An extraordinary presentation ,....

3.  MACULA : Round yellow area at posterior
pole 5.5 mm size – 3 mm temporal
1 mm inferior to disc

4. Fovea - 1.5 mm wide , thin bottom- 22” clivity
thick basement margin
- prone for macular holes
-Henle’s layer-oblique cones
Foveola - 0.35 mm wide , thin pit , Densely cones
Bowing vitreally- fovea externa
Umbo - Tiny depression - Foveal light reflex
0.15 mm - bouquet of cones - narrowed
gateau nucleaire

5.  A dehiscence in the Retina at the location of
Fovea.
 In Lamellar hole - some layer are intact
 Full thickness hole - RPE exposed

6.  Older female patients
 Younger Myopic patients
 Post Traumatic
 Chronic cystoid macular edema
 Associated with Retinal detachment
 Inadvertent exposure to laser therapy

7.  Loss of Central Vision
 Central Scotoma
 Metamorphospia

8.  Oblique/anteroposterior traction via a persistent
vitreofoveolar attachment following perifoveal vitreous
separation.
 Tangential vitreoretinal traction.

9.  Stage O – Premacular hole
- Perifoveal vitreous detachment
- Loss of foveal depression
- Subtle macular topograph changes
- Normal visual acuity

10.  Stage 1a: ‘Impending’ macular hole
- flattening of the foveal depression with an underlying
yellow spot.
- Pseudocyst – a perifoveal vitreoretinal detachment
Pathology: inner retinal layers detach from the
underlying photoreceptor layer, with the formation of
a schisis cavity.

11.  Stage 1b: Occult macular hole
Signs: a yellow ring with metamorphopsia or a mild
decrease in visual acuity.
- Progression of pseudocyst to outer foveal layer
separation
Pathology: loss of structural support with centrifugal
displacement of photoreceptors.

12.  Stage 2: Small /Early full-thickness hole
Signs: full-thickness hole < 400 µm in diameter
The defect may be central, eccentric or crescent-shaped.
Pseudo operculum – prefoveal cortical vitreous
contraction
Pathology: a dehiscence develops in the roof [inner
layer]of the schitic cavity, often with persistent
vitreofoveolar adhesion.

13.  Stage 3: Full-size /Established macular hole
Signs: full-thickness hole > 400 µm in diameter
red base with yellow-white dots seen.
Surrounding grey cuff of subretinal fluid
Pathology: Avulsion of the roof of the cyst with an
operculum and persistent parafoveal and optic disc
attachment of the vitreous cortex.

14.  Stage 4: Full-size macular hole with complete PVD
Pathology: the posterior vitreous is completely
detached, often suggested by the presence of a Weiss ring.

17.  Fluorescein Angiography
Hyperfluorescence -transmission defect (RPE
atrophy)
 OCT
Evaluation of retinal thickness and staging of macular
hole.

19. 

20.  Watzke Allen test
On projecting a thin slit beam of light on to the
macula ,a broken or thinned out appearance is
poistive.
 Laser aiming beam test
A spot of laser beam of 50 microns when projected on
macula has disappeared.

21.  Surgery not recommended in stage 1  50 % chance
of spontaneous resolution .
 Stage 3 and 4 with visual acuity < 6/18 require surgery
 Contraindications for surgery
- Coexisting choroidal rupture
- Traumatic RPE rupture
- Chronic Cystoid macular edema
- Optic nerve disorders

22. 
Pars Plana Vitrectomy

Anaesthesia is local or general .

Conjunctival peritomy is done.

Three sclerotomies in superotemporal ,superonasal and
inferotemporal at 3.5 mm from limbus .

Induction of Posterior vitreous detachment by suction of cutter
, suction cannula or forceps close to disc.

Use of intravitreal triamcinolone acetonide for improving
visualization.

23.  Internal gas tamponade :
A non expansile mixture of C3F8 and air is used and
patient lie down in prone for 14 hours for first 10 days .
 Internal Limiting Membrane (ILM) Peeling :
Stains like trypan blue , Brilliant blue , ICG
, Triamcinolone acetonide to improve visualization
of ILM.
Special forceps to grasp ILM membrane in a circular
fashion around macular hole for 2 disc diameters.

24.  Cataract formation
 Iatrogenic retinal breaks
 Rhegmatogenous retinal detachment
 Transient rise in Intraocular pressure.

25.  Following a macular pucker , there is a centripetal pull
of the inner sides of epiretinal membrane – resembles
Macular hole.

26.  Partial thickness macular hole where the inner layers
of fovea are involved with traction and detached from
underlying cellular layers.

28. 


Gass Atlas of Macular diseases by Anita Agarwal
American Academy of Ophthalmology , Vol 12 ,
Retina and Vitreous
Kanski ,Clinical Ophthalmology , a Systemic Approach
7 th edition