Pathogenesis and management of macular holes with video demonstration.pptx

Presented
By
Dr. Avuru Chukwunalu James
1/11/2023

 INTRODUCTION
 EPIDEMIOLOGY
 PATHOGENESIS
 CLASSIFICATION
 MANAGEMENT
 HISTORY
 PHYSICAL EXAMINATION
 INVESTIGATION
 TREATMENT AND CURRENT TREND IN MH SURGERIES
 CONCLUSION
 REFERENCES

 A macular hole is a break in the macular
commonly involving the fovea.
 Full thickness macular hole: Internal
limiting membrane (ILM) to the outer
segment of the photoreceptor layer.
 First described by knapp in 1869
 Case series as at 1970s reported
predominant causes

 Peak incidence of IDM is in the
seventh decade of life,
 Sex
 Prevalence
 3.3 cases in 1000 in those 55 years
and above in USA
 0.17% with a mean age of 67 years
India
 1.6 out of 1000 elderly Chinese
 4% of retinal diseases in Benin city,
Nigeria
 6.6% in South-South Nigeria
 4.2% - 18% of retinal diseases in
Southwestern Nigeria
 In Ekiti, Ajayi et tal reported MH as
0.5% (new eye cases) and 6.9% of
new cases with retinal diseases,
 In Ibadan, Oluleye et al reported
MH as 14.9% of all macular
diseases seen in UCH(2015- 2019)

 Shrinkage of prefoveal cortical
vitreous
 persistent adherence of vitreous to the
foveal
 VR Traction :Tangential traction and
anterior posterior vitreoretinal traction

 Trauma-related MH: transmission of
contusion force in a contrecoup
manner on the macular.
 Decreased globe’s anterio-posterior
diameter and equatorial expansion
 Immediate rupture of the macula at its
thinnest point.

CLASSIFICATION MACULAR HOLE
CLASSIFICATION- GASS
 Stage 1(impending Macular hole):
 loss of the foveal depression(increased
clinical prominence of xanthophyll
pigment)
 Stage 1A: Foveolar detachment with
loss of the foveal contour and a
lipofuscin-colored spot)
 Stage 1B: foveal detachment
(lipofuscin-colored ring)

 Stage 2: Full thickness break < 400µm in size
 posterior hyaloid still attached to the fovea
 Stage 3: Full thickness break ≥400 µm in size.
 A grayish macular rim.
 Posterior hyaloid is detached over the fovea
 With or without an overlying operculum.
 Posterior hyaloid remains attached to the optic disc

CLASSIFICATION CONTD
• Stage 4: Full thickness break ≥400
µm in size.
• A grayish macular rim.
• Complete posterior vitreous
detachment and Weiss ring.

 Vitreomacular adhesion (VMA):
 No distortion of the foveal contour
 Size of attachment area
 Focal if </= 1500 microns
 Broad if >1500 microns

 Vitreomacular traction (VMT):
 Distortion of foveal contour present
or intraretinal structural changes
 size of attachment area
 focal if </= 1500 microns and
 broad if >1500 microns

 Full-thickness macular hole (FTMH)
 Size -- horizontal diameter at narrowest
point:
 small (≤ 250 μm),
 medium (250-400 μm),
 large (> 400 μm); 2)
 Cause -- primary or secondary;
 Presence or absence of VMT

 HISTORY
 EXAMINATION
 INVESTIGATION
 TREATMENT

 Age
 Sex
 Onset and duration of symptoms
 Blurring
 Straight lines bent or wavy
 Trouble reading small print or
driving
 Dark spot
 A break/discontinuity in calibre

 Myopia
 Trauma
 Ocular inflammation
 Ocular surgeries
 MH in the other eye or Family
 Previous Hysterectomy
 Systemic diseases
 Treatment sofar

 Visual acuity: Reported to vary
with stages.
 VITAL SIGNS
 LID
 ANTERIOR SEGMENT
 VITREOUS
 FUNDUS…….direct and indirect
ophthalmoscope
 GRADING OF MACULAR HOLE

