SIGNS AND SYMPTOMS
Macular holes develop in stages, including: foveal detachments (stage I), partial-thickness holes (stage II), and full-thickness holes (stage III). A stage IV macular hole is an advanced full-thickness hole, with vitreous separation from the optic disc and macula. Depending on the stage, vision may range from 20/20 to <20/400; however, in full-thickness macular holes, the acuity is generally 20/80 to 20/200.
Patients usually report a rather abrupt loss of central vision. A full-thickness macular hole clinically appears as a round, brick-colored lesion in the center of the macula, usually one-third to two-thirds of a disc diameter.
The surrounding retinal tissue appears gray and elevated, and often
there are small yellow deposits within the hole, reminiscent of drusen. Foveal detachments
and partial-thickness holes do not appear red, but rather present as a loss of the
foveolar depression with the development of a central yellow spot or ring. Stage II holes
are accompanied by a red, crescent-shaped retinal break at the lesion's edge. Fluorescein
angiography reveals an RPE "window defect" with early-stage hyperfluorescence.
Currently, the most widely held theory proposes that pre-foveal vitreal shrinkage induces tangential traction on the fovea, eventually promoting hole formation. As contraction ensues, the tangential tugging at the fovea induces a separation of the sensory retina from the underlying RPE. The foveal retina, without a firm attachment to the RPE, suffers a compromised nutrient supply and loses its ability to eliminate waste.
Ultimately, the sensory retina atrophies, forming a break and
progressing to a full-thickness hole. Macular holes may also result from chronic macular
edema, solar retinopathy and blunt ocular trauma.
More recently, research has shown some benefit to surgical excision of the macular vitreoretinal adhesions in eyes at risk for full-thickness holes. The procedure involves pars plana vitrectomy, excision of the attached cortical vitreous and gas/fluid exchange. Growth factors such as transforming growth factor-b2 have been used to induce regeneration of the macular tissue. This procedure has achieved moderate success. Candidates for surgical intervention must have 20/50 visual acuity or worse, and a stage III or IV macular hole in at least one eye.
For cases that do not lend themselves to surgical
intervention, consider low vision services.
Other reports in this section
Eyelids & Eyelashes | Conjunctiva & Sclera | Cornea
Uvea | Vitreous & Retina | Optic Nerve & Brain | Oculosystemic Disease
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