Macular Hole

50.1General Considerations

The question whether to surgically intervene for a macular condition should be decided based neither on the appearance of the posterior pole nor on the VA level.1 Appearance can be deceiving in both directions: what looks like a horrible anatomical situation may still permit good vision; conversely, even a seemingly minor abnormality may cause severe visual loss.

Pearl

In macular diseases where traction plays a part, metamorphopsia is usually more important for the patient’s quality of life than the VA; it is therefore imperative that the ophthalmologist not focus on the VA alone when determining the severity of the condition. This also helps to avoid the sadly common habit of using an arbitrary cutoff VA value to indicate or deny surgery (see Chap. 5).

50.1.1 VMTS

The condition is characterized by an anomalous PVD with strong focal residual adherences to the central retina. The central vitreous may prolapse through an opening in the posterior vitreous cortex and adhere to the foveal region. OCT is a great tool in showing the condition preoperatively and the results of surgery (see Fig. 50.1).2 The posterior cortical vitreous has a sheet-like appearance, which can

1 A very typical example of what should not be said by the ophthalmologist is this quote: “surgery is usually reserved for patients with vision worse than 20/40.”

2 The OCT image may show similarities to that seen in a central RD (see Sect. 56.1), and cataract extraction may exacerbate the traction by increasing the space available for vitreous movement.

F. Kuhn, Vitreoretinal Surgery: Strategies and Tactics,

DOI 10.1007/978-3-319-19479-0_50

Fig. 50.2 Cellophane maculopathy, preoperative view. Very fine folding of the ILM is visible, especially in the superotemporal area. The folds are not full thickness as EMP-induced folds would be

Fig. 50.3 EMP causing severe changes in the macular anatomy. This a rather centrally located scar, which is understandably responsible for a loss in VA. The metamorphopsia it also causes is explained by the traction the contracting scar exerts on the retina, leading to full-thickness folds, hemorrhages, and distorted vessels

membranes are made mostly of collagen with relatively few cells. They may be secondary to a disease4 or treatment5 but in most cases they are idiopathic.

Some ophthalmologists started giving patients with EMP intraocular anti-VEGF injections (see Chap. 43). This medication indeed helps temporarily if the edema is the main culprit in the reduction of the VA. However, recurrence of the fluid is inevitable, and the retinal changes that manifest themselves as metamorphopsia for the patient will not be addressed by any type of medication. The only chance for a definite cure is surgery.6

4Such as RD, VH, and trauma.

5Such as SB, panretinal laser.

6Ocriplasmin is not a viable option since the condition is not caused by VR traction, and the vast majority of the cases already have a spontaneous PVD when the patient presents.

50.1.4 Macular Hole

VR as well as tangential (surface) traction causes the retraction of the retina from the epicenter; it is often accompanied by an EMP.7

50.2Surgical Technique8

50.2.1 VMTS

•Start the vitrectomy in front of the posterior pole and create a small pocket just above the macula.

–The fovea is already under severe traction: start cutting as soon as you start aspirating.9

•Inject a minimal amount of TA so that the vitreomacular interface is clearly delineated.

•Severe the connection between the posterior vitreous and the retina.

–It may be necessary to use scissors if the posterior cortical vitreous has formed a strong, distinct sheet. There is greater control if the cutting is done with scissors. Use of the probe is limited anyway because it is impossible to “sink its teeth into the membrane” as no edge is available (see Fig. 38.2b, right hand side).

•Once the macula is freed from all vitreous adhesions, continue with a careful PVD.

–As mentioned above (Sect. 50.1.1), strong adhesion between the membranelike posterior hyaloid cortex and the retina can exist anywhere. Be slow with the PVD and do not try to carry it too far anterior; even then, the adhesion between retina and the cortical vitreous is similar to two sheets of paper glued together. The strength of this adhesion is shown by the appearance of small hemorrhages as you try to detach the hyaloid, forcing you to choose from two options: continue with the PVD and risk an intraoperative retinal tear formation, or leave the adhesion behind and risk that tears occur postoperatively.10 The dilemma is similar to that described under Sect. 32.3.1.4, except that in the case of a VMTS retinectomy is not an option any surgeon would prefer choosing.

–Be mindful that if the condition has been present for a long time, the central retina may a have convex, rather than concave, configuration.11 This is important to keep in mind both for the creation of the PVD and the peeling of the ILM.

7If the latter is sparing the fovea, it is called a pseudohole; OCT enables the ophthalmologist to determine whether a true, partial-thickness, or pseudo-hole is present.

8See Chap. 32 for many additional details.

9Aspiration without simultaneous cutting, as is done during PVD, is contraindicated.

10Neither is an appealing choice. Logic would tell you that having the problem intraoperatively is favorable since at least no vitreous is left behind and the tear can immediately be treated. However, it may truly be impossible to separate the vitreous from the retina, which only aggravates the problem.

11Much like in an eye with severe macular edema (see Fig. 49.5).