Ocular Disease III: Lecture 4: Macular Holes and the Vitreoretinal Interface

Question 1

(Idiopathic) Macular Holes

1. When do they normally occur (what decade of life)?
2. Affects about how many people? (1/????)
3. Males/Females?
4. % that are Bilateral?

Answer 1

1. 6th or 7th Decade of life
2. 1/5000
3. Females more (2:1)
4. 10-20%

Question 2

(Idiopathic) Macular Holes: SYMPTOMS

1. Painful?
2. Vision loss where?
3. 3 Early Symptoms
4. Late Symptoms
5. When are Symptoms first noticed?

Answer 2

1. NO
2. Central Vision Loss
3. Blur, Central Metamorphopia, and Micropsia
4. Severe Decrease in Central Vision
5. When the other eye is closed

Question 3

(Idiopathic) Macular Holes: Pathophysiology (OCT)

1. What happens in the Perifoveal area?
   a. What can this lead to?
2. What causes VITREOUS TRACTION on the FOVEA?

Answer 3

1. Shrinkage (of Perifoveal Vitreous Cortex)
   a. Incomplete Perifoveal PVD
2. Foveal Adherence of the Posterior Hyaloid!

Question 4

Macular Holes: Stages (1)

1. Stage 1 A
   a. OCT: What is seen on the OCT (What forms)
   b. Ophthalmoscopy: Can you see it? What is probably the 2 main things you will see?

Answer 4

1. a. A Split in the INNER Retina, Causing a CYSTIC SPACE (PSEUDOCYST)
   b. Hard to see; BUT, you’ll probably see a LOSS of the FLR, and a YELLOW SPOT 100-200 um in Diameter

Question 5

Macular Holes: Stages (2)

1. Stage 1B
   a. OCT: What do you see occur?
   i. Causes disruption in what LAYER?

b. Ophthalmoscopy: What will you see?
i. You will also see a LOSS of what?

Answer 5

1. a. Pseudocyst will ENLARGE and Extend to the OUTER RETINA
   i. Photoreceptor Layer
   b. Small Central Yellow Ring
   i. Loss of Foveal Depression

Question 6

Macular Holes: Stages (3)

1. Stage 2 (CAN OPENER STAGE)
   a. OCT: What happens to the Cyst in this stage?
   i. What type of defect is seen?

b. Opthalmoscopy: What is seen w/in the YELLOW RING?

Answer 6

1. a. the Roof of it OPENS
   i. FULL thickness defect less than 400 um in diameter

b. A Small Retinal Defect (hole)

Question 7

Macular Holes: Stages (4)

1. Stage 3
   a. OCT: What happens with the Full thickness defect in this stage?

b. Ophthalmoscopy: What is seen?
i. What surrounds this?

Answer 7

1. a. It gets to be more than 400 um in Diameter w/thickened edges due to Intraretinal Cystoid Spaces
   b. Central, Red, Round thickness retinal defect
   i. Subretinal Fluid Cuff

Question 8

Macular Holes: Stages (5)

1. OCT: What happens with the Full-thickness Defect in this stage?
2. Ophthalmoscopy: What is seen in this stage?
   i. What else is seen?

Answer 8

1. Full-thickness defect of more than 400 um in diameter WITH a Complete PVD
2. Red, Round defect surrounded by a cuff of subretinal fluid, usually w/Tiny Yellowish Deposits w/in the hole.
   i. Complete PVD is seen (usually can see this by the WEISS RING)

Question 9

Visual Acuities at the Various stages

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

Answer 9

1. 20/20 - 20/50
2. 20/50 - 20/200
3. 20/200 - 20/800 (she said usually like 20/400 typically)
4. 20/200 - 20/800

Question 10

Diagnostic Tests

1. There are 3 for Macular Holes

Answer 10

1. Clinical Observation
2. OCT (good for staging the macular hole)
3. Watzke-Allen Test: Project a Narrow slit beam over the Center of the Hole, and the Patient w/a macular hole will report that the beam is THINNED or BROKEN.

