120 - Macular hole

Abstract

Macular hole (MH) is a round full-thickness opening in the foveal center, primary in most cases, that is, due to abnormal vitreomacular traction (VMT). It is preceded by a phase of impending MH, which is VMT associated with various degrees of foveal microstructural changes on optical coherence tomography (OCT), often asymptomatic. The risk of progression of impending MH to full-thickness MH is about 30%. MHs may be classified according to their size (small, medium, or large) and the persistence or not of a VMT. Their diameter is measured on OCT B-scan at the narrowest hole point in the mid-retina. Secondary MH may be due to various causes, among which high myopia is the most common. The treatment of MH is mainly surgical, consisting of pars plana vitrectomy; posterior hyaloid detachment when needed; inner limiting membrane peeling in most cases, in particular in large MH; and fluid-gas exchange. Face-down positioning is not mandatory in small MH. The hole closure rate is about 95%. Visual acuity improvement depends on the level of photoreceptor recovery at the foveal center. The complication rate is low, with less than 2% postoperative retinal detachment and less than 2% late reopening. Vitreolysis might be an alternative to surgery in the subset of very small MH with VMT, which may be closed in about 60% of cases.