Macular Hole

Fundus photograph of a macular hole with drusen-like yellow deposits and a cuff of subretinal fluid and the corresponding OCT study. 

  • Presents as a full thickness central macular defect or tear.
  • Mostly occurs in elderly women.
  • Mechanism:
    • Idiopathic, spontaneous focal contraction or shrinkage of the prefoveal vitreous.
    • Can be secondary to posterior vitreous separation or severe ocular trauma.

Clinical features:

  • Symptoms:
    • Various degrees of decreased visual acuity
    • Metamorphopsia
  • Signs: depends on the staging of the hole according to Gass's classification.
  • Stage 1: "Impending" macular hole
    • Localized foveal detachment, loss of foveal depression associated with retraction of the retinal receptor (occult hole) and the presence of yellowish macular spot or ring
    • Fine radiating retinal striae may be observed
    • Visual acuity usually better than 20/50
  • Stage 2: Small hole begins to develop (<400 µ)
    • A 360-degree can-opener type hole may develop
    • The hole may be covered by an overlying pseudo-operculum (pre-foveal opacity) which usually larger than the hole
    • Visual acuity is in the 20/50 - 20/80 range
  • Stage 3: Larger macular hole (>400 µ)
    • Pseudo-operculum may still present
    • Often has a cuff of subretinal fluid
    • Drusen-like deposits may be seen at the base of the hole
    • Mean visual acuity : 20/200
  • Stage 4: Complete separation of the vitreous from the entire macular surface and optic disc
  • Fluorescein angiography in patients starting from stage 2 typically demonstrates early hyperfluorescence in the area of the hole
  • Optical coherence tomography has proven to be extremely helpful in the diagnosis of macular hole

Management:

  • Pars plana vitrectomy
  • Intravitreal gas tamponade
  • Epiretinal membrane peeling