 6 months after her final follow-up examination. Postmortem histopathologic examination of the right eye was carried out by light microscopy of conventional and immunoperoxidase-stained sections.

RESULTS

The clinical appearance of a stage 2 macular hole in this patient corresponded with findings of intraretinal splitting, which extended beyond an area of surface retinal defect.

CONCLUSION

Surface retinal defects associated with intraretinal splitting are a pathway in the development of a macular hole.

[Traction maculopathies--pathogenesis and diagnostics]

Traction maculopathies are a group of age-related degenerative diseases characterized by pathology of vitreomacular interface including idiopathic epimacular membranes, vitreomacular traction syndrome and idiopathic macular hole. The disorders develop due to mechanical forces caused by focal condensation or incomplete detachement of vitreous and shrinkage of pathological membranes. The forces can be tangential to retinal surface in epiretinal membranes, anterior-posterior in vitreomacular traction syndrome and oblique (trampoline) in idiopathic macular hole. Authors discuss pathogenesis and diagnostics of traction maculopathies with use of optical coherence tomography and microperimetry, based on current literature. This work presents also idiopathic macular hole classification with use of optical coherence tomography images compared with biomicroscopic classification by Gass.

[Senile retinoschisis with tearing of the deep layer--classification and pathogenic hypotheses]

The observations have been made on 52 eyes with senile retinoschisis with tearing of the deep layer. These principle studies are the aspect of tearing, in order to classify and discuss the pathogenic hypotheses. Seven types of tearing are presented. Their modes of formation seem different. We established a pathogenic classification of these tears. The risk of operation on a secondary retinal detachment is always a subject of discussion even if the symptomatic detachment may be considered very rare. From these seven observation of schisis detachment, there is proposed a pathogenic hypothesis. The vitreous have played the principal role in making a traction on the edge of the deep tears where sometimes the retinoschisis is not formed. It is recommended to observe and analyse systematically the tearing of the retinoschisis external layer.

Outcomes of surgery for idiopathic macular hole: a case-control study comparing silicone oil with gas tamponade

BACKGROUND AND OBJECTIVE

To compare outcomes of macular hole surgery using silicone oil with C3F8 gas tamponade.

PATIENTS AND METHODS

A retrospective case-control study of patients who underwent macular hole surgery for stage 2, 3, or 4 macular holes.

RESULTS

Forty-six eyes of 44 patients underwent macular hole surgery involving injection of silicone oil (23 cases) or gas tamponade (23 controls). Anatomic closure occurred in 19 (82.6%) cases and 20 (86.9%) controls. Visual acuity improved to 20/70 or better in 4 (17.3%) of the cases and in 17 (73%) of the controls.

CONCLUSION

In the current study of macular hole surgery, outcomes were better among patients with gas tamponade.

Duration of face-down positioning after macular hole surgery: a comparison between 1 week and 3 days

PURPOSE

To investigate whether shortening the duration of face-down positioning from 1 week to 3 days affects the anatomical success rate of macular hole surgery.

METHODS

A total of 53 consecutive eyes in 50 patients with full thickness macular holes of 2-24 months' (average 10 months) duration were included in the study. In 20 eyes (37.7%) the hole had been present for more than 1 year. All patients were operated with vitrectomy, removal of the posterior hyaloid and a complete fluid-gas exchange. Peeling of the internal limiting membrane (ILM) was not performed. Postoperatively, the duration of face-down positioning differed between two consecutive groups of patients. The first group (29 patients) was instructed to keep their heads face-down for 7 days, while the second group (24 patients) maintained face-down positioning for only 3 days.

RESULTS

Overall, 90.6% of the macular holes closed with one operation. The macular hole closed successfully in 27 (93.1%) of the 29 eyes in the 1-week group and in 21 (87.5%) of the 24 eyes in the 3-day group (p > 0.05).

CONCLUSION

Although the frequency of hole closure differed slightly in the two study groups, the difference was far from statistically significant. Thus, the results indicate that 3 days of strict face-down positioning are sufficient to achieve closure of even longstanding macular holes without removal of the ILM.

Stage 3 macular hole: role of optical coherence tomography and of B-scan ultrasonography

PURPOSE

To analyze the various aspects of Stage 3 macular hole with optical coherence tomography (OCT) and B-scan ultrasonography.

DESIGN

Observational case series.

