Good Hope, Heartlands, and Solihull Eye Clinics

Macular holes and foveal cyst   

David Kinshuck

Macular hole

a macular hole

an OCT scan showing a macula hole  enlarge

A macular hole is a hole in the very centre of the retina, in the fovea. (The fovea is the centre of the macular area.)  Vision is reduced. A patient with small new hole may read a word and may notice a few letters missing, and have about 6/12 vision. (animation

  • Surgery is often helpful, although the operation is quite a major. An epiretinal membrane peel is needed to repair a macula hole.
  • Without surgery >90% holes (bigger than 200µ) may progress and ultimately reduce vision to ~6/60. Therefore surgery is recommended for most well patients, if the sight is still good.
  • high myopes Eye 15
  • 2 types..tractional and degenerative AJO 16

Causes

a normal PVDas the vitresou detaches it pulls the retina

 

The condition occurs as people get older. We do not know the exact cause, but It develops as the vitreous gel shrinks. See posterior vitreous detachment PVD.

A hole with good sight may progress. So a patient with 6/24 vision , for instance, may generally benefit from surgery. Expert advice is needed for individual patients.

Macular holes often follow the condition vitreo-macular traction (VMT). It is probably an advanced form of VMT.

It is 'normal' for the vitreous to detach from the back of the retina as we get older. But in this condition, the vitreous is abnormally 'stuck' to the central part of the retina, and pulls it a little. As it pulls he retina it creates a tiny hole.

 

Foveal cyst

A foveal cyst like the one below may be is an early stage of a hole. The fovea is the centre of the macula, and this may develop a cyst as below. Some cysts are due to macular oedema/inflammation as in diabetes, but others are 'early' macular holes as the one shown here. Unless a hole does develop, surgery is not usually needed. Causes are the same as macular hole as below.

 

a foveal cyst, sometimes develops into a macular holea foveal cyst, sometimes develops into a macular hole

 

Pigment epithelial defect

lamellar macula hole

This is not a hole, but a RPE defect, that may be due to an eclipse burn. It may cause a tiny amount of distortion enlarge  (I am not sure of the exact term for this appearance).

 

Lamellar hole, partial thickness

This is a half-thickness hole in the fovea. It causes distortion of central vision, or missing letters in word. An example would be missing the 'g'  in 'age'. The cause in this cause is an epiretinal membrane BJO 2013. 80% of lamellar holes remain stable, 20% do deteriorate...surgery can be helpful in this group.

 

lamellar macula hole

a lamellar macula hole due to an epiretinal membrane  enlarge

 

  • lamellar hole with and without erm Retina15
  • erm Retina15
  • lamellar holes are either degenerative (no surgery) or part of an ERM (epiretinal membrane: surgery may help some patients)

Full thickness hole as part of epiretinal membrane

lamellar hole, full thickness, diagram

enlarge

 

If there is no remaining foveal tissue, surgery will not improve sight.

 

 

Macular hole from laser

Can be repaired. Eye 17

 

 

Technical, macular holes

  • Incidence is 1/10000 year.
  • Surgery helps stage 2-4, (Films study: Ilm peel best)
  • Larger holes are treated with vitrectomy, similarly to ERM peel.
  • If other eye has VMT, this is likely to progress into a hole (42%).
  • Ocriplasmin may help <400µ NEJM 12    see. Only 16% macula holes are <400µ BJO 16
  • after surgery sight improves for 6 months Retina 16

Classification of macula holes

There is a new classification of macula hole. Stage 1-2 may settle them selves, stage 3-4 need surgery to improve symptoms.

  • Stage 1a..............foveal depression lost, yellow spot, a little VMT, small hole< 200µ
  • Stage 1b...............more VMT
  • Stage 2 ................VMT like a drawbridge, can get complete recovery
  • Stage 3..................bigger hole, > 400µ, <1500
  • Stage 4..................hole>1500µ,
  • Stage 4..................same, with operculum
  • RPE protrusion indicate worse prognosis Retina 17

 

Case: macula hole/cyst

A patient, Age 67, female

macula hole

2011 May 6/18 right, foveal cyst, top photos

macula hole2012 Jan       6/36 macula hole. Patient referred to vitreoretinal surgery team, but the hole started to close and surgery was not recommended.