Optimal management of idiopathic macular holes

Abstract

This review evaluates the current surgical options for the management of idiopathic macular holes (IMHs), including vitrectomy, ocriplasmin (OCP), and expansile gas use, and discusses key background information to inform the choice of treatment. An evidence-based approach to selecting the best treatment option for the individual patient based on IMH characteristics and patient-specific factors is suggested. For holes without vitreomacular attachment (VMA), vitrectomy is the only option with three key surgical variables: whether to peel the inner limiting membrane (ILM), the type of tamponade agent to be used, and the requirement for postoperative face-down posturing. There is a general consensus that ILM peeling improves primary anatomical hole closure rate; however, in small holes (<250 µm), it is uncertain whether peeling is always required. It has been increasingly recognized that long-acting gas and face-down positioning are not always necessary in patients with small- and medium-sized holes, but large (>400 µm) and chronic holes (>1-year history) are usually treated with long-acting gas and posturing. Several studies on posturing and gas choice were carried out in combination with ILM peeling, which may also influence the gas and posturing requirement. Combined phacovitrectomy appears to offer more rapid visual recovery without affecting the long-term outcomes of vitrectomy for IMH. OCP is licensed for use in patients with small- or medium-sized holes and VMA. A greater success rate in using OCP has been reported in smaller holes, but further predictive factors for its success are needed to refine its use. It is important to counsel patients realistically regarding the rates of success with intravitreal OCP and its potential complications. Expansile gas can be considered as a further option in small holes with VMA; however, larger studies are required to provide guidance on its use.

Keywords: expansile gas; inner limiting membrane peel; ocriplasmin; posturing; tamponade agent; vitrectomy.

Figure 1

SD-OCT images of Stage 1 holes. Notes: (A) Focal VMA without traction (Grade 0). (B) VMT with inner retinal changes, (C) VMT with outer retinal changes, (D) VMT with outer retinal changes, and (E) VMT with inner and outer retinal changes. Abbreviations: SD-OCT, spectral-domain optical coherence tomography; VMA, vitreomacular traction; VMT, vitreomacular traction.

Figure 2

SD-OCT images of macular holes at different stages. Notes: Left, fundus photography; right corresponding SD-OCT section, green line corresponds with level of OCT image, (A) Small IMH with VMA. (B) Small IMH with operculum VMA. (C) Large IMH with operculum and without VMT. (D) Large IMH with complete vitreous separation (Gass Stage 4). Abbreviations: SD-OCT, spectral-domain optical coherence tomography; IMH, idiopathic macular hole; VMA, vitreomacular attachment; VMT, vitreomacular traction.

Figure 3

Hole measurements (top), minimum linear diameter (MLD), and base diameter (BD) measurements. Notes: The MLD is the minimum horizontal linear diameter in an area excluding the operculum and can be in the outer (left) or inner retina (right).

Figure 4

SD-OCT image of a macular hole pre- and post-Ocriplasmin injection without closure. Notes: Left, fundus photography; right, SD-OCT, green line corresponds with level of OCT image, (A) immediately pre-ocriplasmin (OCP) injection (note area of VMA was on edge of hole, not shown), (B) 1 week post OCP injection showing widened base diameter, and (C) following successful hole closure after vitrectomy and ILM peel. Abbreviations: VMA, vitreomacular attachment; ILM, inner limiting membrane; OCP, ocriplasmin; SD-OCT, spectral-domain optical coherence tomography.

Figure 5

SD-OCT image of a macular hole pre- and post-Ocriplasmin injection with successful hole closure. Notes: Left, fundus photography; right, SD-OCT, green line corresponds with level of OCT image, (A) small hole with VMA pre-ocriplasmin injection (note the full-thickness defect was eccentric and shown in insert picture), (B) closure of hole 1 week post ocriplasmin with VMA release but note the presence of subfoveal subretinal fluid, and (C) resolution of subretinal fluid 3 months later. Abbreviations: VMA, vitreomacular attachment; SD-OCT, spectral-domain optical coherence tomography.