METHODS

Patients referred for full-thickness macular hole were prospectively screened with OCT and B-scan ultrasonography. OCT examination analyzed the diameter of the hole, the posterior hyaloid, the surrounding retina, and the inconstant presence of a pseudo-operculum. B-scan ultrasonography permitted the distinction between stage 3 and stage 4 holes, based on the detachment of the posterior hyaloid.

RESULTS

The study included 62 eyes with stage 3 holes. On OCT, the typical aspect with a hyaloid detached from the macular area was observed in 37% of the eyes (group 3C). In 42% of the eyes (group 3B), a focal adherence was visible at the margin of the hole, as in stage 2 macular hole, but the hole was long-standing, large, and noneccentric. In 21% of the eyes, the hyaloid was not visible anterior to the retina but was still adherent to it (group 3A). In the absence of B-scan ultrasonography, these OCT features could be confused with a stage 4 macular hole. No difference in the size of the hole was observed between subgroups.

CONCLUSION

OCT can show various aspects of stage 3 macular holes. B-scan ultrasonography was useful for assessing the location of the posterior hyaloid and to distinguish stage 3 from stage 4 macular holes. These features may provide additional information on the pathogenesis of macular hole and may have therapeutic implications.

IS REMOVAL OF INTERNAL LIMITING MEMBRANE ALWAYS NECESSARY DURING STAGE 3 IDIOPATHIC MACULAR HOLE SURGERY?

PURPOSE

To determine the indications for internal limiting membrane (ILM) removal in stage 3 idiopathic macular holes (MHs).

METHODS

Focal posterior vitreous detachments (PVDs) at MH rims were examined preoperatively by optical coherence tomography and binocular slit-lamp fundus examination in 19 patients retrospectively. All eyes underwent pars plana vitrectomy and creation of a PVD, and some eyes underwent a second surgery to remove the ILM. Indications of ILM removal for MH closure were discussed.

RESULTS

Preoperatively, 9 eyes did not (non-PVD group) and 10 eyes did (PVD group) have complete focal PVDs. In all nine eyes in the non-PVD group, MHs were closed after the creation of a PVD without ILM peeling (P <0.05, chi test). In the PVD group, 5 eyes (50%) had MHs closed by making PVD complete without ILM removal, and 5 eyes (50%) required ILM removal in a second surgery. In the end, closure of MHs was achieved in all eyes.

CONCLUSION

Anatomic closure of stage 3 idiopathic MHs without a PVD at the rim of the hole may be achieved only by creating a PVD without ILM removal.

Morphologic analysis of stage 3 and stage 4 macular holes: implications for treatment

PURPOSE

To determine whether the observed anatomy of macular holes can be explained by a hydrodynamic model in which fluid flow through the hole is balanced by fluid pumping across the retinal pigment epithelium. We use this model to draw conclusions about the possible role of vitreomacular traction in determining the anatomy of macular holes and their resolution after vitreous surgery.

DESIGN

Cross sectional.

METHODS

Retrospective study in a clinical practice. The study included 42 eyes of 42 patients with a stage 3 or 4 macular hole (Gass classification). We measured the radius of the macular hole and the radius of the surrounding cuff of subretinal fluid from color or red-free fundus photographs and determined the relationship between these two variables.

RESULTS

The mean age of the patients was 68.0 +/- 7 years (range, 51 to 80). Twenty-five patients had stage 3 macular holes and 17 patients had stage 4 macular holes. The neurosensory detachment radius was related to the square of the macular hole radius for stage 3 and stage 4 holes, with no significant difference between the stage 3 and stage 4 linear trend lines (P = .999). There was no correlation between patient age and the area of the macular hole (r = 0.0645) or neurosensory detachment plus hole (r = 0.156) over the range of age in this study. However, the area of the doughnut-shaped cuff of subretinal fluid increased with increasing patient age (P = .0493), thus suggesting an age-dependent decline in the pumping ability of the retinal pigment epithelium.

CONCLUSIONS

Our data are consistent with a hydrodynamic model in which macular hole anatomy is determined by a balance between fluid flow through the hole and fluid outflow across the retinal pigment epithelium. Because stage 3 and stage 4 macular holes exhibit a similar relationship between the size of the macular hole and the size of the cuff of subretinal fluid around the hole, simple relief of vitreomacular traction would not lead to resolution of the subretinal fluid cuff unless it is accompanied by a reduction in hole diameter due to approximation of wound edges.

