4. EPIDEMIOLOGY
In USA , MH affect about 100,000 people
1.9 % of visual impaired eyes (20/4020/200)
Female > male (2:1)
age 60 – 80 years ( mean 65 years )
VA 20/20 - 20/400
Incidence of MH in fellow eye : 5-10%
not associated with medical dis, refractive
error
5. Natural Hx
EDCCS : vision/ progression
45% loss > 2 snellen lines in 4.5 yrs
28% loss > 3 snellen lines in 4.5 yrs
30% increased in size in 4.5 yrs
8% spont. resolution/regression after 6 yrs
only 3% spont. improve vision
6. Natural Hx
EDCCS : MH in opposite eye
5% at 3 yrs
7% at >6 yrs
0+ % in pre-existing PVD eyes
rarely associated with RRD, higher
incidence in high myopia with posterior
staphyloma
7. Causes
- most common cause is
- the others
-
non-surgical trauma
surgical trauma
pathologic myopia
vascular disease
idiopathic
8. PATHOGENESIS
idiopathic MH begins with contraction of
prefoveolar vitreous cortex that is adherent
to ILM of Mueller cell cone.
Foveal pseudocyst formation
Dehiscence of pseudocyst and Mueller
cell
Full – thickness MH formation (FTMH)
+/- avulsion of operculum (Muller cell cone.
ILM, Henle’s layer, cone nuclei)
11. Abnormal traction
forces of the vitreous
on the macula?
Observed with
CL examination
U/S
OCT
Laser biomicroscopy
12. CLASSIFICATION
Gass and Johnson classification
stage 1 - pre – macular hole lesion
1a yellow spot
1b yellow ring
stage 2 - eccentric or concertric FTMH < 400
stage 3 - FTMH > 400
stage 4 - FTMH with PVD
13.
14. Stage 1
- localized shrinkage of prefoveal cortical
vitreous formed the traction shallow
detachment of foveola
- loss of normal foveola depression and
light reflex
- 1a small yellow spot ( 250 -300 )
- 1b yellow ring ( halo form of foveal
detachment )
-+/-pseudooperculum
- VA < 20/40 , metamorphopsia
- 50 % had spontaneous PVD
15. Stage 2
-
eccentric or oval full thickness
defect diameter < 400 micron
VA 20/50 - 20/80
74 % progress to stage 3
16. Stage 3
- hole > 400 micron, may be foveal
edema & surrounding cuff of subretinal
fluid or operculum
- VA 20/100 – 20/400
- no PVD
17. Stage 4
- FTMH with complete PVD
- may be associated to ERM
- FFA in stage 3 , 4 - mottle
hyperfluorescene from RPE thining, RPE
depigment, loss of xanthophyl
23. CLINICAL AND DIAGNOSIS
FFA - transmission defect at hole
or partial blockage at
surrounding subretinal fluid
OCT and SLO
Macular perimetry - absolute
scotoma
surrounding with relative scotoma
24. MH WITH SPECIFIC CAUSE
1. TRAUMA
- trauma with cystic macular degeneration
associated with MH formation
- concussion effect & residual macular
traction after incomplete PVD
27. 2.PATHOLOGIC MYOPIA
- progressive thining and streching
of posterior pole, loss of choriocapillaris
lead to cystic formation and macular
atrophy
- FFA - abnormal slow choroidal
and retinal blood flow
33. NATURAL COURSE
Different between stage 1 – 4
stage 1 - MH s PVD progress to FTMH
33-52 %
- MH c PVD not turn to FTMH
stage 2 - most turn to stage 3, 4
stage 3,4 – almost always stable or slowly
progress
34. Chance of FTMH in fellow eye
1. if no PVD in both eyes - high risk
2. if PVD in FTMH eye but no PVD
in fellow eye - intermediate risk
3. if PVD in fellow eye
- no/very low
risk
35.
36.
37. DIFFERENTIAL DIAGNOSIS
1.
PSEUDOHOLE
- may be retinal excavation without
tissue loss, RPE atrophy, granular pigment
change around normal foveal depression
- may because of dehiscence of
gliotic preretinal membrane on the
macular
- associated with ERM, vitreomacular
traction syndrome, PDR, RRD, inflammation
38. pseudohole
- VA normal or slightly reduce or
distortion
- FFA normal
- good prognosis
- no evidence of leser therapy
- vitrectomy surgery or membrane
peeling when VA < 20/80 or distortion
39.
40. 2. MACULAR CYST
- intact inner and outer retinal
layer, Intraretinal fluid cystic macular
degeneration with loss of nerve fiber
layer, ganglion cell, IPL , inner aspect of
Inner nuclear layer
- large cyst in chronic or severe
Cystoid macular edema looklike MH
- Watzke – Allen test normal
- VA 20/20 – 20/100
41. - FFA - pooling in cystic space in
late venous phase
- CME associated with intraocular
Gas, trauma, inflammation, exudate
macular degeneration, DM
- fluid accumulated between inner
nuclear and outer plexiform layer
- prognosis depend on underlying
Cause, size, chronicity of cytoid edema
- no treatment
44. • outer lamella hole ( OLH )
- collapse of outer wall of Cyst
follow break down of outer BRB at RPE
- associated with Berlin’ s edema,
macular schisis, LASER
- slightly irregular deep round or oval
Excavation with intact inner retinal tissue
- VA 20/20 – 20/400
- FFA - window defect
45.
46.
47. • Inner lamella hole ( ILH )
- common, may be intermediate stage
to develop FTMH
- rarely develop from chronic CME,
spontaneous rupture at inner wall of cyst
result in round oval excavation in retina
size < 500 micron
- may develop from radiation, gas
C3F8, telangiectasia
- VA 20/20 – 20/80
48. - FFA - no transmitted fluorescene,
minimal window defect or accumulated in
perifoveal cystoid space
52. TREATMENT
Basic step of MH surgery
PPV
Remove of post. Hyaloid
ERM dissection
Check peripheral retinal break
FAX
Inject adjunctive agent ( if use )
Air – gas/SO exchange
prone position
53. 1. PPV and delamination of vitreous cortex
- remove AP, tangential,circumferential
force
- fish – strike or diving rod sign
2. Delamination of ERM
- peeling of visible ERM and / or ILM
- prevalence of ERM
- 80% in Pseudophakic eye
- 63 % in phakic eye
54.
55. 3. Delamination of ILM
- fibroblast like cell
- +/- 0.2 -0.4 cc. Of 0.5% ICG stain
- complication s
- trauma to retina
- Light toxicity – 15 min
- ICG RPE toxicity
57. 5. Temponade of MH
- gas or silicone oil
- postop. 12 -16 % C3F8 facedown
1-3 wks then 6 hr. per day until no gas
( 4 – 6 wks )
6. Elimination or reducing duration position
- short acting gas ( 4 days )
- SO 6 – 12 wks
58.
59. 7. Orther
- macular scleral buckle may be
Used in high myopia, post. Staphyloma
Or MH with extensive subretinal fluid
8. Repaired reopened MH
- repeat vitrectomy or FGX, FGX
With laser photocoagulation
61. RESULT OF SURGERY
Stage 1 lesion
- no benefit to PPV
- stage 1
- VA 20/40 30% turn FTMH
- VA 20/50 – 20/80 % turn FTMH
Stage 2 – 4
position of hole - elevate or flat
edges of hole - open or closed