(Pts w/a Pseudohole or Cyst would seen the beam as DISTORTED)

Question 11

Natural History

1. % of STage 1 holes that resolve spontaneously after Vitreofoveolar Separation
2. What about full thickness macular holes (2,3,4)

Answer 11

1. 50 %

2. Rarely spontaneously resolve w/improvement in VA (should probably refer to a Retinal Specialist at this point)

Question 12

Surgical Treatment (4)

Answer 12

1. Vitrectomy
2. Peeling of the ILM
3. Fluid-Gas Exchange
4. Postoperative Face-Down Positioning
   * Pars Plana Vitrectomy (PPV): 3 incisions: Light source, Infusion Line (to push air/fluid in), and Vitrector

Question 13

Face-Down Positioning

1. What does the Bubble Isolate?
2. What does the Bubble-hole Contact act like?
   a. Allows formation of what?
3. How long does it take for the Gas to be Absorbed and the Eye to naturally refill with Vitreous?
4. Why is vision blurry looking thru the Bubble?
5. Is Flying prohibited? Why?

Answer 13

1. the Liquid Vitreous from the Hole
2. a Band-aid
   a. of a Fibrin Plug
3. A few weeks
4. Due to different Index of Refraction
5. Yes. Due to decreased ATM Pressure…can cause the bubble to expand and raise the INTRAOCULAR PRESSURE to dangerous LEVELS!

Question 14

Complications of Macular Hole Surgery

1. Main issue?
2. Others?

Answer 14

1. Cataracts (> 75%)

2. Retinal Detachment (3%); Endophthalmitis (<1%), and Late reopening of the hole (2-10%)

Question 15

At What stage should surgery be performed?

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

Answer 15

1. Surgery here had NO BENEFIT over the natural course of the disease.
2. Results of study supported Surgery was HELPFUL!

3,4. Surgery improved VA, 70% surgical success. Final VA was not that much different, although it improved a little bit (part of that is that they probably developed CATARACTS!…almost universally)

Question 16

How long should face-down positioning be maintained?

Answer 16

1. they did a metanalysis concluded that there was a slight improvement if they were face down for 5-10 days vs. 24 hrs.
   * Depends on Retinal Specialist.

Question 17

Epiretinal Membrane (ERM)

1. AKA: Macular Pucker, Cellophane Maculopathy
   a. How common is it?

b. Bilateral involvement?
2. What is a big thing that can tell u that they have it?

Answer 17

1. a. pretty common in peeps over age 40
   b. 20-30% of cases
2. If you have a 40-50 yr old patient and they have the healthy 20 yr old shimmer

Question 18

Epiretinal Membrane (ERM)

1. Causes.

Answer 18

1. Mostly IDIOPATHIC (but trauma, intraocular inflammation, retinal vascular disease, after Intraocular surgery)

Question 19

Epiretinal Membrane (ERM)

1. Symptoms

Answer 19

1. Blurred Vision
2. Macropsia (due to crowding of the photoreceptors)
3. Metamorphopsia
4. Mild, Transparent ERM (usually Asymptomatic)

Question 20

Epiretinal Membrane (ERM)

1. What can you see on the exam?

Answer 20

1. Tortuosity of the vessels in the Area around the macula.
2. Shimmer/Whitish Gray membrane along the inner retinal surface
3. Striations along the retina

Question 21

Epiretinal Membrane (ERM)

1. What will you see in the FA?
2. Do you need it to Diagnose the disease?

Answer 21

1. Highlights Vascular Tortuosity
2. Can show Hyperfluorescence if vascular leakage present
3. NO! (Rarely used in diagnosis or management)

Question 22

Epiretinal Membrane (ERM): OCT

1. ERMs run how along the Retinal Surface?
2. What will the OCT show?
3. Contraction of the membrane causes what to be seen in the Inner Retina?
4. In some cases, there may be what visible? (as what on the OCT)

Answer 22

1. TANGENTIAL
2. a Thick, Highly reflective Membrane on the surface of the retina
3. Distortion/Folds of the inner retina
4. May be EDEMA Visible as BLACK SPACES in the OUTER RETINA

Question 23

Epiretinal Membrane (ERM): Pathophysiology

1. It’s due to PROLIFERATION of what cells?
2. The Cells gain access to the Retinal Surface thru breaks in what?
3. What is believed to play a role in the Development of ERM?

Answer 23

1. of Retinal Glial Cells (also RPE cells, Hyalocytes, Myofibroblasts) at the Vitreoretinal Interface
2. in the ILM
3. PVD

Question 24

Epiretinal Membrane (ERM): History of it

1. % of ERMs that spontaneously resolve?
2. How many are stable after an initial period of growth and contraction?
3. When is surgery recommended for these patients?

Answer 24

1. s SEVERE METAMORPHOPSIA

Question 25

Epiretinal Membrane (ERM): TREATMENT 1. What is the surgical procedure? 2. Membranectomy: What is it? 3. Outcome expected?

