MACULAR HOLE

Pathogenesis
• Traumatic Theory*
– associated with direct or indirect ocular trauma
– Trauma causes immediate macular hole
formation from mechanical energy created by
vitreous fluid waves and contrecoup macular
necrosis or laceration
– More common in young boys

*Kopp CJ.Macular holes:a clinical contribution.Am ophthalmology 1908; 11:518-

528
• Cystoid degeneration theory*:
– cystic degeneration of the central macula
– due to :hypertension, retinal vessel occlusion, trauma
– Cyst coalescence FTMH

*Coats G. The pathology of macular holes. Roy London Hospital Report 1907; 17:69-96
• Vascular theory:
– Age related changes of retinal vasculature

cystoid degeneration

macular hole formation

• Vitreous Theory:
– Antero posterior fibrous traction band

Macular traction

Macular cystoid degeneration

Macular hole
Current theory Posterior hyaloid applies traction to
the foveola/umbo and causes it to
stretch

umbo dehisces because it is the

thinnest point in the fovea

middle and inner retina absorbs

vitreous fluid at the exposed edges
of the hole and begins to swell
 hole enlarges because of a
lateral extension of fluid into
the outer plexiform layer

inner retina is breached

due to the hydration of the

fovea and perifoveal macula,
the macular hole progresses
• Concept of tangential traction*
– Spontaneous tangential traction of external
part of the perifoveolar cortical vitreous
detaches foveolar retina
– Creates an intraretinal yellow spot
approximately 100-200μm in diameter
– Yellow color may result from intraretinal
xanthophyll pigment

* Avila MP, Jalkh AE, Murakami K, et al. Biomicroscopic study of the vitreous in macular
breaks. Ophthalmol 1983; 90:1277-83
 Classification
• Primary macular hole: is commonly an idiopathic
macular hole
– Caused by vitreous traction on the foveal from
an abnormal vitreous seperation
• Secondary Macular hole: caused by other
pathologies not associated with vitereomacular
traction
– blunt trauma, high myopia, macular
telangiectasia type2, diff causes of macular
oedema
Macular hole
 Lamellar Macular Hole
• Lamellar macular hole (LMH) is a partial-thickness foveal defect that typically appears
on biomicroscopy as a round or oval, wellcircumscribed,reddish lesion.
• Clinical detection of early LMH may be difficult using biomicroscopy alone.
• Anatomic OCT-based features of LMH include the following:
(1) an irregular foveal contour;
(2) a defect in the inner fovea (may not have actual loss of tissue);
(3) intraretinal splitting (schisis), typically between the outer plexiform and outer nuclear
layers; and
(4) maintenance of an intact photoreceptor layer. Lamellar macular hole can be
distinguished from FTMH on OCT best by the presence of intact photoreceptors at the
base
 Macular Psseudohole
• Macular pseudohole is a clinical diagnosis based on slit-lamp
biomicroscopic examination of the macula.
• Specific morphologic features are confirmed best with OCT.
• Clinically, a pseudohole appears as a discrete, reddish, round or
oval lesion in the fovea that typically is 200 to 400 mm in
diameter and similar in appearance to a small or medium FTMH.
• Slit-lamp examination of the macula can result in a false
diagnosis of FTMH, hence the term pseudohole.
• Although a large cystic lesion in the central macula also can
mimic a pseudohole, careful biomicroscopy will reveal the
difference. Optical coherence tomography with multiple foveal
line scans is 100% sensitive in ruling out FTMH.
Pre operative
parameters

Hole form factor > 0.9 and MacularHole

index > 0.5 also have a better prognosis
a = base diameter, b = minimumdiameter
c = left arm length, d = right arm length
OCT based anatomic classification of
FTMH

vitreous adhesion to
central macula with no
demonstrable retinal
morphology changes

vitreous adhesion to
central macula , demonstrable
changes like tissue cavitation,
cystoid changes, loss of foveal
contour, elevation of fovea
OCT based anatomic classification of FTMH

Small Hole ≥250μ, round or have a

f flap adherent to vitreous,
operculum ₊/-

Medium FTMH hole 250 - 400μ,

• round/ flap adherent to vitreous

Large FTMH hole >400μ,

• vitreous more likely to be fully
seperated
• from macula