Stage 0 macular holes: observations by optical coherence tomography

OBJECTIVE

To introduce the concept of a stage 0 macular hole based on optical coherence tomographic observations of the vitreoretinal interface in fellow eyes of patients with unilateral idiopathic macular holes, and to evaluate the subsequent risk of progression to a full-thickness macular hole.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Ninety-four patients with a unilateral stage 2, 3, or 4 full-thickness macular hole.

METHODS

The medical records of patients with a unilateral macular hole diagnosed between 1994 and 2000 at the New England Eye Center were reviewed.

MAIN OUTCOME MEASURE

Development of a full-thickness macular hole in the fellow eye on biomicroscopic fundoscopy or optical coherence tomography (OCT).

RESULTS

In 27 (28.7%) of 94 clinically normal fellow eyes, OCT detected an abnormality of the vitreoretinal interface but normal foveal anatomy. The vitreoretinal abnormalities were further subclassified into severe (4 eyes), moderate (8 eyes), and mild (15 eyes) based on the intensity and morphology of the OCT signal. One of the 4 (25%) severe cases progressed to a full-thickness macular hole, 4 of the 8 (50%) moderate cases became full-thickness macular holes, and no (0%) mild cases progressed to a full-thickness macular hole. Severe and moderate eyes seemed to share characteristic features on OCT that increased their risk of macular hole development (stage 0 macular hole). The macular hole-free survival at 48 months was 94% for stage 0-negative patients, versus 54% for stage 0-positive patients. Univariate analysis revealed that the presence of a stage 0 macular hole was significantly associated with an almost 6-fold increase in the risk of macular hole formation (relative risk: 5.8, 95% confidence interval: 1.16-28.61, P = 0.03).

CONCLUSIONS

A stage 0 macular hole has a normal biomicroscopic appearance clinically, but has salient features on OCT as a result of oblique vitreous traction. Optical coherence tomographic findings consist of a normal foveal contour and normal retinal thickness and must include the presence of a preretinal, minimally reflective, thin band inserting obliquely on at least one side of the fovea. The presence of a stage 0 macular hole in the fellow eye is a significant risk factor for the development of a second macular hole.

[OCT in macular holes]

The traditional Gass classification of macular holes can now be supplemented by additional and more detailed morphologic information obtained with optical coherence tomography (OCT). The perifoveal vitreous detachment and subsequent anterior foveal traction is considered to be the primary pathomechanism of macular hole formation. In cases of persistent traction on the fovea it may lead to foveal dehiscence. A possible explanation for intraretinal cyst formation may be secondary vitreous body fluid accumulation within the retina. A classification of macular holes based on additional information from OCT images is possible. Thus, OCT is a valuable tool for differential diagnosis of a pseudo macular hole versus macular hole, precise stage classification, therapy decision making process, outcome control after macular surgery, and prognosis prediction.

Predictors of success in macular hole surgery with emphasis on the internal limiting membrane (ILM) and ILM peeling

BACKGROUND AND OBJECTIVE

To study the predictors of success in macular hole surgery.

PATIENTS AND METHODS

Twenty-two eyes of 21 patients underwent macular hole surgery. The hole closure rate and the visual improvement were studied based on the preoperative visual acuity, stage and duration of the macular hole, the type of intravitreal tamponade used, and internal limiting membrane peeling. The internal limiting membrane was peeled only when it was clinically prominent.

RESULTS

Macular holes were closed in 19 of the 22 eyes and visual improvement of 2 lines or more was achieved in 17 eyes. Preoperative visual acuity, duration of the macular hole, type of intraocular tamponade used, and internal limiting membrane peeling did not affect the outcome. A final visual acuity of 20/70 or better was more common after surgery for stage 2 holes (P = .019).

CONCLUSION

The best predictor of outcome was the stage of the hole, with best results obtained in stage 2 holes.

Retrospective analysis of vitrectomy with and without internal limiting membrane peeling for stage 3 and 4 macular hole

BACKGROUND AND OBJECTIVE

To evaluate the efficacy and safety of pars plana vitrectomy with indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling versus pars plana vitrectomy without ILM peeling for stage 3 and 4 primary idiopathic macular hole.