Answer 25

1. VITRECTOMY (so they remove all or part of the vitreous) 2. ERM is engaged w/forceps or a pick and gently peeled from the Inner retinal surface 3. About 1/2 of their VA back, decrease in Metamorphopsia, CATARACTS is MOST COMMON COMPLICATION, and Small chance of RECURRENCE

Question 26

Vitreomacular Traction Syndrome 1. It's similar to ERM: Main difference is that instead of the force being tangential to the retina it's what? 2. It's a complication of what? 3. What is the definition of a VMT?

Answer 26

1. It's ANTERIOR-POSTERIOR to the RETINA (fovea) 2. of an Incomplete PVD 3. Basically, that the Vitreous gel has an Abnormally Strong Adhesion to the Retina

Question 27

Vitreomacular Traction Syndrome 1. What are the Main Clinical Signs?

Answer 27

1. Early stages hard to see on Exam 2. Maybe see Glistening of the Posterior Hyaloid 3. Partial PVD USUALLY PRESENT! 4. Center of Fovea may have a REDDISH or YELLOWISH SPOT 5. Macula may look Thickened due to EDEMA

Question 28

Vitreomacular Traction Syndrome 1. OCT: What is usually seen?

Answer 28

1. BRIGHT Posterior HYALOID TENTING UP the Fovea and Surrounding Area. and Perifoveal Vitreous Detachment

Question 29

Vitreomacular Traction Syndrome 1. Main threats to Vision include what 2 things? 2. When is Force exerted on the macula GREATEST and leads to GREATER risk of Macular Hole formation? 3. Can it resolve spontaneously? 4. Can occur simultaneously with what other disease?

Answer 29

1. Cystic Macular Edema or Macular Hole Formation 2. With the narrower Vitreomacular Attachment 3. Yes when the PVD is done 4. With ERM

Question 30

Vitreomacular Traction Syndrome !. Treatment a. Early, and Asymptomatic? b. Main treatment?

Answer 30

1. a. Observe for progression b. Vitrectomy was the only treatment, but now they can do Intravitreal injections of an Enzymatic Agent as a new treatment approach. (Ocriplasmin) (JETREA) (Breaks down the vitreous and helps to decrease traction) * Jetrea: Resolution, improvement of BCVA all was a little better....Side Effects (Floaters is NUMBER 1!; Inflammation and increased IOP) and 1 pt had lens subluxation occur. * Just recently, 2 case reports showed Severe impaired vision.

Question 31

Pseudoholes 1. Sometimes w/an Epiretinal membrane you can get what? a. They have retinal tissue where? b. Is there a surrounding cuff of sub-retinal fluid? c. Are there any deposits at the base of the hole? d. Pts w/Pseudoholes tend to have what kind of VA?

Answer 31

1. Sometimes a Pseudohole. (Epiretinal membrane is contraction and can cause what may look like a hole) a. at the BASE of the Hole (intact photoreceptor layer) b. NO c. NO d. Normal VAs (20/40 or better)

Question 32

Pseudoholes 1. OCT a. What does the foveal contour look like? b. What about Central Foveal Thickness? c. What about Parafoveal Thickness?

Answer 32

1. a. STEEPENED (Cylindrical) b. Near normal c. INCREASED

Question 33

Pseudoholes: Treatment 1. What happens to VA? 2. Surgical Peeling of ERM is indicated when vision is what?

Answer 33

1. usually it's maintained | 2. reduced (typically worse than 20/40)

Question 34

Lamellar Holes 1. It's usually the result of what? 2. VA? 3. Macula shows what?

Answer 34

1. of an abortive process of macular hole formation 2. preserved (20/40 or better) 3. a Stable, Round, and Well-circumscribed Reddish Lesion

Question 35

Lamellar Holes: OCT: 1. Foveal Contour 2. Split b/w the Inner Layers and what? 3. What is intact? 4. What kind of SHAPE is it?

Answer 35

1. Irregular 2. and the Underlying Retina at the edges 3. Photoreceptors 4. Bilobed or Anvil-Shaped

Question 36

Vitreomacular Traction Syndrome: Treatment 1. It's usually stable. Why? 2. When the ERM is involved in forming of the Lamellar Hole, the ERM peeling may be good or bad? 3. Surgical Peeling may do what to the lamellar hole configuration? a. What could it lead to?

Answer 36

1. Cuz the Vitreous has completely separated 2. It may be Beneficial 3. May destabilize it. a. could lead to the Progression of a Full-thickness Hole