1. MACULAR HOLE
Nawat Watanachai
Orn (จำำนำมสกุลใหม่ไม่ได้)
Ramathibodi Hospital

2. INTRODUCTION
- Macular Hole (MH) is a full-thickness
depletion of the neural tissue in the center
of the macula that result in visual loss

3. History
1869 : Herman Knapp :
initial published
description of MH

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)

9. Pathogenesis

10. Pathogenesis
 Unknown in
traumatic MH
 tangential vit
traction
 retinal necrosis?
 Estrogen?
 Elevated serum
fibrinogen levels
(EDCCS)

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

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

18. MH stage IV

19. HISTOPATHOLOGY
- MH is the full thickening circular retinal
defect at fovea
- size 100 – 800 micron
- operculum composed of ILM, Mueller
cell cone, superficial inner cone fiber and
cone nuclei.

21. CLINICAL AND DIAGNOSIS
 VA loss
20/80 – 20/400
mean 20/200
 Central scotoma / Amsler grid
 metamorphopsia

22. CLINICAL AND DIAGNOSIS
• Watzke – Allen test ( WAT )
• laser aiming beam test ( LAM )

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

25. traumatic MH

26. traumatic MH

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

28. 3.
LASER
- LASER eg. Argon, dye laser, Xenon,
Krypton, YAG
- Thermal pigment absorption

29. LASER

30. LIGHTNING

31. 4. ELECTRIC CURRENT
- electric current can cause of
cataract by current pass to the eye
- study ; 2 from 159 electric burn
patient develop MH

32. 5. ORTHERS
- pilocarpine
- Best’s disease
- intravitreous ceftazidime
- Alport
- Von Hippel

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

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

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

43. 3. PARTIAL THICKNESS HOLE
- outer lamella hole (OLH )
- inner lamella hole ( ILH )

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

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

51. Treatment
Kelly and Wendel
1991
concepts
release traction force
re-position the
displaced neural
tissue

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

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

56. 4. Adjuvant
- growth factor B2, collagen plug,
thrombin – activated fibrinogen, thrombin
autologous platlet concentration,
autologous serum
- endolaser

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

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

60. Other alternatives
macular buckle
minimal vitrectomy (Rick Spaide)
pharmacological vitreolysis eg plasmin,
hyaluronidase, TPA, urokinase,
plasminogen
RPE laser treatment

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

62. Anatomical outcome
1. elevate/oper - failed surgical
2. flat/open - VA rarely better than
20/50
3. flat/close - VA > 20/30

65. COMPLICATIONS
 cataract 70% in 2 yrs
 RD 2 – 11%
 ERM
 Periphery iatrogenic retinal break 5.5 %
 VF defect ( temporal wedge)
 Increase IOP
 RPE change
 Endophthalmitis < 1 : 1000
 Ulnar neuropathy

66. THANK YOU