Este documento define el agujero macular lamelar, discute su etiología, epidemiología, diagnóstico y tratamiento. Un agujero macular lamelar es un defecto parcial en el grosor de la mácula que causa una irregularidad en el contorno foveal sin pérdida completa de tejido. La tomografía de coherencia óptica es fundamental para el diagnóstico. Aunque muchos son asintomáticos, aquellos con pérdida de agudeza visual pueden requerir cirugía como la vitrectomía con
2. Definición
• Gass 1975
• International Vitreomacular Study Group 2013
Gass JD. Lamellar macular hole: a complication of cystoid macular edema after cataract extraction: a clinicopathologic case report. Trans Am
Ophthalmol Soc. 1975;73:231-50.
Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, et al. The International Vitreomacular Traction Study Group classification of
vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013;120(12):2611-9.
• Contorno foveal irregular.
• Defecto en la retina interna
(puede que no implique pérdida
de tejido).
• Esquisis intrarretiniana,
típicamente entre la capa plexifor-
me externa y la capa nuclear
externa.
• La capa de fotorreceptores se
mantiene intacta.
3. Epidemiología y Patogenia
• Infradiagnóstico
• 28% - 37% biomicroscòpia
• Gass
• Haouchine et al
• Desprendimiento de vítreo posterior
y tracción centrífuga
Witkin AJ, Ko TH, Fujimoto JG, Schuman JS, Baumal CR, Rogers AH, et al. Redefining lamellar holes and the
vitreomacular interface: an ultrahigh-resolution optical coherence tomography study. Ophthal- mology.
4. Govetto, A., et al., Lamellar
Macular Hole: Two Distinct
Clinical Entities? Am J
Ophthalmol, 2016. 164: p. 99-
109.
5. Etiología
• Tras Cirugía de cataracta
• Miopía magna. Retinosquisis 4,8%
• Uveítis
• DMAE
• Desprendimiento de retina
• Telangiectasias idiopáticas parafoveales
Panozzo G, Mercanti A. Optical coherence tomography findings in myopic traction maculopathy. Arch
Ophthalmol. 2004;122(10):1455-60.
Takahashi H, Kishi S. Tomographic features of a lamellar macular hole formation and a lamellar hole that
progressed to a full-thickness macular hole. Am J Ophthalmol. 2000;130(5):677-9.
8. Govetto, A., et al., Lamellar
Macular Hole: Two Distinct
Clinical Entities? Am J
Ophthalmol, 2016. 164: p. 99-
109.
Clasificación
Agujero lamelar atrófico o degenerativo
Agujero lamelar traccional
9. Govetto, A., et al.,
Lamellar Macular Hole:
Two Distinct Clinical
Entities? Am J
Ophthalmol, 2016. 164: p.
99-109.
10. Govetto, A., et al., Lamellar Macular Hole: Two Distinct Clinical Entities? Am J
Ophthalmol, 2016. 164: p. 99-109.
11. Govetto, A., et al., Lamellar
Macular Hole: Two Distinct
Clinical Entities? Am J
Ophthalmol, 2016. 164: p. 99-
109.
12. Govetto, A., et al., Lamellar
Macular Hole: Two
Distinct Clinical Entities?
Am J Ophthalmol, 2016.
164: p. 99-109.
13. • Watze Allen
• Asintomáticos/ microperimetria / metamorfopsia
• Progresión lenta
• Theodossiadis 2009: 78% estables
• Tanada 2011 Miopia magna
Clínica
Chen JC, Lee LR. Clinical spectrum of lamellar macular defects inclu- ding pseudoholes and pseudocysts defined by
optical coherence tomography. Br J Ophthalmol. 2008;92(10):1342-6.
Theodossiadis PG, Grigoropoulos VG, Emfietzoglou I, Emfietzoglou I, Nikolaidis P, Vergados I, et al. Evolution of lamellar
macular hole studied by optical coherence tomography. Graefes Arch Clin Exp Ophthalmol. 2009;247(1):13-20.
