Macular Hole Clinical Presentation
- Author: Kean Theng Oh, MD; Chief Editor: Hampton Roy, Sr, MD more...
Patients with idiopathic macular holes present with a variety of symptoms.
Initial symptoms include blurred central vision or metamorphopsia. Patients may characterize these symptoms as being mild and only apparent when reading or driving. Because the initial changes may be mild and gradual, it may be some time before the patient discovers that something is wrong with their vision. Macular holes may only be discovered when patients cover one eye and notice blurred vision and metamorphopsia in the opposite eye.
Rarely, some patients may describe the exact moment at which the hole developed, but more commonly, they describe the onset as slow and gradual if at all noticeable.
Later, a larger macular hole may produce a central defect, or scotoma, in the central vision of the patient.
Some patients may be asymptomatic, and the hole is diagnosed only on routine ophthalmologic examination.
The visual acuity of the patient varies according to the size, location, and the stage of the macular hole. Patients with small, eccentric holes may retain excellent visual acuity in the range of 20/25 to 20/40. In addition, a macular hole that is not full thickness can have very good visual acuity in the range of 20/30 to 20/50. However, once a macular hole is well developed or full thickness, the usual range of visual acuity is from 20/80 to 20/400, averaging at 20/200.
A full-thickness macular hole visualized with direct ophthalmoscopy is characterized by a well-defined round or oval lesion in the macula with yellow-white deposits at the base. These yellow dots probably represent lipofuscin-laden macrophages or nodular proliferations of the underlying pigment epithelium with associated eosinophilic material as shown below.
Biomicroscopic (slit lamp) examination
With biomicroscopic (slit lamp) examination, a round excavation with well-defined borders interrupting the beam of the slit lamp can be observed.
In most patients, an overlying semitranslucent tissue, representing the pseudo-operculum, can be seen suspended over the hole. There is often a surrounding cuff of subretinal fluid as depicted below.
Cystic changes of the retina also may be evident at the margins of the hole. The retinal pigment epithelium is usually intact and normal in acute stages but may undergo chronic changes, such as atrophy and hyperplasia, with time.
Fine crinkling of the inner retinal surface caused by an epiretinal membrane may be present and sometimes may even distort the appearance of the hole.
Watzke-Allen and the laser aiming beam tests
The most useful diagnostic tests for ophthalmologists to distinguish full-thickness macular holes from other lesions are the Watzke-Allen and the laser aiming beam tests.
The Watzke-Allen test is performed at the slit lamp using a macular lens and placing a narrow vertical slit beam through the fovea. A positive test is elicited when patients detect a break in the bar of light that they perceive. This reaction is due to the fact that there is a lack of retinal material in the area of the hole, thus producing a central defect or scotoma. Narrowing or distortion of the bar of light is not diagnostic of full-thickness macular holes and should be interpreted with caution.
The laser aiming beam test also is performed similarly, but this time a small 50-µm spot size laser aiming beam is placed within the lesion. A positive test is obtained when the patient fails to detect the aiming beam when it is placed within the lesion but is able to detect it once it is placed onto normal retina.
In addition, some slit lamps are equipped with a setting to project a small test object, often a star, onto the fovea. Again, the patient is asked whether they perceive the test object.
Of patients experiencing a contusion injury of the eye, 6% develop a macular hole following the trauma.
Trauma is also commonly associated with commotio retinae involving the macula, subretinal hemorrhage, and intraretinal hemorrhage.
Progressive high myopia (foveal schisis)
Patients with high myopia may develop foveal schisis and/or lamellar holes, which can progress to a full-thickness macular hole.
Of those patients in whom foveal schisis identified, 31% developed macular holes.
Tanaka et al reviewed 24 eyes of 21 consecutive patients with lamellar holes and high myopia. Over a mean follow-up of 19.2 months, these lamellar macular holes remained very stable; only one eye progressed to a full-thickness macular hole.
Risk factors include axial eye length, macular chorioretinal atrophy, and vitreoretinal interface factors.
Preceding rhegmatogenous retinal detachment
Less than 1% of patients with a successfully repaired rhegmatogenous retinal detachment will present with a subsequent macular hole.
Vitreoretinal traction theory (idiopathic macular holes)
Vitreous syneresis results in shrinkage of cortical vitreous and traction on the fovea.
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