Idiopathic macular holes – A review of current management strategies

Abstract

Description of the Condition Macular holes (MHs) are retinal defects which involve the center of the anatomical fovea. [1,2] Severity may range from asymptomatic incidentally discovered MHs, to advanced vision-threatening ones. [2,3] MHs are often described according to the extent of retinal layers involvement. Full-thickness MHs (FTMHs) encompass all the layers of the retina from the internal limiting membrane (ILM) to the retinal pigmented epithelium (RPE) [Figure 1]. [2] Partialthickness MHs, also termed lamellar holes, involve only the inner retinal layers, while the photoreceptors layer may remain intact [Figure 2]. [2,3] Although the majority of cases are idiopathic (>85%), MHs may also be secondary to various conditions, among the most common of which are high myopia and ocular trauma. [2,4,5] Kumawat et al. described in detail other infrequent causes of secondary MHs. [5] Epidemiology The reported prevalence of idiopathic MHs (IMHs) in the general population ranges between 0.02% and 0.33%. [1,4] IMHs are more common in women (approximately 70% of cases) and usually appear in the 6 th and 7 th decades of life. [1,4,6] For patients with an idiopathic FTMH in one eye, the risk for developing an MH in the fellow eye is 10-20%. [1,7] Pathophysiology IMHs are the sequelae of vitreomacular adhesion (VMA) and traction (VMT). [2] The vitreous is a clear gel-like structure enveloped by a hyaloid membrane (the vitreous cortex), the posterior part of which is attached to the ILM of the retina. With aging, the vitreous body liquefies, shrinks, and gradually detaches from the retina, starting at the posterior pole. Physiologically, the vitreous will continue to detach from the retina and eventually remain firmly attached to the retina only at the vitreous base, straddling the ora serrata. In most cases, this process results in no retinal damage. [2,8,9] However, incomplete or abnormal detachment may result in pathologic VMA and VMT, which can distort the foveal contour and result in MH formation [Figure 3]. [8] The traction forces affect the foveola and might impair central vision, causing distorted vision or decreased visual acuity (VA). [2,5,10]

Secondary macular holes – A review of current management strategies

“…[7,12,13,15,16] It has been suggested that while idiopathic MH (IMH) formation is related to chronic traction, TMHs are the result of acute traction forces on the macula. [1,12,13] However, in contrast to IMHs, a significant portion of TMH cases (10-67% according to different reports) may resolve spontaneously. [7,17] Therefore, observation before any intervention is a reasonable option for many patients.…”

“…Macular holes (MHs) are full thickness retinal defects involving the anatomical fovea. [1] The first staging system for MHs was described by Gass in 1988. [1,2] The use of optical coherence tomography (OCT) led to the development of newer staging systems.…”

“…[1,2] The use of optical coherence tomography (OCT) led to the development of newer staging systems. [1,3,4] At present, the international vitreomacular traction (VMT) study classification system is generally accepted and used: [4] (1) Vitreomacular adhesion (VMA) -an incomplete perifoveal vitreous detachment with preserved foveal contour. This is a part of the natural course of posterior vitreous detachment (PVD), in which the vitreous remains strongly attached to the retina at a certain perifoveal area and is usually asymptomatic.…”

“…Most MHs are idiopathic, but some are secondary to trauma, severe myopia, or other conditions. [1,5,6] This review focuses on the most common etiologies for secondary MHs, treatment modalities, and relevant considerations.…”