14. • Biomicroscopia
• OCT
• Angiografía fluoresceínica
• Ecografía B
Diagnóstico
Chen JC, Lee LR. Clinical spectrum of lamellar macular defects inclu- ding
pseudoholes and pseudocysts defined by optical coherence tomography. BrJ
15. Masayuki H, Yuki M, A., et
al,. Assessment of
Lamellar Macular Hole
and Macular Pseudohole
With a Combination of
EnFace and Radial B-
scan Optical Coherence
Tomography imaging.
AJO, 2018 . 01.016.
16. • Atróficos: mayor afectación retina externa
• Agujeros maculares traccionales
• VPP + pelado MER + MLI + taponador
• No consenso tratamiento coadyuvante
Tratamiento
Sato T, Emi K, Bando H, Ikeda T. Retrospective comparisons of vitrec- tomy with and without air tamponade to
repair lamellar macular hole. Ophthalmic Surg Lasers Imaging Retina. 2015;46(1):38-43.
Coassin M, Mastrofilippo V, Stewart JM, Fanti A, Belpoliti M, Cimino L, et al. Lamellar macular holes: surgical
outcome of 106 patients with long-term follow-up. Graefes Arch Clin Exp Ophthalmol. 2018; 256(7):1265-73.
Kuo BI, Yang CM, Hsieh YT, J. Lamellar macular hole in diabetic reti- nopathy. Eur J Ophthalmol.
2019;1120672119879665. [Epub antes de impresión].
Lai T-T, Yang C-M. Lamellar Hole-Associated Epiretinal Proliferation in Lamellar Macular Hole and Full-Thckness
Macular Hole in High Myopia. Retina. 2018;38(7):1316-23.
Figueroa MS, Noval S, Contreras I. Macular structure on optical coherence tomography after lamellar macular
hole surgery and its correlation with visual outcome. Can J Ophthalmol. 2011;46(6):491-7.
19. • Inducción iatrogénica agujero macular de espesor completo
• Catarata
• Neovascularización coroidea
• Edema macular quístico
• Desgarros o desprendimiento de retina
Complicaciones
Figueroa MS, Noval S, Contreras I. Macular structure on optical coherence tomography after lamellar macular
hole surgery and its correlation with visual outcome. Can J Ophthalmol. 2011;46(6):491-7.
20. Puntos clave
• El agujero macular lamelar es un defecto parcial del grosor macular.
• Hay diferentes teorías sobre su etiopatogenia.
• Muchos de ellos pasan desapercibidos porque son asin-
tomáticos.
• El principal diagnóstico diferencial es el agujero macular y el
pseudoagujero macular.
21. Puntos clave
• La principal prueba diagnóstica es la tomografía de cohe- rencia
óptica macular.
• La mayoría de agujeros maculares lamelares únicamente precisan
controles tomográficos evolutivos.
• Aquellos pacientes con pérdida de agudeza visual y metamorfopsia
precisan cirugía.
• La cirugía del agujero macular es la vitrectomía pars plana 23, 25 o 27
G acompañado de pelado de la membrana epirretiniana y la limitante
interna.
• No existe consenso sobre el uso de otros tratamientos coadyuvantes.
Notas del editor
Comunicación digital sol·licitada
El agujero macular (AM) lamelar fue descrito por Gass en 1975 como una lesión macular secundaria a edema macular quístico. Desde entonces, ha habido mucho interés en la definición de esta patología y en distinguirla de otras enfermedades maculares, como el AM de grosor completo, el pseudoagujero macular y la tracción vitreomacular1.
Por definición, es un AM de grosor parcial donde las capas inter- nas de la fóvea están traccionadas y desprendidas de las capas retinianas externas.
En 2013, el International Vitreomacular Traction Study Group (grupo IVTS) estableció la definición de AM lamelar y de pseudoagujero
2 macular basándose en las imágenes tomográficas .
Es una clasificación basada en la anatomía macular que clasifica la patología de la interfase vitreomacular, facilitando la toma de decisiones tanto médicas como quirúrgicas, la nomenclatura estándar en los estudios clínicos, y la comparación entre los dife- rentes manuscritos pasados, presentes y futuros2.
Dentro de esta clasificación el AM lamelar se define como un agujero de grosor parcial, y sus características anatómicas basadas en la tomografía de coherencia óptica (OCT) son las siguientes:
La tomografía de coherencia óptica ha sido de gran ayuda tanto para el diagnóstico de esta patología como también para com- prender su patogenia.
