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