Macular Hole Treatment & Management
- Author: Kean Theng Oh, MD; Chief Editor: Hampton Roy, Sr, MD more...
Case reports exist that describe the use of autologous plasmin for idiopathic and traumatic macular holes. Ongoing clinical trials are evaluating the role of plasmin as a means of “chemovitrectomy.” In these studies, case illustrations have demonstrated resolution of idiopathic macular holes following intravitreal injection of plasmin and no surgical intervention.
In October 2012, ocriplasmin (Jetrea) was approved by the US Food and Drug Administration (FDA) for the treatment of vitreomacular adhesion. Ocriplasmin is a recombinant proteolytic enzyme that underwent study by the MIVI-TRUST study group. This protease demonstrated activity against fibronectin and laminin. In a randomized, double-blind study, 652 eyes with vitreomacular adhesion were treated with an intravitreal injection of ocriplasmin. A secondary endpoint of the study was nonsurgical closure of a full-thickness macular hole, which can result from vitreomacular adhesion. In the study, 40.6% of treated eyes experienced nonsurgical closure of the macular hole compared to 10.6% in the placebo group (P< 0.001). FDA approval was based on this study. This injectable medication provides a nonsurgical means of treating macular holes.
There are concerns with the potential for retinal toxicity from the use of ocriplasmin (See Medication below).
The potential for better vision, as well as the 12% chance that the fellow eye will develop another macular hole, has prompted ophthalmologists to seek for a viable treatment of this condition.
Indications for consideration of the surgical management of macular holes are based on the presence of a full-thickness defect. Once this defect has developed, the potential for spontaneous resolution is low. Thus, surgical management is recommended with documentation of a stage 2 or higher, full-thickness macular hole. Stage 1 holes and lamellar holes are managed conservatively with observation at this time. See Controversies surrounding the surgical repair of macular holes.
Historically, therapy for macular holes has evolved from pharmacologic interventions, such as anxiolytics and vasodilators, to an assortment of surgical techniques, such as cerclage, scleral buckles, direct photocoagulation of the hole edges, and intraocular gas tamponade without the aid of vitrectomy. In 1982, Gonvers and Machemer were the first to recommend vitrectomy, intravitreal gas, and prone positioning for retinal detachments secondary to macular holes.
Kelly and Wendel reported that vision might be stabilized or even improved if it were possible to surgically relieve tangential traction on the macula, reduce the cystic changes, and reattach the cuff of detached retina surrounding the macular hole. They proposed that by performing this surgery, they could flatten the retina and possibly reduce the adjacent cystic retinal changes and neurosensory macular detachment.
In 1991, Kelly and Wendel demonstrated that vitrectomy, removal of cortical vitreous and epiretinal membranes, and strict face-down gas tamponade could successfully treat full-thickness macular holes. The overall results of their initial report were a 58% anatomic success rate and visual improvement of 2 or more lines in 42% of eyes. A succeeding report showed a 73% anatomic success rate and 55% of patients improving 2 or more lines of visual acuity. Present anatomic success rates range from 82-100% depending on the series.
A prospective, randomized, and controlled series by the Vitrectomy for Treatment of Macular Hole Study Group for stage 2, 3, and 4 holes showed that vision was improved in surgically treated eyes compared with observed eyes. However, more frequent adverse effects were observed in the surgically treated eyes compared to the control eyes, with the most common adverse effects being macular retinal pigment epithelium changes and cataractogenesis.
Some aspects of the surgery may vary, but the basic technique is the same. The anterior and middle vitreous is removed via a standard 3-port pars plana vitrectomy. Patients with macular hole frequently undergo vitrectomy using smaller gauge vitrectomy systems (ie, 27 gauge, 25 gauge, 23 gauge). Associated instruments have been developed for these smaller gauge, transconjunctival vitrectomy systems.
The critical step appears to be the removal of the perimacular traction. Factors contributing to this traction, such as the posterior hyaloid, the ILM, and coexisting epimacular membranes, need to be addressed. The traction exerted by the posterior hyaloid on the macula should be relieved by either removing just the perimacular vitreous or combining it with the induction of a complete posterior vitreous detachment. Various surgical techniques have been described to accomplish this task, including the use of a soft-tipped silicon cannula or the vitrectomy cutter with the cutter disengaged. A "fish-strike sign" or bending of the silicon cannula has been described as a sign that the posterior hyaloid has been engaged. Then, it may be released from the underlying retina and removed with the vitrectomy cutter.
