Macular Holes

Question 1

Presentation of Macular hole?

Answer 1

• May be incidental finding – if px has normal vision in other eye
• Loss of central vision – blurred central vision w/ distortion
• If full thickness defect at macula – vision is rarely better than 6/18
• Metamorphopsia
• More common in females than males (~4:1)
• Anyone who has hole in one eye is at relatively high risk of developing a hole in other eye during lifetime (~1:6 risk of bilateral hole)

Question 2

Differential diagnosis of macular hole: Pseudohole - describe this?

Answer 2

o Hole in ERM over fovea
o Looks like macular hole but:
 Vision is 6/18 or better
 No thickening of retina at edges of “hole” – edges are not elevated
o Treat as ERM – only refer if patient is symptomatic

Question 3

Differential diagnosis of macular hole: lamellar hole - describe (2 types)?

Answer 3

o Vision usually 6/18 or better
o No treatment shows to be beneficial (or improve sight)

Degenerative lamellar hole:
 Irregular foveal contour
 Foveal cavitation & loss of foveal tissue (seen on OCT)
 Preretinal epiretinal tissue may be visible – low reflectivity & does not contract
 Lamellar hole-associated epiretinal proliferation (LHEP)
 Ellipsoid zone disruption – with loss of photoreceptors

ERM foveoschisis:
 Contractile epiretinal membrane
 Schisis at level of Henle’s layer
 Retinal thickening and wrinkling (&splitting)
 Outer retina remains intact

Question 4

Full thickness macular hole (FTMH) management?

Answer 4

• Observe:
  o Unlikely to improve
  o Delay reduces visual recovery
• Best recovery if hole is repaired within 6 months of onset
• Some pxs may choose not to have surgery – px needs to understand this is an irrevocable decision
• Surgery:
  o PPV (pars plana vitrectomy), ILM peel & gas +/- phaco & IOL
  o Generally, v effective

Question 5

FTMH referral?

Answer 5

Refer all pxs to vitreoretinal clinic URGENTLY