FIGURE 7. Optical coherence tomography findings for similar conditions. Tractional forces caused by epiretinal membranes may produce a distortion of the foveal anatomy (white arrows). Occasionally, tractional forces may contract the epiretinal membrane, resulting in the formation of a macular pseudohole. In myopic retinoschisis, tractional forces of different etiologies may contribute to the separation of the neurosensory retina, typically characterized by bridges of tissue between outer nuclear and outer plexiform layers (black star). In tractional lamellar macular hole, epiretinal membranes generate tractional forces that may cause alterations in the fovea and a definite cleavage plane (black arrows), resulting in a schitic separation similar in morphology and location to myopic retinoschisis. Differently, in degenerative lamellar macular hole no signs of traction are visible and the intraretinal cavitation does not follow a definite cleavage plane (gray arrows).
Vicens granell
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FIGURE 1. Optical coherence tomography measurements of tractional and degenerative lamellar macular hole. (Top) Tractional lamellar macular hole. The widest inner diameter (gray arrows) is the maximum distance between the edges of the hole at the level of the internal limiting membrane. The widest outer diameter (white arrows) is the maximum diameter of the intraretinal schisis. The minimum foveal retinal thickness (black arrows) is the minimum thickness of the retina at the level of the foveal floor. All measure- ments were made on any cut of a given study. (Bottom) Degenerative lamellar macular hole. The widest inner diameter (gray arrows) is the maximum distance between the edges of the hole at the level of the internal limiting membrane. The widest outer diameter (white arrows) is the maximum diameter of the intraretinal cavitation. The minimum foveal retinal thickness (black arrows) is the minimum thickness of the retina at the level of the foveal floor, typically adjacent to the foveal bump. All measurements were made on any cut of a given study.
FIGURE 2. Optical coherence tomography features of tractional and degenerative lamellar macular hole. (Left column) Tractional lamellar macular hole. (Top left) The intraretinal schisis is located between outer nuclear and outer plexiform layers (black star) and is characterized by hyperreflective bridges of tissue across wider hyporeflective spaces. (Middle left) Epiretinal membranes are irreg- ular, thin, and hyperreflective lines above the inner retinal surface. Direct and uniform contact with the underlying retina is not al- ways present and is indicative of traction. Note hyporeflective spaces between the epiretinal membrane and the inner retina (white arrows). (Bottom left) Intraretinal cystoid spaces are visible in the inner plexiform layer of tractional lamellar macular holes as small, well delimited hyporeflective areas distinct from schisis, as seen above (black arrows). (Right column) Degenerative lamellar macular hole. (Top right) The intraretinal cavitation is visible as a wide, homogeneous, hyporeflective area involving layers of the neurosen- sory retina (black star). (Middle right) Lamellar macular hole–associated epiretinal proliferation is visible as homogeneous material with medium reflectivity (white arrows). Note direct, uniform contact between the proliferation and the underlying retina without evidence of traction. (Bottom right) Intraretinal cysts are not typically observed in degenerative lamellar macular hole.
FIGURE 4. Lamellar macular hole and ellipsoid layer status. (Top) Degenerative lamellar macular hole. Disruption of the ellipsoid layer (white arrows) is accompanied by the presence of the lamellar hole–associated epiretinal proliferation (black arrows). A retinal bump of presumably spared tissue is located in the foveal region (gray arrow). (Bottom) Tractional lamellar macular hole. The ellip- soid layer is intact (white arrows) and the schitic separation of the neurosensory retina does not spare the central foveal region (gray arrow).
FIGURE 6. Natural history of tractional and degenerative lamellar macular hole. (Left) Tractional lamellar macular hole. Formation of a tractional lamellar macular hole due to vitreomacular traction. At the end of the follow-up period, the lesion has the typical ‘‘moustache’’ morphology. Images are presented in black on white to enhance the visualization of the vitreous. (Right) Degenerative lamellar macular hole. The presence of epiretinal proliferation and ellipsoid defect is noticeable at early stages of degenerative lamellar macular hole formation, without signs of traction. The pathophysiological process seems slow but progressive, and involves all retinal layers. At the end of the follow-up period, the lesion has the typical ‘‘top hat’’ morphology.