The removal of ILM is considered to be a contributing factor in the success of macular hole surgeries. Its removal is also associated with a reduced risk of subsequent reopening of the macular hole. ILM peeling may be accomplished via a "rhexis" not unlike that of a capsulorrhexis in lens surgeries. Very fine forceps may be used to peel the ILM from the underlying retina. Care should be taken not to include the deeper layers in the forceps' grasp, which may further damage the surrounding retinal tissues. Currently, many surgeons use indocyanine green dye to stain the ILM making it easier to visualize and manipulate.
Epiretinal membranes, if present, also should be removed. Techniques in completing this procedure vary from surgeon to surgeon.
After careful indirect ophthalmoscopic examination of the peripheral retina for tears, a total air-fluid exchange is performed to desiccate the vitreous cavity. A nonexpansile concentration of a long-acting gas is exchanged for air. Studies have shown that a longer period of internal tamponade equated to a higher success rate.
Sterile air and varying concentrations of either perfluoropropane or sulfur hexafluoride have been used based on surgeon preference for internal tamponade. The primary difference achieved using different gases is the duration of the gas bubble and, consequently, the amount of internal tamponade achieved within the first several days after surgery. Silicone oil has also been used as an internal tamponade for patients with difficulty positioning or altitude restrictions. However, the use of silicone oil necessitates a second subsequent surgery to remove the oil. Furthermore, the visual results are not comparable to the use of gas tamponade, possibly as a result of silicone oil toxicity at the level of the photoreceptors and RPE.
Tafoya et al showed, at 1 year, a final postoperative visual acuity difference of 20/96 (LogMAR 0.208) for silicone oil eyes versus 20/44 (LogMAR 0.453) for gas treated eyes. Lai et al also showed the visual acuity advantage of gas tamponade with a smaller difference (20/70 vs 20/50). However, Lai et al also showed the rate of single operation closure being only 65% for silicone oil and 91% for gas tamponade. Thus, unless limited by patient circumstances, gas tamponade for macular hole repair is preferable to silicone oil tamponade.
Controversies surrounding the surgical repair of macular holes
20-gauge versus 23-gauge versus 25-gauge vitrectomy systems
While no one system poses a significant long-term advantage, smaller gauge vitrectomy systems, with frequently self-sealing wounds, avoid induced astigmatism from suturing sclerotomies, resulting in a more rapid recovery of vision.
An initial increase in endophthalmitis appears to have been addressed by changing the means of wound construction but may still be considered a disadvantage to small gauge vitrectomy systems.
Smaller-gauge vitrectomy systems, such as 27-gauge and 25-gauge systems, lack shaft stiffness because of the smaller barrel and may also complicate the actual vitrectomy surgery for surgeons trained using 20-gauge systems.
Internal limiting membrane (ILM) peeling
ILM peeling increases the rate of hole closure 93-100%.
The rate of visual recovery was postulated to be slowed by ILM peeling, but no recent literature supports this assertion (see next bullet point).
Spiteri-Cornish et al compared peeling with not peeling ILM in a meta-analysis of 4 randomized controlled trials. The results demonstrated an effect favoring ILM peeling for macular hole closure and final visual acuity. The analysis did not identify any difference in the rate of recovery. The benefit of ILM peeling became evident even by 3 months postoperatively.
Use of vital dyes
Indocyanine green (ICG) dye was the first vital dye used for macular surgery. There is considerable literature questioning the toxicity of ICG dye to the retina and retinal pigment epithelium (RPE). Despite the laboratory science and literature cautioning the use of ICG dye, an equal amount of literature documented good surgical and visual results. ICG dye is still used by surgeons with care taken to limit the exposure of the retina and, potentially more importantly, the RPE to the dye.
Trypan blue has also been used to stain the ILM without the literature suggesting toxicity. On the other hand, trypan blue does not appear to stain the ILM as effectively as ICG dye.
Triamcinolone acetonide has also been used to facilitate peeling of the ILM. As of 2008, it is the only surgical adjunct to peeling of the ILM that is FDA approved for use in the eyes.
Management of lamellar holes
Lamellar holes cause symptoms but minimal loss of central visual acuity. Management has historically been conservative.
Surgical intervention has been undertaken with vision loss or patient symptomology with the recent advances in small gauge vitrectomy and further experience with ILM peeling.
Garretson et al reported a series of successfully repaired lamellar macular holes, wherein 93% eyes demonstrated improved visual acuity. The mean improvement was 3.2 Snellen lines.
Historically, strict face-down positioning had been recommended for patients for up to 4 weeks, with consequent difficulties of compliance and patient quality of life during that period.
