Macular Hole

Consensus OCT-based definitions for Lamellar macular hole.{Hubschman JP, Govetto A, Spaide RF, Schumann R, Steel D, Figueroa MS, Sebag J, Gaudric A, Staurenghi G, Haritoglou C, Kadonosono K, Thompson JT, Chang S, Bottoni F, Tadayoni R. Optical coherence tomography-based consensus definition for lamellar macular hole. Br J Ophthalmol. 2020 Dec;104(12):1741-1747.}

Mandatory criteriae:

• Lamellar macular hole:
  • presence of irregular foveal contour
  • presence of a foveal cavity with undermined edges
  • apparent loss of foveal tissue
• Epiretinal membrane foveoschisis
  • presence of ERM
  • presence of schisis at the level of Henle’s fibre layer
• Macular pseudohole
  • presence of a foveal sparing ERM
  • presence of a steepened foveal profile
  • increased central retinal thickness

International Vitreomacular Traction Study (IVTS) Group anatomic OCT-based classification system definitions:{Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, Sadda SR, Sebag J, Spaide RF, Stalmans P. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013 Dec;120(12):2611-2619.}

• Vitreomacular adhesion: perifoveal vitreous separation with remaining vitreomacular attachment and unperturbed foveal morphologic features.
• Vitreomacular traction: anomalous posterior vitreous detachment accompanied by anatomic distortion of the fovea, which may include pseudocysts, macular schisis, cystoid macular edema, and subretinal fluid.
  • Focal: Vitreous attachment to macular surface 1500 μm or less
  • Broad: Vitreous attachment to macular surface more than 1500 μm
• Full-thickness macular hole: a foveal lesion with interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium.

Vitrectomy is effective in improving visual acuity, resulting in a moderate visual gain, and in achieving hole closure in people with idiopathic macular hole.{Parravano M, Giansanti F, Eandi CM, Yap YC, Rizzo S, Virgili G. Vitrectomy for idiopathic macular hole. Cochrane Database Syst Rev. 2015 May 12;2015(5):CD009080.}

Internal limiting membrane peeling during macular hole surgery reduces the likelihood of macular hole reopening; The reopening rate without ILM peeling was 7.12% compared with 1.18% with ILM peeling.{Rahimy E, McCannel CA. IMPACT OF INTERNAL LIMITING MEMBRANE PEELING ON MACULAR HOLE REOPENING: A Systematic Review and Meta-Analysis. Retina. 2016 Apr;36(4):679-87.}

The inverted flap technique is more effective than internal limiting membrane peeling in achieving Macular Hole (MH) closure (risk-ratio: 1.25), including in all subgroups: idiopathic large MH, myopic MH without retinal detachment, and MH retinal detachment.{Marques RE, Sousa DC, Leal I, Faria MY, Marques-Neves C. Complete ILM Peeling Versus Inverted Flap Technique for Macular Hole Surgery: A Meta-Analysis. Ophthalmic Surg Lasers Imaging Retina. 2020 Mar 1;51(3):187-A2.}

Of 130 patients undergoing autologous retinal transplantation (ART) for the repair of primary and refractory macular holes (MHs) and combined MH-rhegmatogenous retinal detachment (MH-RRD), 89% of MHs closed, with a 95% closure rate in MH-RRD. Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes.{Moysidis SN, Koulisis N, Adrean SD, Charles S, Chetty N, Chhablani JK, Cortes JC, Embabi SN, Gordon C, Gregori NZ, Habib A, Hamza H, Hassaan H, Hassan TS, Houghton O, Kadonosono K, Kusaka S, La Mantia A, Lai CC, Lumi X, Maeno T, Mahgoub MM, Mohamed El Baha S, Morales-Cantón V, Nowara M, Okonkwo ON, Parolini B, Rezende FA, Rogalinska I, Rojas S, Steel DH, Stopa M, Wu AL, Yamada K, Yamada M, Mahmoud TH. Autologous Retinal Transplantation for Primary and Refractory Macular Holes and Macular Hole Retinal Detachments: The Global Consortium. Ophthalmology. 2021 May;128(5):672-685.}

Facedown positioning following large full-thickness macular hole surgery is more likely to achieve closure compared with facing forward, but do support the possibility that visual acuity outcomes may be superior.{Pasu S, Bell L, Zenasni Z, Lanz D, Simmonds IA, Thompson A, Yorston D, Laidlaw DAH, Bunce C, Hooper R, Bainbridge JWB; Positioning In Macular Hole Surgery (PIMS) Study Group. Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole: A Multicenter Randomized Clinical Trial. JAMA Ophthalmol. 2020 Jul 1;138(7):725-730.}

Postoperative face-down posturing could generally improve the overall MH closure rate compared to nonsupine posturing (odds ratio 1.828).{Xia S, Zhao XY, Wang EQ, Chen YX. Comparison of face-down posturing with nonsupine posturing after macular hole surgery: a meta-analysis. BMC Ophthalmol. 2019 Jan 28;19(1):34.}

There is insufficient evidence from which to draw firm conclusions about the impact of postoperative face-down positioning on the outcome of surgery for macular hole.{Solebo AL, Lange CA, Bunce C, Bainbridge JW. Face-down positioning or posturing after macular hole surgery. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD008228.}

Reoperation for idiopathic full-thickness macular hole that failed to close or reopened achieved a clinically meaningful visual acuity improvement in more than half of patients; high levels of vision (≥6/12), however, were uncommon.{Reid GA, McDonagh N, Wright DM, Yek JTO, Essex RW, Lois N. FIRST FAILED MACULAR HOLE SURGERY OR REOPENING OF A PREVIOUSLY CLOSED HOLE: Do We Gain by Reoperating?-A Systematic Review and Meta-analysis. Retina. 2020 Jan;40(1):1-15.}

In most eyes with VMT, pneumatic vitreolysis (PVL) induced hyaloid release. In eyes with FTMH, PVL resulted in hole closure in approximately one third of eyes. These studies were terminated early because of safety concerns related to retinal detachments and retinal tears.{Chan CK, Mein CE, Glassman AR, Beaulieu WT, Calhoun CT, Jaffe GJ, Jampol LM, MacCumber MW, Maguire MG, Maturi RK, Salehi-Had H, Rofagha S, Sun JK, Martin DF; DRCR Retina Network. Pneumatic Vitreolysis with Perfluoropropane for Vitreomacular Traction with and without Macular Hole: DRCR Retina Network Protocols AG and AH. Ophthalmology. 2021 Nov;128(11):1592-1603.}