Macular hole

Narciso F. Atienza, Jr. MD, DPBOMichael Shea Vitreo-Retina Fellow,

University of TorontoSt. Michael’s Hospital (2002-2004)

Chief Retina Service: Cardinal Santos Medical Center

First described by Knapp (1869) and Noyes (1870)

First coined by Ogilve (1900) Initially thought as untreatable. Patho-physiology unknown.

Factors inciting macular hole formation Vitreous syneresis Posterior vitreous separation Cystoid macular edema

• Previous ocular surgery

• Inflammatory process Traumatic blunt ocular injury

• Accidental laser injury• Lightning• Electrical shock

High Myopia

Theory on Macular hole formation

Lister (1924) Stated the importance of the vitreous in

the pathogenesis.

Tangential traction on the macula• Remnant posterior vitreous membrane on the macula

with contractile cells. Focal shrinkage of foveal vitreous cortex Tractional elevation of the Henle’s nerve fiber

layer. Intraretinal foveolar cyst formation. “Unroofing” of the cyst.

Gass JDM. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol 1988: 106:629-639.

Hydration theory• Together with peri-foveal traction, hydration of

the edges of the hole causes the bridge to expand, increasing the size of the hole.

Tornambe, P. Macular Hole Genesis: The Hydration Theory. Retina: 23 (3) June 2003 421-424

Other theories in macular hole formation

Retinal/choroidal ischemia theory• Affected by RPE dysfunction and possible

intraretinal fluid accumulation in the fovea

Involutional retinal thinning

Incidence and Risk factors (?)

Incidence• 0.05%

• Female predominance

• Lack of Estrogen use

• Bilateral in 3 to 22%

Risk factors• History of glaucoma

• Increased plasma fibrinogen

Gass classification

Stage 1 - localized shrinkage of prefoveal cortical vitreous, tractional shallow detachment of the foveola (loss of the normal foveolar depression and light reflex), retinal striae, Lack of Watzke sign.• Stage 1A - small yellow spot (250-300 mm)

• Stage 1B - foveal detachment progresses, a yellow halo forms

Stage 1

Stage 2 - minute holes form near the center of the detached fovea. This is not an inevitable process. In 50% of cases, the vitreofoveal attachment spontaneously separates.

Followed by restoration of the normal foveal depression and improved visual acuity.

Stage 2

Stage 3 – full thickness macular hole greater than 450 um in size, with no posterior vitreous separation.

Most common presentation in the clinics• Yellow deposits at the level of the retinal pigment

epithelium

• Cuff of subretinal fluid

• Operculum

• Cystoid macular edema

• Positive Watzke’s sign

Stage 3

Stage 4 – full thickness macular hole with a posterior vitreous detachment

Stage 4

The Watzke-Allen test• Slitlamp biomicroscopy

The laser aiming beam test.

Questions asked

(1) Is it possible to reattach the retina around the macular hole?

(2) If it is reattached, will the patient's central vision improve?

Vitrectomy and fluid/gas exchange

Kelly, EK, and Wendel, RT.

Vitreous surgery for idiopathic macular holes: results of a pilot study, Arch Ophthalmol 109:654, 1991

In 30 (58%) of 52 patients, successful reattachment of the detached macula.

In 22 (73%) of the 30 patients in whom the macula was successfully reattached, there was an improvement in visual acuity of two lines or better.

In the 22 patients in whom reattachment of the macular hole was not obtained, there was no significant improvement in visual acuity.

Personal experience

91 cases macular hole surgery (since 7/2004)

76 patients 62 female vs 14 male patients 15 patients (bilateral) VA (CF 4 feet - 20/60)

80 cases – phakic• 68 - PPV alone

• 15 - PPV + phaco IOL

11 cases - pseudophakic Tamponade

• 55 cases - C3F8

• 36 cases - Silicone oil

80 patients (90%) - successful hole closure in one surgery• 71 patients- improvement in BCVA (more than 2 lines)

6 cases - did not close• 2 cases had re-operation (closed after 2nd surgery)

Conclusions

Importance of compliance• (Face down positioning)

Combined surgery • Does not affect closure rate

Tamponade• No direct relationship between gas and oil

(too small for comparison)

Observation

100% of patients will claim compliance • Face down position

Sign of compliance• 41/101 (40%)

Post-operative course

15 developed cataract within 2 years (3 months - 2 years)

No retinal detachments 3 cases of high IOP Failure to close

• 6 cases (1 case still had ILM, 4 cases patients did not position)

Technical modifications

ILM peeling - 91% - 100% No face down requirement - 79%

Surgical adjuncts

Transforming growth factor• 91% vs 53% (Smiddy)

Recombinant TGF-beta• 78% vs 61% (Thompson)

Autologous platelet• 94% vs 81% (Paques)

“If you don’t have complications, then you haven’t operated enough”

Dr. Michael Shea

1st Fellow of Charles Schepens

1st Retina Surgeon in Canada (U of Toronto)