More evaluation placed into shorter periods of face-down positioning, though, traditionally, it has been believed that the shorter the period of face-down positioning, the lower the rate of successful hole closure. In 1997, Tournambe et al described a pilot study of patients without face-down positioning. They reported a success rate with one surgery of 79% and suggested that pseudophakia was necessary for consideration of liberalization of positioning requirements.
The advent of ILM peeling has encouraged a second look at minimal to no face-down positioning. Rubinstein et al described a case series of 24 eyes of patients who underwent ILM peeling and then did not position postoperatively. In this case series, 22 eyes were successfully closed and had visual improvement with both eyes that failed being stage 4 large holes.
Others have reported comparable, if not better, results in patients with only 1 day of positioning. Dhawahir-Scala et al suggests that a critical factor is the size of the gas bubble on postoperative day 1 being greater than 70%. Tranos et al showed, however, that there may be more rapid progression of cataract formation with less face-down positioning. Tranos et al were among several authors who recommended combined phacovitrectomy for phakic patients to allow less stringent positioning requirements. Iezzi and Kapoor reported a series of 68 eyes that underwent macular hole repair with broad ILM peeling and SF6 tamponade without any face-down positioning. They reported a 100% rate of closure with a single procedure.
Alberti and Ia Cour compared face-down positioning with nonsupine positioning and found equivalent macular hole closure rates and noninferiority of nonsupine positioning. However, they also identified that gas fill in nonsupine positioning correlated with macular hole closure.[18, 19] These authors used perfluoropropane and ILM peeling in their study.
A different study assessed face-down positioning and withholding face-down positioning, as well as using a shorter-acting gas such as sulfurhexafluoride. These authors determined that withholding face-down positioning (essentially nonsupine positioning) was noninferior to face-down positioning and that sulfurhexafluoride was noninferior to perfluoropropane. However, when they looked more carefully at their data, they identified risk factors for lowered macular hole closure success, including hole size larger than 400 microns, no ILM peeling, older age of patient, and hole duration of greater than 9 months. They cautioned withholding face-down positioning based on their results.
The use of pharmacologic adjuncts, such as a transforming growth factor-beta (TGF-beta) and autologous serum, to facilitate hole closure has not been proven to have any added benefit as compared to controls such that their use has not gained much popularity.
Morizane et al reported a series of 10 patients with refractory macular holes who were managed with autologous transplantation of ILM. These eyes represented eyes that did not respond to initial surgery with standard ILM peeling or other modifying conditions such as myopic foveoschisis or trauma. All eyes responded to this procedure.
Lister W. Holes in the retina and their clinical significance. Br J Ophthalmol. 1924. 8:1-20.
Johnson RN, Gass JD. Idiopathic macular holes. Observations, stages of formation, and implications for surgical intervention. Ophthalmology. 1988 Jul. 95(7):917-24. [Medline].
Steel DH, Lotery AJ. Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment. Eye (Lond). 2013 Oct. 27 Suppl 1:S1-21. [Medline].
Tanaka Y, Shimada N, Moriyama M, Hayashi K, Yoshida T, Tokoro T, et al. Natural history of lamellar macular holes in highly myopic eyes. Am J Ophthalmol. 2011 Jul. 152(1):96-99.e1. [Medline].
Ciardella AP, Lee GC, Langton K, Sparrow J, Chang S. Autofluorescence as a novel approach to diagnosing macular holes. Am J Ophthalmol. 2004 May. 137 (5):956-9. [Medline].
Stalmans P, Benz MS, Gandorfer A, Kampik A, Girach A, Pakola S, et al. Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med. 2012 Aug 16. 367(7):606-15. [Medline].
Gonvers M, Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthalmol. 1982 Oct. 94(4):468-72. [Medline].
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991 May. 109(5):654-9. [Medline].
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. [Medline].
Tafoya ME, Lambert HM, Vu L, et al. Visual outcomes of silicone oil versus gas tamponade for macular hole surgery. Semin Ophthalmol. 2003 Sep. 18(3):127-31. [Medline].
Lai JC, Stinnett SS, McCuen BW. Comparison of silicone oil versus gas tamponade in the treatment of idiopathic full-thickness macular hole. Ophthalmology. 2003 Jun. 110(6):1170-4. [Medline].
Spiteri Cornish K, Lois N, Scott NW, Burr J, Cook J, Boachie C, et al. Vitrectomy with Internal Limiting Membrane Peeling versus No Peeling for Idiopathic Full-Thickness Macular Hole. Ophthalmology. 2014 Mar. 121(3):649-55. [Medline].