PATIENTS AND METHODS

Sixty-two eyes of 60 consecutive patients with idiopathic macular hole underwent vitrectomy with gas (C3F8) injection. The first 46 eyes underwent vitrectomy without ILM peeling; of these, 14 had epiretinal membrane peeling and were excluded, leaving 32 eyes (no ILM group). The remaining 16 eyes underwent vitrectomy with ICG-assisted ILM peeling (ICG-ILM group). Follow-up data at 6 to 48 months postoperatively were recorded and analyzed.

RESULTS

Macular hole closure was achieved in 13 (81%) of 16 patients in the ICG-ILM group and 16 (50%) of 32 patients in the no ILM group (P = .036). Analysis of the data from eyes with closed holes indicates that the ICG-ILM group achieved a better mean final visual acuity compared with the no ILM group (20/60 vs 20/100, respectively) (P = .017). No complications were attributed to the use of ICG.

CONCLUSIONS

ICG-assisted ILM peeling significantly increased the rate of hole closure in eyes with stage 3 or 4 idiopathic macular hole. The use of ICG did not adversely affect the visual acuity results, and it appears to be a safe adjunct to macular hole surgery.

Late-onset retinal detachment associated with regressed retinopathy of prematurity

PURPOSE

To study the characteristics of late-onset retinal detachments in patients with regressed retinopathy of prematurity (ROP) and the condition of their fellow eyes.

METHODS

We carried out a retrospective review of 29 patients (38 eyes) who had been treated at two institutions, one in the US and the other in Japan, between 1986 and 1997. The age at the time of treatment ranged from 6 to 51 years (mean=23.1). Five of the 38 eyes with tractional detachment were treated with either open-sky vitrectomy, closed vitrectomy, or scleral buckling; 27 of the 38 eyes with rhegmatogenous retinal detachment underwent scleral buckling or closed vitrectomy or both. The remaining 6 of the 38 eyes had subclinical rhegmatogenous detachment and were treated with photocoagulation or cryopexy, or followed without treatment. The most characteristic retinal breaks were multiple holes with a prevalence of equator and posterior types.

RESULTS

Overall, anatomical reattachment was accomplished in 27/32 eyes (84%) that underwent surgery. Two thirds of the patients who underwent vitrectomy either initially or at a later time had poor postoperative visual acuity. More than half of the fellow eyes had retinal detachment and others had various characteristic fundus changes of regressed ROP.

CONCLUSIONS

Long-term, probably life-long follow-up of high-risk patients is necessary so that diagnosis and treatment can be instituted at an early stage of retinal detachment.

Spontaneous closure of stage 2 macular hole observed with optical coherence tomography

PURPOSE

To report the clinical course and images of optical coherence tomography of an eye with a stage 2 macular hole which closed spontaneously.

DESIGN

Observational case report.

METHODS

Serial optical coherence tomographic images were obtained.

RESULTS

A 67-year-old woman received a diagnosis of stage 2 idiopathic macular hole in her right eye. The diagnosis was made with a tomographic image of a full-thickness dehiscence of the neurosensory retina at the fovea. The posterior hyaloid membrane was adhering to the edge of the dehiscence. Four weeks later, the closure of the macular hole was ascertained with optical coherence tomography. The posterior hyaloid membrane was fully separated from the fovea.

CONCLUSION

A stage 2 macular hole may close spontaneously with the separation of the hyaloid membrane.

Anatomic and functional results of vitrectomy and long-term intraocular tamponade for stage 2 macular holes

PURPOSE

To investigate the results of pars plana vitrectomy combined with long-term intraocular tamponade in patients with a stage 2 macular hole.

METHODS

In a retrospective study, 50 consecutive eyes operated on for stage 2 macular hole were reviewed. The surgical technique included pars plana vitrectomy, separation of the posterior hyaloid, and intraocular tamponade with either 12.5% perfluropropane (C(3)F(8)) gas or silicone oil. Patients treated with C(3)F(8) were instructed to keep face-down positioning for 3 or 4 weeks. Removal of silicone oil took place 4 or 5 weeks after the vitrectomy.

RESULTS

Closure of the macular hole was achieved in all 50 eyes after one operation. The mean postoperative best-corrected distance visual acuity was 20/32 (range, 20/63-20/20), with 49 eyes (98%) having a postoperative visual acuity of 20/50 or better. Visual acuity improved in all eyes postoperatively, with a mean gain of 4.84 +/- 1.95 ETDRS lines.

