Vitreoretinal Interface And Macular Hole

International Vitreomacular Traction Study classification (OCT-dependent)

• Vitreomacular adhesion: adhesion to central macula only

• Vitreomacular traction: adhesion plus OCT changes (eg. cystoid, loss of contour), but no full thickness defect

• Macular hole:

  • Small: ≤250 microns
  • Medium: >250-≤400 microns
  • Large: >400 microns

Gass’s classification (clinical)

Gass's classification preceded the era of OCT imaging

• Stage 1a (impending): absent foveal reflex, yellow spot at foveola

• Stage 1b (occult): yellow ring, reduced vision, metamorphopsia

  • Equivalent to IVTS classification of vitreomacular adhesion

    • 60% spontaneous vitreo-foveolar detachment with no further progression

• Stage 2 (early): enlargement of yellow ring, <400 microns, full-thickness defect

• Stage 3 (developed): >400 micron hole with surrounding rim of SRF, yellow deposits

• Stage 4: >400 micron hole associated with PVD

Macular hole

• 1 in 10,000 per year

• F>M

• Mean age of 65

• Typically idiopathic/primary

  • 15.6% risk of MH in fellow eye if no PVD present (<1% if PVD)

• Secondary: high myopia, trauma, solar retinopathy

• Diagnostic tests

  • Watzke-allen test
  • Laser beam aiming test
  • OCT
    FFA

Management

• Observation: high rate of spontaneous resolution in stage 1 cases

• Medical:

  • Ocriplasmin is approved by NICE for adults with stage 2 hole but no ERM

• Vitrectomy, ILM peel and gas tamponade is the treatment of choice

  • Better preoperative vision predicts high rate of anatomical closure and visual improvement
  • Shorter duration of symptoms associated with better rates of closure and visual improvement
  • RCT evidence (see Cochrane review) for face-down posturing for 5 days in cases >400 microns

• Autologous platelets have shown increased rate of anatomical closure but no difference in final VA

Prognostic factors for macular holes

• Baseline visual acuity
• Preoperative maximum linear diameter
• Preoperative basal diameter (horizontal size at level of RPE)
• Duration of symptoms (prognosis declines after 6 months)

Traumatic macular hole

• Unclear pathogenesis
• Occurs hours to weeks after injury
• Typically after ocular contusion
• Higher spontaneous closure rates (50%) compared to idiopathic holes so can typically be observed for around 4 months
• Vitrectomy, ILM peel and gas tamponade is effective