Garretson BR, Pollack JS, Ruby AJ, et al. Vitrectomy for a symptomatic lamellar macular hole. Ophthalmology. 2008 May. 115(5):884-886.e1. [Medline].
Rubinstein A, Ang A, Patel CK. Vitrectomy without postoperative posturing for idiopathic macular holes. Clin Experiment Ophthalmol. 2007 Jul. 35(5):458-61. [Medline].
Dhawahir-Scala FE, Maino A, Saha K et al. To posture or not to posture after macular hole surgery. Retina. 2008. 28:60-5.
Tranos PG, Peter NM, Nath R, et al. Macular hole surgery without prone positioning. Eye. 2007 Jun. 21(6):802-6. [Medline].
Iezzi R, Kapoor KG. No face-down positioning and broad internal limiting membrane peeling in the surgical repair of idiopathic macular holes. Ophthalmology. 2013 Oct. 120(10):1998-2003. [Medline].
Alberti M, la Cour M. NONSUPINE POSITIONING IN MACULAR HOLE SURGERY: A Noninferiority Randomized Clinical Trial. Retina. 2016 Apr 4. [Medline].
Alberti M, la Cour M. Face-down positioning versus non-supine positioning in macular hole surgery. Br J Ophthalmol. 2015 Feb. 99 (2):236-9. [Medline].
Essex RW, Kingston ZS, Moreno-Betancur M, Shadbolt B, Hunyor AP, Campbell WG, et al. The Effect of Postoperative Face-Down Positioning and of Long- versus Short-Acting Gas in Macular Hole Surgery: Results of a Registry-Based Study. Ophthalmology. 2016 Feb 23. [Medline].
Morizane Y, Shiraga F, Kimura S, Hosokawa M, Shiode Y, Kawata T. Autologous transplantation of the internal limiting membrane for refractory macular holes. Am J Ophthalmol. 2014 Apr. 157(4):861-869.e1. [Medline].
Singh RP, Li A, Bedi R, Srivastava S, Sears JE, Ehlers JP. Anatomical and visual outcomes following ocriplasmin treatment for symptomatic vitreomacular traction syndrome. Br J Ophthalmol. 2014 Mar. 98(3):356-60. [Medline].
Tibbetts MD, Reichel E, Witkin AJ. Vision Loss After Intravitreal Ocriplasmin: Correlation of Spectral-Domain Optical Coherence Tomography and Electroretinography. JAMA Ophthalmol. 2014 Feb 27. [Medline].
Fahim AT, Khan NW, Johnson MW. Acute Panretinal Structural and Functional Abnormalities After Intravitreous Ocriplasmin Injection. JAMA Ophthalmol. 2014 Feb 27. [Medline].
Chung SE, Kim KH, Kang SW. Retinal breaks associated with the induction of posterior vitreous detachment. Am J Ophthalmol. 2009 Jun. 147(6):1012-6. [Medline].
Bhatnagar P, Kaiser PK, Smith SD, et al. Reopening of previously closed macular holes after cataract extraction. Am J Ophthalmol. 2007 Aug. 144(2):252-9. [Medline].
Wendel RT, Patel AC, Kelly NE. Chapter 120: Macular Hole Surgery. Guyer DR, Yannuzzi LA, Chang S, Shields JA, Green WR, eds. Retina-Vitreous-Macula. Philadelphia: WB Saunders Co; 1999. Vol 2: 1432-1448.
Al-Abdulla NA, Thompson JT, Sjaarda RN. Results of macular hole surgery with and without epiretinal dissection or internal limiting membrane removal. Ophthalmology. 2004 Jan. 111(1):142-9. [Medline].
Baba T, Yamamoto S, Arai M, et al. Correlation of visual recovery and presence of photoreceptor inner/outer segment junction in optical coherence images after successful macular hole repair. Retina. 2008 Mar. 28(3):453-8. [Medline].
Benzerroug M, Genevois O, Siahmed K, et al. Results of surgery on macular holes that develop after rhegmatogenous retinal detachment. Br J Ophthalmol. 2008 Feb. 92(2):217-9. [Medline].
Boldt HC, Munden PM, Folk JC, et al. Visual field defects after macular hole surgery. Am J Ophthalmol. 1996 Sep. 122(3):371-81. [Medline].
Chan A, Duker JS, Schuman JS, et al. Stage 0 macular holes: observations by optical coherence tomography. Ophthalmology. 2004 Nov. 111(11):2027-32. [Medline].
Cox MS, Schepens CL, Freeman HM. Retinal detachment due to ocular contusion. Arch Ophthalmol. 1966 Nov. 76(5):678-85. [Medline].
