Retina 3 - Macula Holes

Question 1

What do macular holes result from a combination of?

Answer 1

•Antero-posterior vitreous traction
•traction from internal limiting membrane

Question 2

Average size of macular hole?

Answer 2

400um
or 1/3rd optic disc

Question 3

Stage 1 hole macular hole?

Answer 3

Vitro-macular traction

Question 4

Stage 2 macular hole?

Answer 4

Full thickness hole less than 400um

Question 5

Stage 3 macular hole

Answer 5

Full thickness hole with diameter over 400um

Question 6

Stage 4

Answer 6

Any size, associated with poster vitreous detachment (PVD)

Question 7

Where is the hole diameter measured from?

Answer 7

The narrowest point in the hole

Question 8

What is the basal Diameter hole measured?

Answer 8

The hole diameter from the retina joins the RPE

Question 9

List the presentation of macular hole and its risks?

Answer 9

•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

Question 10

Difference between Macula hole and Lamellar hole?

Answer 10

Macula hole is full thickness hole with minimum 6/18 VA, while Lamellar hole is partial thickness hole, with 6/18 or better

Question 11

Define Character of degenerate lamellar hole

Answer 11

•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

Question 12

Define epiretinal membrane foveoschisis lamellar hole

Answer 12

• Retinal thickening and wrinkling
• Contractile epiretinal membrane
•Schisis at level if Henle’s layer

Question 13

Pseudo hole character definition + difference from Macular hole?

Answer 13

•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

Question 14

Management of Full-thickness Macular Hole

Answer 14

•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

Question 15

Management of Fullthickness macular hole

Answer 15

•2020
- Face down overnight
- Gas bubble lasts 30-35 days

Question 16

Risks of Full-thickness macular hole surgery

Answer 16

•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

Question 17

Quality of life outcomes following FTMH surgery

Answer 17

• Significant improvements
•Reduced metamorphopsia
- little correlation with improved VA

Question 18

Describe character of Viteromacular traction

Answer 18

•Vitreous adheres to macula, causing elevation +/- distortion
•Usually asymptomatic
- May progress to FTMH
•May cause metamorphopsia/blurring
• Very common on OCT

Question 19

Management if Viteromacular traction

Answer 19

•If asymptomatic
- No management as treatment not needed
• If symptomatic
- Vitrectomy + peel
- Ocriplasmin (Jetrea) injection; £2500 per shot, less effective than vitrectomy

Question 20

Define character of Epiretinal Membrane

Answer 20

•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

Question 21

Signs of Epiretinal membrane

Answer 21

•Pre-macular sheen
- Shiny appearance
• Retinal folds
• Distortion of blood vessels
- Vessels straightened
- Vessels wrinkled
• Visible white/gray pre-retinal membrane

Question 22

Causes of Epiretinal membrane

Answer 22

•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

Question 23

Management of epiretinal membrane

Answer 23

•Asymptomatic
- no management/treatment
• Symptomatic
- Vitrectomy + membrane peel
- can do +/-cataract surgery
•80% reported to improve
- may improve metamorphopsia even if VA unchanged