Diagnostic Considerations

Pseudohole due to epimacular membrane

Cystoid macular edema

Lamellar macular hole

Vitreomacular traction syndrome

Primary consideration should be given to conditions that may mimic the appearance of a macular hole. While most of these conditions are readily apparent clinically, subtle presentations may present as a macular hole. These conditions include any disease that can cause the development of cystoid macular edema (eg, choroidal neovascularization, retinal vein occlusions, retinitis pigmentosa). An appropriate workup and examination should identify these conditions.

Differential Diagnoses

Epiretinal Membrane

Workup

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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Muqit MMK, Hamilton R, Ho J, Tucker S, Buck H. Intravitreal ocriplasmin for the treatment of vitreomacular traction and macular hole- A study of efficacy and safety based on NICE guidance. PLoS One. 2018. 13 (5):e0197072. [QxMD MEDLINE Link].
Chaudhary K, Mak MY, Gizicki R, Muni RH, Wong DT, Altomare F, et al. PROPORTION OF PATIENTS WITH MACULAR HOLE SURGERY WHO WOULD HAVE BEEN FAVORABLE OCRIPLASMIN CANDIDATES: A Retrospective Analysis. Retina. 2017 Jan. 37 (1):76-79. [QxMD MEDLINE Link].
Feng HL, Roth DB, Hasan A, Fine HF, Wheatley HM, Prenner JL, et al. INTRAVITREAL OCRIPLASMIN IN CLINICAL PRACTICE: Predictors of Success, Visual Outcomes, and Complications. Retina. 2018 Jan. 38 (1):128-136. [QxMD MEDLINE Link].
Schumann RG, Langer J, Compera D, Luedtke K, Schaumberger MM, Kreutzer T, et al. Assessment of intravitreal ocriplasmin treatment for vitreomacular traction in clinical practice. Graefes Arch Clin Exp Ophthalmol. 2017 Nov. 255 (11):2081-2089. [QxMD MEDLINE Link].
Gonvers M, Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthalmol. 1982 Oct. 94(4):468-72. [QxMD MEDLINE Link].
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991 May. 109(5):654-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology. 2010 Oct. 117 (10):2018-25. [QxMD MEDLINE Link].
Narayanan R, Singh SR, Taylor S, Berrocal MH, Chhablani J, Tyagi M, et al. SURGICAL OUTCOMES AFTER INVERTED INTERNAL LIMITING MEMBRANE FLAP VERSUS CONVENTIONAL PEELING FOR VERY LARGE MACULAR HOLES. Retina. 2018 Apr 23. [QxMD MEDLINE Link].
Ch'ng SW, Patton N, Ahmed M, Ivanova T, Baumann C, Charles S, et al. The Manchester Large Macular Hole Study: Is it time to reclassify large macular holes?. Am J Ophthalmol. 2018 Jul 30. [QxMD MEDLINE Link].
Kannan NB, Kohli P, Parida H, Adenuga OO, Ramasamy K. Comparative study of inverted internal limiting membrane (ILM) flap and ILM peeling technique in large macular holes: a randomized-control trial. BMC Ophthalmol. 2018 Jul 20. 18 (1):177. [QxMD MEDLINE Link].
Rizzo S, Tartaro R, Barca F, Caporossi T, Bacherini D, Giansanti F. INTERNAL LIMITING MEMBRANE PEELING VERSUS INVERTED FLAP TECHNIQUE FOR TREATMENT OF FULL-THICKNESS MACULAR HOLES: A COMPARATIVE STUDY IN A LARGE SERIES OF PATIENTS. Retina. 2018 Sep. 38 Suppl 1:S73-S78. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Garretson BR, Pollack JS, Ruby AJ, et al. Vitrectomy for a symptomatic lamellar macular hole. Ophthalmology. 2008 May. 115(5):884-886.e1. [QxMD MEDLINE Link].
Rubinstein A, Ang A, Patel CK. Vitrectomy without postoperative posturing for idiopathic macular holes. Clin Experiment Ophthalmol. 2007 Jul. 35(5):458-61. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Alberti M, la Cour M. NONSUPINE POSITIONING IN MACULAR HOLE SURGERY: A Noninferiority Randomized Clinical Trial. Retina. 2016 Apr 4. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Fahim AT, Khan NW, Johnson MW. Acute Panretinal Structural and Functional Abnormalities After Intravitreous Ocriplasmin Injection. JAMA Ophthalmol. 2014 Feb 27. [QxMD MEDLINE Link].
Chow N, Hong T, Chang A. Multimodal imaging of macular subretinal deposits following intravitreal ocriplasmin injection. Am J Ophthalmol Case Rep. 2018 Mar. 9:80-84. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Boldt HC, Munden PM, Folk JC, et al. Visual field defects after macular hole surgery. Am J Ophthalmol. 1996 Sep. 122(3):371-81. [QxMD MEDLINE Link].
Chan A, Duker JS, Schuman JS, et al. Stage 0 macular holes: observations by optical coherence tomography. Ophthalmology. 2004 Nov. 111(11):2027-32. [QxMD MEDLINE Link].
Cox MS, Schepens CL, Freeman HM. Retinal detachment due to ocular contusion. Arch Ophthalmol. 1966 Nov. 76(5):678-85. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Park SS, Marcus DM, Duker JS, et al. Posterior segment complications after vitrectomy for macular hole. Ophthalmology. 1995 May. 102(5):775-81. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Schumann RG, Rohleder M, Schaumberger MM, et al. Idiopathic macular holes: ultrastructural aspects of surgical failure. Retina. 2008 Feb. 28(2):340-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sjaarda RN, Glaser BM, Thompson JT, et al. Distribution of iatrogenic retinal breaks in macular hole surgery. Ophthalmology. 1995 Sep. 102(9):1387-92. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