Da Mata AP, Burk SE, Foster RE, et al. Long-term follow-up of indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for idiopathic macular hole repair. Ophthalmology. 2004 Dec. 111(12):2246-53. [Medline].
de Bustros S. Vitrectomy for prevention of macular holes. Results of a randomized multicenter clinical trial. Vitrectomy for Prevention of Macular Hole Study Group. Ophthalmology. 1994 Jun. 101(6):1055-9; discussion 1060. [Medline].
Federman JL, Gouras P, Schubert H, et al. Macular disorders. Podos SM, Yanoff M, eds. Retina and Vitreous: Textbook of Ophthalmology. 1994. Vol 9.: 15-17.
Gass JD. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol. 1988 May. 106(5):629-39. [Medline].
Gaucher D, Haouchine B, Tadayoni R, et al. Long-term follow-up of high myopic foveoschisis: natural course and surgical outcome. Am J Ophthalmol. 2007 Mar. 143(3):455-62. [Medline].
Guyer DR, Gragoudas ES. Idiopathic macular holes. Albert DN, Jakobiec FA, eds. Principles and Practice of Ophthalmology. 1994. 883-888.
Ho AC. Macular hole. Retina Vitreous Macula. 1999. Vol 2: 217-229.
Ho AC, Guyer DR, Fine SL. Macular hole. Surv Ophthalmol. 1998 Mar-Apr. 42(5):393-416. [Medline].
Judson PH, Yannuzzi LA. Macular hole. Ryan SJ, ed. Retina. 1994. Vol 2.: 1169-1185.
Kusuhara S, Teraoka Escano MF, Fujii S, et al. Prediction of postoperative visual outcome based on hole configuration by optical coherence tomography in eyes with idiopathic macular holes. Am J Ophthalmol. 2004 Nov. 138(5):709-16. [Medline].
Madreperla SA, McCuen BW II. Macular Hole: Pathogenesis, Diagnosis and Treatment. 1999.
Nomoto H, Shiraga F, Yamaji H, et al. Macular hole surgery with triamcinolone acetonide-assisted internal limiting membrane peeling: one-year results. Retina. 2008 Mar. 28(3):427-32. [Medline].
Park SS, Marcus DM, Duker JS, et al. Posterior segment complications after vitrectomy for macular hole. Ophthalmology. 1995 May. 102(5):775-81. [Medline].
Ruiz-Moreno JM, Staicu C, Pinero DP, et al. Optical coherence tomography predictive factors for macular hole surgery outcome. Br J Ophthalmol. 2008 May. 92(5):640-4. [Medline].
Sakuma T, Tanaka M, Inoue M, et al. Efficacy of autologous plasmin for idiopathic macular hole surgery. Eur J Ophthalmol. 2005 Nov-Dec. 15(6):787-94. [Medline].
Schumann RG, Rohleder M, Schaumberger MM, et al. Idiopathic macular holes: ultrastructural aspects of surgical failure. Retina. 2008 Feb. 28(2):340-9. [Medline].
Sen P, Bhargava A, Vijaya L, et al. Prevalence of idiopathic macular hole in adult rural and urban south Indian population. Clin Experiment Ophthalmol. 2008 Apr. 36(3):257-60. [Medline].
Sjaarda RN, Glaser BM, Thompson JT, et al. Distribution of iatrogenic retinal breaks in macular hole surgery. Ophthalmology. 1995 Sep. 102(9):1387-92. [Medline].
Thompson JT. The effect of internal limiting membrane removal and indocyanine green on the success of macular hole surgery. Trans Am Ophthalmol Soc. 2007. 105:198-205; discussion 205-6. [Medline].
Tournambe PE, Poliner LS, Grote K. Macular hole surgery without face-down positioning. A pilot study. Retina. 1997. 17:179-85.
Wang S, Xu L, Jonas JB. Prevalence of full-thickness macular holes in urban and rural adult Chinese: the Beijing Eye Study. Am J Ophthalmol. 2006 Mar. 141(3):589-91. [Medline].
Welch JC. Dehydration injury as a possible cause of visual field defect after pars plana vitrectomy for macular hole. Am J Ophthalmol. 1997 Nov. 124(5):698-9. [Medline].
Wu PC, Chen YJ, Chen YH, et al. Factors associated with foveoschisis and foveal detachment without macular hole in high myopia. Eye. 2007 Dec 7. [Medline].
Wu WC, Drenser KA, Trese MT, et al. Pediatric traumatic macular hole: results of autologous plasmin enzyme-assisted vitrectomy. Am J Ophthalmol. 2007 Nov. 144(5):668-672. [Medline].