Table 1. Recommendation Grading
|I||High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias|
|I||Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias|
|I-||Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias|
|II||High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal|
|II||Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal|
|II-||Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal|
|III||Nonanalytic studies (e.g., case reports, case series)|
|G - Good quality||Further research is very unlikely to change our confidence in the estimate of effect|
|M - Moderate quality||Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate|
|In - Insufficient quality||Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate|
Any estimate of effect is very uncertain
|S - Strong recommendation||Used when the desirable effects of an intervention clearly outweigh or clearly do not outweigh the undesirable effects|
|D - Discretionary recommendation||Used when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced|
- People with vitreous traction and no macular hole (stage 1-A or 1-B) should be observed. They often remain stable or even improve. Currently, there is no evidence that treatment improves the prognosis.
- Most people with stage 2–4 macular holes have a poor prognosis without treatment. With successful macular hole closure, however, visual prognosis is usually good. Therefore, an ophthalmologist should discuss treatment options that include the opportunity for macular hole closure and the associated visual benefits.
- Recent studies report that approximately 90% of recent macular holes that are 400 µm or smaller are closed by means of vitrectomy surgery.
- Macular holes that have been present for over 6 months have a lower closure rate following vitrectomy, and such patients have less return of vision.
- Macular holes are more common in females than males and usually occur after age 55. There is a high rate of macular hole formation in the fellow eye (10%–15%) in the 5-year period after a macular hole occurs in the first eye.
- Approximately 40% of holes 400 µm or smaller that are associated with vitreous traction were closed following an intravitreal injection of ocriplasmin.
- To prevent visual field loss, prolonged air flow during the air-fluid exchange should be minimized.
- Cataract is a frequent complication of vitrectomy surgery to repair macular holes. This risk should be discussed with patients preoperatively, and postoperative monitoring is advised.
- Most investigators believe that macular holes are caused by pathologic vitreoretinal traction at the fovea. Uncontrolled series also suggest that trauma may be responsible for a minority of macular hole cases.
- The formation of a macular hole typically evolves over a period of weeks to months, although some macular holes may develop more rapidly. In either case, macular holes are frequently detected when the patient’s symptoms change relatively abruptly.
- Typically, the patient will experience metamorphopsia and decreased visual acuity.
- A lamellar macular hole is a partial-thickness defect in the neurosensory retina, whereas a macular pseudohole is an epiretinal membrane with a circular or oval configuration that gives the false clinical appearance of a full-thickness macular hole (FTMH).
- In the United States, a population-based retrospective study of the largely Caucasian residents (>90%) of Olmsted County, Minnesota, estimated the age- and sex-adjusted incidence of macular holes to be 7.8 people and 8.7 eyes per 100,000 people per year.
- More than 50% of holes were found in individuals 65–74 years of age and 72% in women.
- The 5-year risk of a patient with a FTMH of developing a FTMH in the fellow eye is approximately 10%–15%, especially when the vitreous remains attached or a lower risk when the vitreous appears detached.
Table 2. Stages and Characteristics of Macular Holes
|a Drusen-like or yellow deposits may represent macrophages at the level of the retinal pigment epithelium, suggesting chronicity of disease.|
- The initial evaluation of a patient with symptoms and signs suggestive of macular hole includes all features of a comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to macular hole. (II++, G, S)
- A complete history includes: duration and location of symptoms, ocular history, and medication use that may be related to macular cystoid edema. (III, G, D)
- Physical examination includes slit-lamp biomicroscopy of the macula and vitreoretinal interface, and the optic disc to rule out an optic pit or advanced cupping. (III, G, S)
- Physical examination also includes an indirect peripheral retinal examination and an Amsler grid test. (III, G, S)
- OCT offers detailed information about the anatomy and size of the macular hole and the presence of vitreous traction or an epiretinal membrane, all of which aid in the diagnosis, staging, and follow-up. (III, M, D)
- The initial evaluation should include a careful assessment of the fellow eye. (III, G, S)
- It is important to diagnose a macular hole in the fellow eye as soon as possible, and patients should be educated about warning signs such as metamorphosia or mild decreases in central visual acuity. (III, G, S)
- OCT may also help to identify at-risk eyes evident by vitreous traction at or near the center of the macula. (III, In, D)
Table 3. Idiopathic Macular Hole (Initial Evaluation and Therapy)
Initial Exam History (Key Elements)
- Duration of symptoms
- Ocular history: glaucoma, retinal detachment or tear, other prior eye diseases or injuries, ocular surgery, or prolonged sun or eclipse gazing
- Medications that may be related to macular cystoid edema (e.g., systemic niacin, topical prostaglandin analogues)
Initial Physical Exam (Key Elements)
- Visual acuity
- Slit-lamp biomicroscopic examination of the macula, vitreoretinal interface, and optic disc to rule out an optic pit or advanced cupping
- Indirect peripheral retinal examination