CONCLUSION

For stage 2 macular holes, vitrectomy combined with long-term intraocular tamponade can result in a very favorable anatomic and functional outcome that is as good as or better than the results described for other modalities. This approach simplifies the surgical technique, and both adjuvant-related complications and potential retinal damage related to internal limiting membrane peeling or use of indocyanine green are avoided.

Macular holes: classification, epidemiology, natural history and treatment

BACKGROUND

Macular hole is a retinal disease primarily affecting elderly women. Its overall prevalence in the Danish population is estimated to be 0.14%. The majority of cases are unilateral. The fully developed macular hole evolves through a series of stages starting with an impending hole. About half of impending macular holes regress spontaneously. The remaining half progress to full thickness macular holes. In a patient with a macular hole in one eye, the risk of development of a macular hole in the fellow eye is less than 2% if posterior vitreous detachment is present. If the posterior vitreous is attached, the risk is approximately 15%. If an impending hole is found in the other eye, the risk rises to 50%.

TREATMENT AND OUTCOMES

Macular hole surgery is able to close full thickness macular holes in approximately 90% of cases. Visual acuity of 20/50 or better can be obtained in approximately half of patients with recent onset of symptoms. Complications include retinal detachment, endophthalmitis, late reopening of an initially successfully closed hole and retinal pigment epithelial abnormalities. Retinal detachment should be expected in less than 5% of cases.

[Study of internal limiting membrane peeling in stage-3 and -4 idiopathic macular hole surgery]

PURPOSE

To evaluate the advantages of peeling the internal limiting membrane (ILM) in macular hole surgery.

PATIENTS AND METHODS

Retrospective analysis of the results of macular hole surgery, comparing two surgical protocols performed by the same surgeon. Both protocols included a standard pars plana vitrectomy with intravitreous nonexpansile gas and adjunction of autologous plasma over the macular hole. In addition, in the second group, the ILM of the eyes was systematically peeled after its coloring by indocyanine green (infracyanine) in the latter patients.

RESULTS

We studied 39 eyes of 36 patients with stage-3 or -4 macular hole surgery. The duration of symptoms before surgery was on average 9 months. Twenty-one eyes (53.8%) underwent ILM peeling. Macular hole closure after one procedure was significantly more frequent postoperatively in the group of eyes with ILM peeling than in the other group (90% and 50%, respectively, p<0.01); after two procedures, macular hole closure reached 61% in the second group. The macular hole seemed to have disappeared on angiographic examination and on OCT in 90% of eyes with anatomical success in the group with ILM peeling and in only 22% of eyes with anatomical success in the group without. Visual acuity improved by two lines or more in 62% of eyes with ILM peeling and in 44% of eyes without. The difference in improvement in the macular threshold was statistically significant (p<0.001).

CONCLUSION

This study would suggest that peeling of the ILM is an important adjuvant for successful closure of macular holes. Its possible mechanism of action is discussed. Further studies are needed to confirm these data by controlled randomized trial.

[Macular holes. Review of the current status of knowledge of pathogenesis and treatment methods]

This article is based on the author's personal views and clinical experience and offers an overview of the current state of knowledge on the pathogenesis of macular holes including currently available therapy strategies. Special attention is paid to the prevailing controversial issues regarding treatment concepts for macular holes.

Types of macular holes encountered during diabetic vitrectomy

PURPOSE

To determine the types of macular holes encountered during vitrectomy for complicated cases of diabetic retinopathy.

METHODS

This is a retrospective study of consecutive cases of macular holes diagnosed either before or during pars plana vitrectomy for complications of proliferative diabetic retinopathy over a 6-year period. The morphology of these holes is described. Possible mechanisms of their development, surgical considerations, and results after a follow-up of at least 3 months are discussed.

RESULTS

Nineteen consecutive cases of macular holes associated with proliferative diabetic retinopathy were reviewed over a 6-year period. Five cases were lamellar and 14 were full thickness. The 14 cases of full thickness macular holes occurred in patients with the following conditions: tractional rhegmatogenous retinal detachment (5); tractional retinal detachment (3); premacular hemorrhage (3); and cystic macular edema (3). Closure of the full thickness holes was achieved in 8 of 11 patients who were followed up for at least 3 months. All the patients had visual improvement, but no patient had a visual acuity of better than 20/100.