EXAMINATION:
BIOMICROSCOPIC (SLIT LAMP
+78 D/+90D)
 A round excavation with well-defined
borders interrupting the beam of the slit
lamp
 An overlying semitranslucent tissue,
representing the pseudo-operculum, may
be seen suspended over the hole.
 Surrounding cuff of subretinal fluid
 Yellow-white deposits at the base,

 Amsler grid test:Not specific for macular
hole  Watzke-Allen TEST: Performed
on the slit lamp

LASER AIMING BEAM TEST
 Performed at the slit lamp
 A small 50-µm spot size used
 Positive test when the patient fails
to detect

MICROPERIMETRY
 Can be done by using Goldmann
III stimuli (10 cd/m2 luminance)
randomly presented for a duration
of 200 milliseconds on a
1.27 cd/m2 background.
 Central 10° from fixation
accessed.

 Laboratory tests are not indicated
for diagnosis; Determine general
well being of patient and
optimization for surgery.
 FBC
 FBS
 E/U/CR
 Ocular imaging and
electrophysical tests
 OCT
 FFA
 FAF
 B-SCAN
 Multifocal electroretinography

 OCT; Gold standard test for
confirmation
 FFA

 There is a strong subfoveal
autofluorescence signal in full-
thickness macular holes
 Punctate autofluorescence for stage
1

B-SCAN
ULTRASONOGRAPHY
 Helpful in elucidating the
relationship of the macula to the
vitreous
 May be helpful in staging the
disease

MULTIFOCAL
ELECTRORETINOGRAPHY
 Provides a topographic map of
electrophysiological activity in the central
retina.
 mfERG responses show lower amplitudes in the
fovea in macular hole
 Shows loss of retinal function corresponding to
the macular hole.

 Pseudo-hole due to epimacular
membrane
 Lamellar macular hole
 Cystoid macular edema
 Vitreomacular traction syndrome

 General measures
 Medical treatment
 Surgical treatment

 STAGE O AND STAGE 1
 Asymptomatic
 No Vitreomacular traction Stage 0

 Intravitreal ocriplasmin 0.125mg in
0.1ml
 MIVI-TRUST clinical trials was a
double-blind study, 652 eyes with
vitreomacular adhesion were
evaluated
 58.3% closure rate for holes of less
than 250 µm diameter

Removal of vitreous
traction
Removal of scaffold for
myofibroblast, fibrocytes,
RPE proliferation
Intraocular tamponade
Head positioning
In 1991, Kelly and Wendel
 Pars plana vitrectomy
 Epiretinal membrane removal
 Internal limiting membrane (ILM)
peeling
 Gas endotamponade
 Prone posturing postoperatively

 Standard 3-port (light source, vitreous
cutter, irrigation/drainage) pars plana
vitrectomy systems (ie, 27 gauge, 25
gauge, 23 gauge)
 Non-contact lens e.g Zeiss RESIGHT,
Oculus BIOM
 Contact lens e.g DORC flat vitrectomy
lens
 The anterior and middle vitreous is
removed

 Removal of the perimacular traction exerted by
the posterior hyaloid on the macula
 Use soft-tipped silicon cannula or the vitrectomy
cutter with the cutter disengaged.

EPIRETINAL MEMBRANES
REMOVAL
 Epiretinal membranes, if present,
should be removed.
 ERM in pseudo macular hole.

REMOVAL
OF INTERNAL LIMITING MEMBRANE
(ILM) AND INVERTED ILM FLAP
 Removal by pinch and peel technique
 Vital dyes /Stains for ILM

SURGICAL TREATMENT:
AUTOLOGOUS
TRANSPLANTATION OF ILM
 Involves ILM peeled off to make a free flap
 Transplanted and placed inside the macular hole
 Failure of standard ILM peeling
 Eyes with myopic foveoschisis
 Trauma.
 Air–fluid exchange performed.