Full-thickness macular hole showing a surrounding cuff of subretinal fluid.
Full-thickness macular hole with typical yellowish granular deposits on the retinal pigment epithelium.
Fluorescein angiogram showing a central window defect.
Preoperative fundus photograph of a macular hole.
Fundus photograph of the same patient as in the image above at 6 months postoperatively. Note the increased media opacity caused by cataractous changes of the lens.
Fundus photograph of a stage 1a macular hole with characteristic yellow spot at the center of the fovea.

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Author

Kean Theng Oh, MD Consulting Staff, Associated Retinal Consultants, PC

Kean Theng Oh, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Michigan Society of Eye Physicians & Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Neal H Atebara, MD Private Practice, Retina Center of Hawaii

Neal H Atebara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Retina Society, American Medical Association, Hawaii Medical Association

Disclosure: Nothing to disclose.

John H Drouilhet, MD, FACS Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine

John H Drouilhet, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Douglas R Lazzaro, MD, FAAO, FACS Chairman, Professor of Ophthalmology, The Richard C Troutman, MD, Distinguished Chair in Ophthalmology and Ophthalmic Microsurgery, Department of Ophthalmology, State University of New York Downstate Medical Center; Chief of Ophthalmology, Director of Cornea, Director of Surgical Training, Kings County Hospital Center

Douglas R Lazzaro, MD, FAAO, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Association of University Professors of Ophthalmology, Brooklyn Ophthalmological Society, Cornea Society, New York Society for Clinical Ophthalmology, Ophthalmic Laser Surgical Society

Disclosure: Nothing to disclose.

Additional Contributors

Brian A Phillpotts, MD Ophthalmologist, St Luke's Cataract and Laser Institute

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Association of University Professors of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Bradley M Hughes, MD Assistant Professor, Department of Ophthalmology, Retina and Vitreous Service, University of Arkansas for Medical Sciences

Bradley M Hughes, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Sherman O Valero, MD Consulting Staff, Department of Ophthalmology, Makati Medical Center, Philippines

Disclosure: Nothing to disclose.

Sections Macular Hole
Overview
Presentation
- History
- Physical
- Causes
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DDx
Workup
Treatment
Medication
Media Gallery
References

Macular Hole Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

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