The development and evolution of full thickness macular hole in highly myopic eyes

Abstract

Purpose: To evaluate the morphological changes before and after the formation of a full-thickness macular hole (MH) in highly myopic eyes.

Patients and methods: Retrospective observational case series. From 2006 to 2013, clinical records of patients with MH and high myopia who had optical coherence tomography (OCT) before the development of MH were reviewed. All patients had been followed for more than 1 year since MH formation to observe the morphological changes.

Results: Twenty-six eyes of 24 patients were enrolled. The initial OCT images could be classified into four types: (1) normal foveal depression with abnormal vitreo-retinal relationship (eight cases), (2) macular schisis without detachment (six cases), (3) macular schisis with concomitant/subsequent detachment (nine cases), and (4) macular atrophy with underlying/adjacent scar (three cases). After MH formation, one case in type 1 and one case in type 4 group developed retinal detachment (RD). In type 2 group, four cases developed RD at the same time of MH formation. The preexisting detachment in type 3 group extended in eight cases and improved in one case. Among all the cases, 14 eyes received vitrectomy and 7 eyes received gas injection. MH sealed in nine eyes after vitrectomy and four eyes by gas injection.

Conclusion: The study revealed four pathways of MH formation in highly myopic eyes. MH from macular schisis tended to be associated with detachment. However, the evolution and the results of surgical intervention were not always predictable.

Figure 1

(a–d) Case 1, a 53-year-old female. (a) The initial presentation was an impending hole. (b) Vitreomacular separation with vitreofoveal adhesion caused the disruption of the inner lamina and the formation of MH 1 week later. (c) The MH enlarged 1 month later. (d) The MH sealed after vitrectomy. (e–g) Case 7, a 53-year-old male. (e) The initial presentation was lamellar MH with premacular tangential traction. (f) The MH developed 12 months later. (g) The MH sealed after vitrectomy.

Figure 2

(a–e) Case 14, a 56-year-old male. (a) The initial presentation was schisis on the macular area. (b) The lamellar MH developed 8 months later. (c) Inner lamina dehiscence (arrow) was noted 30 months later. (d) The MH developed 5 months later. The duration from lamellar MH to MH formation was 35 months. The height of the schisis decreased and the retina remained attached. (e) The MH persisted after vitrectomy. (f–i) Case 23, a 66-year-old female. (f) The initial presentation was schisis with foveal detachment. (g) Outer lamina disruption developed nine months later. (h) It progressed to MH with retinal detachment 2 months later. (i) The MH sealed but subretinal fluid remained after vitrectomy.

Figure 3

Case 25, a 61-year-old female. (a) The initial presentation was chorioretinal atrophy with macular scar. (b) MH developed in the area adjacent to the macular scar 18 months later. (c) Macular schisis with epiretinal membrane developed within 2 years after MH formation. (d) It proceeded to macular detachment involving the whole posterior pole 3 years after MH formation. (e) Retinal reattached but the MH persisted after three intravitreal injections of C3F8 0.2 ml.

Figure 4

(a–d) Case 5, a 57-year-old female. (a) The initial presentation was lamellar MH. (b) MH developed 2 weeks later. (c) Prominent outer schisis and enlargement of the MH and the surrounding detachment developed within just 6 weeks. (d) The MH sealed after vitrectomy. (e–h) Case 3, a 60-year-old female. (e) The initial presentation was lamellar MH. (f) MH developed 12 months later. (g) The MH with extensive retinal detachment developed 20 months later. (h) The retinal detachment resolved but MH persisted after vitrectomy. (i–l) Case 22, a 46-year-old male. (i) The initial presentation was schisis with retinal detachment. (j) It progressed to MH with decreased schisis and resolution of retinal detachment 3 months later. (k) The MH sealed after surgery. (l) However, the MH recurred 34 months later.