MACULAR HOLE

Case Study : 70 year female came with complaints of left eye decrease in vision and distortion of images we found left eye large full thickness macular hole

Before Surgery (Macular Hole Opened)

After Surgery (Macular Hole Closed)

What is macular hole ?

Full thickness macular hole (FTMH) is the presence of hole or loss of retinal layers in the most important central part of retina called macula.

What are the Symptoms?

central vision loss (central scotoma), distortion of images and straight lines appear wavy (metamorphosis) in the affected eye at routine sight test or seen after closing other eye with no problem. In early stages of the disease the symptoms are very mild can be missed by patients highlighting the need of regular eye checkup. It is more common in females aged 60-70 but can be seen in males of same age group. The other eye involvement risk in 5 years is 10%.

What are the Causes?

It is idiopathic the cause is not known. vitreo-macular traction (VMT) is thought to be a cause for hole formation causing pulling force on the centre of retina, the macula. A new OCT based classification has been published by International vitreomacular traction study (IVTS). Other causes can be high myopia( which can lead to macular retinal detachment), trauma etc.

How to diagnose?

OCT (optical coherence tomography): is extremely useful in diagnosis, staging and deciding about surgery .

Amsler grid chart : patient with macular hole cannot follow the straight lines on this chart when asked to over right on the preprinted straight vertical and horizontal lines showing that patient is seeing distorted lines which are actually straight.

Watzke-Allen test : it is performed by projecting a narrow slit of light over the centre of the hole. A patient with a macular hole will tell that the beam is broken.

FAF shows a markedly hyperfluorescent foveolar spot in stages 3 and 4

FA (fluorescein angiography) in a full-thickness hole shows an early well-defined window defect due to xanthophyll displacement and RPE atrophy. Now due to availability of OCT in this condition there is no need to perform FA in routine cases.

Any Treatment to close the hole? How the hole is closed? :

Surgery: main stay of treatment considered in stage 2,3 and stage 4 holes.

Observation : half of stage 1 holes resolve following spontaneous vitreofoveolar separation, so these are managed conservatively, no need of surgery.

Pharmacological vitreolysis : Ocriplasmin may be suitable for small early-stage holes

How are the results of surgery?

Results depend on size, shape duration of hole however due to good and advanced technique, “micro-incision vitreous surgery” 80-90% of holes achieve closure with good vision

What precautions I should take after surgery?

Along With surgery SF6/C3F8 gas is put inside the eye to help hole closure thus patient has to maintain face down (prone) position 8-10 hours at least for 3-4 days and should avoid immediate Aeroplan travel because it causes sudden rise in eye pressure due to expansion of the gas. The gas evaporates in 2-3 weeks and no need to remove it.