Macular Hole Follow-up
- Author: Kean Theng Oh, MD; Chief Editor: Hampton Roy, Sr, MD more...
Further Outpatient Care
Because complications, such as cataracts and retinal detachment, can follow treatment for macular holes, regular examinations are necessary.
Surgical complications include retinal detachments, iatrogenic retinal tears, enlargement of the hole, macular light toxicity, postoperative pressure elevation, and cataractogenesis.
Postoperative pressure elevation usually can be treated pharmacologically but may sometimes require an anterior chamber or vitreous tap.
Failure of hole closure/hole reopening
Histopathologic evaluation of specimens from patients with failed initial macular hole surgery demonstrated massive proliferation of cells and newly formed collagen associated with remaining ILM. The residual ILM and the associated collagen fibrils may become the source of persistent traction that prevents macular hole closure.
Retinal detachment/iatrogenic tears
The rate of postoperative retinal detachment is reported from 2-14%. Chung et al identified that the induction of a posterior vitreous detachment during surgery was a key risk factor for the development of iatrogenic retinal breaks. They found an overall incidence of 14.6% (20 of 137 eyes) for retinal breaks. Only one retinal break (3.1%) was identified in a macular hole patient who did not require the induction of a PVD. However, only 32 of 137 eyes undergoing vitrectomy for macular hole surgery did not require this step in the procedure, owing to the underlying pathophysiology of macular holes.
Visual field defects
Visual field defects have been noted following macular hole surgery.
They are related to dehydration of the nerve fiber layer.
The rate is reduced by shorter surgical times, lower air flow, and oblique placement of infusion cannulas caused by beveled incisions of smaller gauge vitrectomies.
There is a small risk of hole reopening in the immediate postoperative period following cataract surgery.
Consideration of prophylaxis versus cystoid macular edema may reduce the risk of hole reopening after cataract surgery.
A retrospective case series by Bhatnagar et al (2007) suggest that prior or simultaneous cataract extraction may carry a better long-term visual prognosis than cataract extraction following macular hole repair due to the risk of reopening of the hole following cataract surgery.
In 1994, Wendel reported a series of 235 consecutive eyes undergoing repair of macular holes. In this series, 93% of patients were successfully managed with only a single operation; 60% patients experienced 4+ lines of visual improvement; and 84% patients experienced 2+ lines of improvement. Within this group, 58% of patients achieved 20/40 or better final visual acuity.
Multiple other studies cite similar success rates, though vision recovery may be protracted and also further delayed by onset of cataract formation. Use of ILM peeling may further increase the rate of single operation success, though it may potentially slow or affect final vision recovery. See Controversies surrounding the surgical repair of macular holes.
OCT imaging preoperatively and postoperatively has provided additional prognostic data for visual recovery following macular hole surgery. Factors on OCT predictive of good visual acuity macular hole surgical outcome are as follows:
Size of macular hole (minimum diameter < 311 µm)
Traction on macular hole edges as defined by various parameters (eg, macular hole height)
Development of a normal photoreceptor inner segment and outer segment junction, which can occur as early as 1 month postoperatively but typically by 6 months postoperatively as shown in the images below.
While surgery for macular holes is considered elective, it is important for the patient to consider prognostically that there is potentially a risk for the fellow eye to develop a macular hole as well (12%).
Older individuals should be educated on the necessity of a yearly eye examination since early symptoms of a macular hole can easily go undetected by the patient.
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