Current Practice Pattern for Macular Hole Management

Abstract

Macular holes can be idiopathic, post-traumatic, myopic or secondary to conditions like chronic cystoid macular edema and epiretinal membrane formation. Optical coherence tomography (OCT) is an imaging modality which has revolutionized the diagnosis and management of macular holes. 1-3 The extraordinary high axial resolution of OCT provides an insight of the internal architecture of the retina thereby helping in predicting the anatomical and functional prognosis of a macular hole surgery. Idiopathic macular hole stages were originally described by Gass 4 and modifi ed by Gaudric et al who presented a study of macular hole formation documented by optical coherence tomography (OCT) in the 1990s. 5 Microincision vitrectomy surgery (MIVS) has greatly enhanced the success rate with minimal complication rate of a macular hole surgery. We will discuss the preferred practice patt ern with a few of the leading vitreoretinal surgeons. The questions have been prepared by Dr Manisha Agarwal, head of vitreoretina Services at Dr. Shroff 's Charity Eye Hospital, Daryaganj, New Delhi. The answers by the experts have been summarized by Manisha Agarwal at the end of each question. Manisha Agarwal-Q. When do you advise a macular hole surgery? Your cut off for best corrected visual acuity (BCVA), duration and etiology of macular hole which helps you decide? A.Giridhar-In patients with a recent macular hole of a maximum duration of not more than 4-6 months. I operate on patients with visual acuity 6/9 or less. I also operate on patients with poor vision i.e. counting fi ngers, because sometimes vision cannot be correlated with the size of the hole as one may have a patient with a reasonably small hole and a visual acuity of less than 6/60. Cyrus M. Shroff-I advise surgery for almost all macular holes provided the patient is symptomatic and understands regarding the process of surgery, post-op prone positioning, possible limitations in the fi nal visual recovery. I would operate even at 6/9 vision if the patient is symptomatic. One situation where I may not advise surgery is when there is a small hole with the posterior hyaloid att ached to an elevated fl ap of the hole as there is a fair chance of spontaneous closure and therefore observes for 4-6 weeks. I don't consider the duration of the macular hole as a deciding factor though the recent holes generally do bett er anatomically and functionally. Regarding etiology, idiopathic holes generally do the best. I would dissuade someone who developed a hole after long standing cystic disease in the macula or underlying RPE atrophy or scar and vision was poor even prior to macular hole formation. Lalit Verma-Today because of the ease and advances in vitreoretinal surgery any macular hole is worth operating however generally advise macular hole surgery in patients with BCVA less than 6/12.It is not easy to determine the exact duration of the macular hole unless the patient has the previous records of vision, fundus photographs and optical coherence tomography. Mahesh P. Shanmugam-Eyes with ...