CONCLUSION

Macular holes may occur in proliferative diabetic retinopathy in different configurations. Full thickness macular holes can be closed in most cases. Functional improvement can be achieved.

Correlation between optical coherence tomography data and biomicroscopic interpretation of idiopathic macular hole

PURPOSE

This study was designed to assess the new clinical information given by optical coherence tomography in patients with idiopathic macular hole.

METHODS

Sixty-one consecutive eyes of 47 patients with idiopathic macular hole at different stages of development were studied clinically. Patients with myopia, epiretinal macular membrane, and any other ocular disease were excluded. Best-refracted visual acuity and biomicroscopic fundus examination with macular contact lens were performed. Optical coherence tomography was performed through a dilated pupil. The optical coherence tomography findings were correlated with the Gass biomicroscopic classification of idiopathic macular hole.

RESULTS

Optical coherence tomography provided different or additional information in 22 of 24 eyes (91.7%) biomicroscopically classified in stages 1-A and stage 1-B, according to the Gass macular hole classification, and in seven of 37 eyes (18.9%) biomicroscopically classified in stages 2, 3, and 4. The main difference from Gass biomicroscopic classification was a macular pseudocyst instead of a foveolar detachment in the first stages. The main additional optical coherence tomography observation, not detected biomicroscopically, was the presence of retinal tissue on the bottom of the macular hole. Optical coherence tomography may be particularly useful in evaluation of early stages in development of idiopathic macular hole.

CONCLUSIONS

Compared with classic biomicroscopical observation, optical coherence tomography frequently gives different or additional information on idiopathic macular hole, especially in its early stages. Correct diagnosis and surgical indication of idiopathic macular hole may benefit from optical coherence tomography imaging.

[Formation of idiopathic macular holes]

Sixty-eight patients (136 eyes) with idiopathic macular hole (IMH) were examined, using optic coherent tomography. 91% of these patients were women, mean age 66.6 years. Preholes were detected in 14 eyes, lamellar ruptures in 11, and perforating ruptures in 78 eyes. Specific functional and morphological changes in the retina, vitreous, and vascular membrane were detected. Three main mechanisms of IMH formation were distinguished. Conceptual scheme of the pathogenesis of this condition was developed and a new more complete pathogenetically justified classification of IMH is offered, which helps more objectively diagnose, predict the functional outcome, determine the treatment strategy, and evaluate the efficiency of surgery.

Surgical management of macular holes: a report by the American Academy of Ophthalmology

OBJECTIVE

The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique.

METHODS

A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented.

RESULTS

There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%).

CONCLUSIONS

The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

Peripheral visual field defects after macular hole surgery: a complication with decreasing incidence

AIM

To prospectively evaluate peripheral visual fields after vitrectomy for idiopathic macular holes.

METHODS

Goldmann perimetry was performed in 105 patients before, as well as 6 weeks and 12 months after macular hole surgery.

RESULTS

Only one patient (< 1%) with a stage III macular hole developed an asymptomatic postoperative visual field defect. The scotoma was wedge-shaped, peripherally located in the temporal quadrant, and remained unchanged during the following 12 months.

CONCLUSION

Peripheral visual field defects after macular hole surgery can be a complication of very low incidence. A rather low pressure set during air-fluid exchange as well as special aspects of the surgical technique may be responsible for this low incidence of peripheral visual field defects.

[Classification of idiopathic macular ruptures]

Based on comprehensive examinations making use of optic coherent tomography, idiopathic macular ruptures were classified (by severity) as pre-ruptures, lamellar and perforating ruptures. A 10-point scale is proposed for quantitative analysis of ruptures. Regularities in retinal changes characteristic of each type of ruptures are detected. This helps accurately evaluate the rupture, choose treatment strategy, and evaluate its results.

[Surgery for idiopathic macular hole: use of internal limiting membrane peeling]

In order to evaluate the hypothesis that macular internal limiting membrane peeling is useful for closing stages III and IV, but not stages II idiopathic macular holes, anatomic and functional surgical results are compared in a consecutive series of 54 operated eyes including 3 groups: 17 eyes with a stage II macular hole and 18 eyes with a stage III-IV macular hole without additional internal limiting membrane peeling, and 19 eyes with stage III-IV macular hole with additional internal limiting membrane peeling.