Full thickness macular holes (FTMH) refer to complete defects of the neurosensory retina down to the retinal pigment epithelium (RPE) at the fovea. Patients can present with blurred vision, central scotoma and/or metamorphopsia. Macular holes can be idiopathic or secondary to myopic traction maculopathy, trauma, cystoid macular edema, solar retinopathy, retinal detachment, laser, proliferative vitreoretinopathy (PVR), macular telangiectasia type II or Alport Syndrome. Idiopathic macular holes are more frequent in females (3.3:1) and are bilateral in approximately 12% of patients.[1]
McCannel CA, Ensminger JL, Diehl NN, Hodge DN. Population-based incidence of macular holes. Ophthalmology 2009; 116 (7): 1366-1369.
There are two main classifications for macular holes. Gass firstly described the evolution of macular holes based on the biomicroscopic feature[2,3] but this classification has largely been replaced by the International Vitreomacular Traction Study (IVTS) group which introduced an anatomic classification for diseases of the vitreomacular interface based on OCT findings in 2013.[4]
Gass JD. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988; 106 (5): 629-639.
Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995; 119 (6): 752-759.
Duker JS, Kaiser PK, Blinder F, de Smet MD, Gaudric A, Reichel E, Sadda SR, Sebag J, Spaide RF, Stalmans P. The international vitreomacular traction study group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology 2013; 120 (12): 2611-2619.
Approximately 50% of “stage 1” impending macular holes regress spontaneously.[5] About 11.5% of stage 2 FTMH close spontaneously in one year, while only 4% of stage 3 or 4 FTMH close spontaneously.[6,7] For symptomatic stage 2-4 FTMH, vitrectomy and membrane peeling is indicated as most of the macular holes will close following surgery. After successful closure of macular hole, visual acuity is generally improved unless there is irreversible photoreceptor or RPE damage associated with chronic macular hole.[7]
Ia Cour M, Friis J. Macular holes: classification, epidemiology, natural history and treatment. Acta Ophthalmol Scand 2002; 80: 579-587.
Ezra E, Gregor ZJ. Surgery for idiopathic full-thickness macular hole: two-year results of a randomized clinical trial comparing natural history, vitrectomy, and vitrectomy plus autologous serum: morfields macular hole study group report no. 1. Arch Ophthalmol 2004; 122: 224-236.
Freeman WR, Azen SP, Kim JW, EI-Haig W, Mishell DR, Bailey I. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for treatment of macular hole study group. Arch Ophthalmol 1997; 115 (1): 11-21.
Freeman WR, Azen SP, Kim JW, EI-Haig W, Mishell DR, Bailey I. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for treatment of macular hole study group. Arch Ophthalmol 1997; 115 (1): 11-21.
Using microincisional vitrectomy system, transconjunctival PPV (23-, 25- or 27-gauge) can be performed with small sclerotomy wounds which can be self-sealing. The vitreous core should be first removed by the vitreous cutter. Peripheral vitrectomy can be performed after posterior vitreous detachment (PVD) induction.
Following core vitrectomy, the posterior hyaloid is aspirated and lifted off the optic disc by using aspiration of the vitrectomy probe. In difficult cases or if there is uncertainty if a PVD is present, intravitreal stains can be used. Although intravitreal triamcinolone acetonide stains vitreous the most clearly, since an internal limiting membrane dye (e.g. Brilliant Blue G or Indocyanin Green) is often required for later membrane peeling, it can be used to stain the vitreous too. Further details regarding PVD induction can be found in Chapter 4 Posterior Vitreous Detachment Induction.
ILM is difficult to visualize but vital dyes can help to highlight it. Vital dye-assisted ILM peeling can facilitate macular hole closure when compared to vitrectomy alone.[8] Various types of vital dyes are described in Chapter 6 Membrane Stains.
Gaudric A. Macular hole surgery: simple or complex?. AJO 2009; 147(3): 381-383.
Farah ME, Maia M, Rodrigues EB. Dyes in ocular surgery: principles for use in chromovitrectomy. Am J Ophthalmol 2009; 148 (3): 332-340.
Saeed MU, Helamnn H. Atrophy of the retinal pigment epithelium following vitrectomy with trypan blue. Int Ophthalmol 2009; 29: 239-241.
Gouws P, Merriman M, Goethals S, Simcock PR, Greenwood RJ, Wright G. Cystoid macular oedema with trypan blue use. BJO 2004; 88: 1348-1349.
Shimada H, Nakashizuka H, Hattori T, Mori R, Mizutani Y, Yuzawa M. Double staining with brilliant blue G and double peeling for epiretinal membranes. Ophthalmology 2009; 116:1370-1376.
Rodrigues EB, Meyer CH, Mennel S, Farah ME. Mechanisms of intravitreal toxicity of indocyanine green dye- implications for chromovitrectomy. Retina 2007; 27 (7): 958-970.
Lanzetta P, Polito A, Del Borrello M, Narayanan R, Shah VA, Frattolilo A, Bandello F. Idiopathic macular hole surgery with low-concentration infracyanine green-assisted peeling of the internal limiting membrane. AJO 2006; 142: 771-776.
BBG / ICG only stains ILM but not ERM; hence a “negative stain” is seen where ERM is present
Before the injection of the dye, all air bubbles in the syringe should be carefully expelled. If not using a dual bore canula, the infusion can be clamped prior to dye injection into the vitreous cavity to prevent flow from the infusion line blowing the dye off the macula. This is usually unnecessary with new vitrectomy systems and valved cannulae. Some dyes contain a 4% PEG solution that allow them to sink directly onto the macula.[15] Dyes without this may sometimes diffuse throughout the globe, obscuring the intraoperative view of the fundus. Another method to stain the membrane (with better visualization of the retina maintained during the removal of the dye) is to perform partial fluid-air exchange until the level of BSS® is just above the retinal surface before injection of the dye (Figure 16.2.1). After approximately 30 seconds of staining, fluid is infused and is aspirated simultaneously with the dye in the vitreous cavity. Of note, staining under air may increase the relative concentration of the dye and the stain with a potentiald increased risk of retino-toxicity.
Veckeneer M, Mohr A, Alharthi E, Azad R, Bashshur ZF, Bertelli E, Bejjani RA, Bouassida B, Bourla D, Crespo IC, Fahed C, Fayyad F, Mura M, Nawrocki J, Rivett K, Scharioth GB, Shkvorchenko DO, Szurman P, Van Wijck H, Wong IY, Wong DSH, Frank J, Oellerich S, Bruinsma M, Melles GRJ. Novel “heavy” dyes for retinal membrane staining during macular surgery: multicenter clinical assessment. Acta Ophthalmol 2014;92: 339–344.
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Westmead Eye Manual
This invaluable open-source textbook for eye care professionals summarises the steps ophthalmologists need to perform when examining a patient.