FIGURE 3. Representative en face images at internal limiting membrane (ILM) level (first and second columns), at 10 mm below ILM level (third column), and at approximately the outer nuclear layer level (fourth column), and B-scan images (fifth column). The first row is from a normal subject, and the second to the fifth rows are images of patients from Groups A-D in Figure 2, respec- tively. The white solid and dotted arrows in the second column indicate the location corresponding to the B-scan section of the fifth column. (Top row) A 53-year-old man without eye disease. Epiretinal membrane (ERM) and retinal folds are not observed in en face image or B-scan image. (Second row) A 70-year-old female patient from Group A. ERM (first column) and retinal cleavage (arrow- head in the fourth column) were seen with en face imaging, but retinal folds were not observed. The B-scan image indicates that this case is degenerative LMH with lamellar hole–associated epiretinal proliferation (arrowheads in the fifth column). (Third row) A 73-year-old female patient from Group B. ERM (first column) and retinal folds (arrows in the third column) were found with en face imaging, but retinal cleavage was not observed. The B-scan image indicates that this case is macular pseudohole (MPH) with ERM (arrowheads in the fifth column). (Fourth row) A 74-year-old female patient from Group C. ERM (first column), retinal folds (arrows in the third column), and retinal cleavage (arrowhead in the fourth column) were found by en face imaging. The B-scan image indicates that this case is symmetric tractional LMH with ERM (arrowheads in the fifth column). (Fifth row) A 47-year-old male patient from Group D. Parafoveal epicenter of contractile ERM (PEC-ERM, outlined in the second column), retinal folds (arrows in the third column), and retinal cleavage (arrowhead in the fourth column) were observed by en face imaging. The B-scan image indicates that this case is asymmetric tractional LMH (fifth column upper) when the cross section (the optical coherence tomography [OCT] scan direction is indicated by solid arrow in the second column) passed through the PEC-ERM (arrowhead in the fifth column upper). The cross-section image (the fifth column lower) vertical to the solid arrow (the OCT scan direction is indicated by dotted arrow in the second column) indicates that this case has not only asymmetric tractional LMH but also symmetric tractional LMH.
Paciente mujer de 73 años que presenta un agujero macular lamelar en su ojo ambliope con una agudeza visual de 0,3.
Pueden permanecer estables sin progresión durante años
17/12/18
Figura 3. Paciente varón pseudofáquico de 89 años con pérdida de agudeza visual progresiva en su ojo derecho. A. Muestra un agujero macular lamelar, con presencia de membrana epirretiniana y tejido proliferativo prerretiniano. Se ob- jetivan alteraciones significativas en la retina externa, con pérdida de integridad de membrana limitante externa y una capa elipsoide. B. Se realizó una cirugía mediante vitrectomía 25 G con pelado de membrana epirretiniana y limitante interna y hexafloruro de azufre al 20%. A los seis meses de la cirugía, su agudeza visual era de 0,5; se objetiva un cierre anatómico del agujero, con normalización parcial de la anatomía foveolar y con persistencia de una leve alteración en la retina externa.
El tratamiento quirúrgico de los agujeros maculares lamelares no está exento de riesgo; este factor, unido a la lenta progresión o estabilidad de algunos pacientes, hace ser cauto a la hora de indicar la cirugía.
Una de las complicaciones más temidas es la inducción iatrogéni- ca de un agujero macular de grosor completo. Esta complicación parece ser más frecuente en los agujeros atróficos y aquellos agujeros que asocian tejido proliferativo prerretiniano36.
La presencia o progresión de una catarata es otra de las com- plicaciones más frecuentes de la cirugía del agujero lamelar en particular y de la vitrectomía en general. Algunos autores propo- nen cirugías combinadas, aunque este dato no está del todo bien recogido o estipulado en muchos de los artículos quirúrgicos28. Otras complicaciones descritas son comunes a la cirugía macular, como la presencia de neovascularización coroidea, la presencia de edema macular quístico o complicaciones derivadas de la propia vitrectomía, como la presencia de desgarros en la retina o desprendimiento de retina27,28,36.
