Retina 3 - Macula Holes Flashcards
What do macular holes result from a combination of?
•Antero-posterior vitreous traction
•traction from internal limiting membrane
Average size of macular hole?
400um
or 1/3rd optic disc
Stage 1 hole macular hole?
Vitro-macular traction
Stage 2 macular hole?
Full thickness hole less than 400um
Stage 3 macular hole
Full thickness hole with diameter over 400um
Stage 4
Any size, associated with poster vitreous detachment (PVD)
Where is the hole diameter measured from?
The narrowest point in the hole
What is the basal Diameter hole measured?
The hole diameter from the retina joins the RPE
List the presentation of macular hole and its risks?
•May be incidental if other eye is healthy
•Loss of central vision, minimum 6/18
•Metamorphopsia
•Females>Males 4:1
•Approx 1:6 risk of bilateral hole if unilateral
•Prevalence 3/1,000>50 Incidence 7-8/100,000
Difference between Macula hole and Lamellar hole?
Macula hole is full thickness hole with minimum 6/18 VA, while Lamellar hole is partial thickness hole, with 6/18 or better
Define Character of degenerate lamellar hole
•Irregular foveal contour due to:
•Foveal loss + loss of foveal tissue
Can cause:
•Lamellar hole-associated epiretinal proliferation
•Ellipsoid zone disruption
- Loss of photo-receptors
Define epiretinal membrane foveoschisis lamellar hole
• Retinal thickening and wrinkling
• Contractile epiretinal membrane
•Schisis at level if Henle’s layer
Pseudo hole character definition + difference from Macular hole?
•Hole in ERM over fovea
•Similar appearance to macular hole but:
- Good VA - 6/18+
- Edges not elevated
• Treat as ERM
ONLY REFER IF SYMPTOMATIC
Management of Full-thickness Macular Hole
•Observe?
- Unwise as unlikely to improve, delays recovery. Best prognosis is treatment within 6months!
• Surgery
- Prognosis 19/20 holes closed
- PPV, ILM peel and gase +/- phaco and IOL
Management of Fullthickness macular hole
•2020
- Face down overnight
- Gas bubble lasts 30-35 days
Risks of Full-thickness macular hole surgery
•Cataract
- Vitrectomy surgery will 100% develop cataract, with some surgeons doing a simultaneous surgery.
• Retinal detachment
- <1%
•Poor outcome
- Unable to predict final VA
- Some Px improve less than 10 letters
- Some px do not improve for 6-12months
Quality of life outcomes following FTMH surgery
• Significant improvements
•Reduced metamorphopsia
- little correlation with improved VA
Describe character of Viteromacular traction
•Vitreous adheres to macula, causing elevation +/- distortion
•Usually asymptomatic
- May progress to FTMH
•May cause metamorphopsia/blurring
• Very common on OCT
Management if Viteromacular traction
•If asymptomatic
- No management as treatment not needed
• If symptomatic
- Vitrectomy + peel
- Ocriplasmin (Jetrea) injection; £2500 per shot, less effective than vitrectomy
Define character of Epiretinal Membrane
•Common in older ppl
- 11-15% of ppl >70
• Glial tissue growth on surface of retina
- Following posterior vitreous seperation
:- Cellophane maculopathy
:- Pre-macular fibrosis
• Contracts
- Distortion of retina
- Elevation and thickening
• Symptoms include Metamorphopsia and reduced VA
Signs of Epiretinal membrane
•Pre-macular sheen
- Shiny appearance
• Retinal folds
• Distortion of blood vessels
- Vessels straightened
- Vessels wrinkled
• Visible white/gray pre-retinal membrane
Causes of Epiretinal membrane
•PVD
- Commonly associated with ERM
- Speculated damage to ILM resulting in glial proliferation
•Retinal breaks
- RPE cells migrate through break and proliferate over macula
•Retinal vein occlusion
• Diabetes
Management of epiretinal membrane
•Asymptomatic
- no management/treatment
• Symptomatic
- Vitrectomy + membrane peel
- can do +/-cataract surgery
•80% reported to improve
- may improve metamorphopsia even if VA unchanged