AIR-FLUID
EXCHANGE (INTERNAL TAMPONADE-AIR,
GAS, SILICON OIL)
 Silicone oil vs Intravitreal gas vs
Air tamponade
 Duration of tamponade
 Toxicity
 Number of surgeries
 Anatomic and Visual outcome

 If visual acuity is good and stable, observe most lamellar holes- no surgery
(Theodossiadis et al)
 If visual acuity worsens, surgical intervention is indicated
 Pars plana vitrectomy, ERM peeling, and ILM peeling without intraocular
tamponade may be enough ( Michalewska et al)

ADJUNCTIVE
 AUTOLOGOUS SERUM; Instilled over the macular hole following an air–fluid
exchange to enhance anatomic success.
 Helps to remove ICG dye used in surgery
 Reduces ICG toxicity
 Amniotic membrane graft
 Autologous platelet concentrate
 Transforming growth factor beta 2
 Manipulation of the edges of the macular hole using Tano diamond membrane
scrapper or other instrument to mobilize the edge of the holes towards closure

REMOVAL OF INTERNAL
LIMITING MEMBRANE
(ILM) CONTD
 The Manchester Large Macular Hole Study showed that the standard ILM peeling was
very effective for macular holes up to 650 microns.
 The closure rate of 90% for holes smaller than 650 microns
 76% closure rate for holes larger than 650 microns.
 Rizzo et al demonstrated a significant difference in hole closure rates for patients with
axial eye lengths of more than 26mm (39% with ILM peeling vs 88% with ILM flap)
 Rizzo et al also showed that macular holes of more than 400 microns closure rate (79%
with ILM peeling vs 96% with ILM flap).
 CONSIDERATIONS: Dyes retinotoxicity, structural integrity, b-wave recovery

CURRENT TREND: FACE-
DOWN POSITIONING
 Historically, strict face-down
positioning:recommended for patients for up
to 4 weeks
 Further study advocated shorter periods of
face-down positioning such as 1 day
 The advent of ILM peeling has encouraged
minimal to no face-down
 Tranos et al showed more rapid progression
of cataract formation with less face-down
positioning
 Alberti and Ia Cour compared face-
down positioning with nonsupine
positioning
 found equivalent macular hole closure
rates and noninferiority of nonsupine
positioning
 Hu et al, reported no difference with
positioning for MH < 400 microns.

 Preoperative visual acuity: most important
 Closure rates higher with shorter duration of symptoms: Jaycock et al, Thompson et
al
 Macular hole size
 ILM peeling
 Age of patient

 Retinal detachments: 2-
14%(development of iatrogenic retinal
breaks following induction of a
posterior vitreous detachment)
 Iatrogenic retinal tears
 Enlargement of the hole
 Macular light toxicity
 Postoperative IOP elevation
 Cataractogenesis.
 Visual field defects
 Failure of hole closure/hole
reopening

 Macular hole is one of the retinal problems that causes loss of central vision
 Early presentation and appropriate intervention will guarantee a better
outcome.
 Adequate counselling of patients preoperatively that anatomical closure
success rate does not amount to visual success rate is necessary.

 Kanski J. Clinical Ophthalmology: A Systematic Approach. Nineth Ed. Elsevier Health
Sciences; 2020.macular hole. p. 592-7.
 Channa R, Adrienne W. Managing Macular Holes-Common questions associated
with this anomaly are addressed. Retina Today. Jan 2016. [Accessed October 31,
2023]. Available from https://retinatoday.com/articles/2016-jan-feb/managing-
macular-holes
 Kean Theng Oh, Macular Hole Treatment & Management: Medscape.Updated: Jan 02,
2020
 Omesh P. Gupta et’al, Macular Hole. Eyewiki:Updatedby Christina Y. Weng, MD, MBA
on August 7, 2021. https://eyewiki.aao.org/Macular_Hole#Figure2
 Macular holes. N Engl J Med. 2012;367(7):606–615.
 Idiopathic Macular Holes, American Academy of ophthalmology: Retna and vitreous,
2016-2017BCSC

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