The development and evolution of lamellar macular hole in highly myopic eyes

Abstract

Background/objectives: To study the development, evolution, outcomes, and prognostic factors of lamellar macular hole (LMH) in highly myopic (HM) patients.

Methods: Fifty eyes from 47 HM patients with LMHs were retrospectively enrolled. Relevant pre- and post-LMH optical coherence tomography findings and visual acuity were collected. Structural progression was defined as an increase in the height of retinoschisis, and the development of foveal detachment, full-thickness macular hole, or retinal detachment.

Results: Four traction-related developmental processes were identified. Type 1 LMHs (8, 16%) developed from foveal avulsion caused by vitreomacular traction. Type 2 (32, 64%) and type 3 LMHs (5, 10%) formed from ruptured parafoveal and central foveal cysts, respectively. Progressive foveal thinning caused by epiretinal membranes (ERMs) without cystic changes led to type 4 LMHs (5, 10%). Retinoschisis developed before (9 eyes), after (10 eyes), or simultaneously with (6 eyes) the LMH formation. Structural progression was noted in 50%, 53%, 0%, 100% of patients with type 1-4 LMHs, respectively. Multivariable Cox proportional hazard model showed that greater residual foveal thickness (P = 0.001, adjusted odds ratio = 0.22, 95% confidence interval [CI], 0.08 ~ 0.56), and the absence of retinoschisis were protective against structural progression. Multivariable linear regression showed that poor baseline visual acuity (P < 0.001, β = 0.74, 95% CI 0.41 ~ 1.07) and type 4 LMH predicted worse visual outcomes.

Conclusions: Four traction-related LMH developmental processes were observed in HM eyes and exhibited different evolution and outcomes. LMHs with foveal thinning induced by ERMs had the worst outcomes.

Fig. 1. Lamellar macular holes (LMHs) with different developmental processes and temporal relationship with retinoschisis.

a–h Four types of developmental processes of LMH (a, b) Type 1 LMH develops after the avulsion of foveal tissue induced by vitreomacular traction (c, d) Type 2 LMH develops after the disruption of the medial wall of the parafoveal cyst (e, f) Type 3 LMH develops after the deroofing of the central foveal cyst (g, h) Type 4 LMH develops from the progressive central foveal thinning induced by the epiretinal membrane. Intraretinal cyst or schisis is not observed. i–l A representative case of LMH evolved from the “tractional configuration” into “degenerative configuration”. i, j LMH develops from the disruption of the foveal cyst by vitreomacular traction (type 1). k It has the features of “tractional LMH” with foveoschisis and a sharp edge. l Four years later, it has transformed into a “degenerative LMH” with a foveal bump and a round edge (asterisk). m–r The different chronological sequences of the LMH and macular retinoschisis (m, n) Group 1: LMH formed before the development of retinoschisis (o, p) Group 2: LMH and retinoschisis developed concurrently (q, r) Group 3: LMH developed in the presence of retinoschisis.