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    Idiopathic macular holes: When to perform vitrectomy

    Take-home message: Retina specialists and comprehensive ophthalmologists should identify full thickness macula holes and, generally, recommend a vitrectomy to close them and improve vision.

     

    The management of idiopathic macular holes can be a challenge for retina specialists. James C. Folk, MD, recently offered guidance on the topic.

    Macular holes are more common in females and patients over the age of 55. There is a 10% to 15% risk of a macula hole in the fellow eye. However, the risk decreases substantially if there is already a posterior vitreous detachment present, said Dr. Folk, who is the Judith (Gardner) and Donald H. Beisner, MD, professor of vitreoretinal diseases and surgery at the Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City.

    “Gass divided macula holes into four stages. Stage 1A and 1B macula holes are characterized by localized perifoveal vitreous detachment, loss of the fovea depression, a cystic change to the retina, and occasionally a foveal yellow spot. Dr. Mark Johnson1 and others have demonstrated that a perifoveal vitreous detachment is often the first stage of a prolonged process that can lead to total posterior vitreous detachment,” he said.

    “Many eyes with Stage 1 holes will have spontaneous release of the vitreous traction and will not progress to become macula holes. They usually should be followed carefully without initial vitrectomy surgery,” Dr. Folk said.

    Stages 2 to 4 are full thickness macula holes. The posterior vitreous is still attached to the fovea in Stages 2 and 3 but detached in Stage 4. “In most cases, macula holes enlarge over time and develop epiretinal membranes,” he said.

    The closure rate and postoperative visual return is lower in macula holes that are older than 6 months compared with more recent holes. There are uncommon exceptions to the natural course of Stage 2 to 4 macula holes but, overall, the results of surgery are much better compared to observation.

    Ocriplasmin (Jetrea, ThromboGenics) is a protease for enzymatic dissection of the vitreous from the retinal surface to remove traction. Excellent, randomized studies showed that an intravitreal injection of ocriplasmin closed 40% of stage 2 macula holes compared with 10% in a saline-injected control group, he said. The injection works best in younger patients, phakic eyes, smaller areas of vitreoretinal adhesion, and the absence of an associated epiretinal membrane.2

    “There is some concern because ocriplasmin can cause macula subretinal fluid, acute vision loss, dyschromatopsia, and electroretinogram (ERG) changes,” Dr. Folk said.3 “The acute vision loss and submacular fluid resolved, however, and the dyschromatopsia and ERG changes, although serious, were rare. On the flip side, modern vitrectomy surgery will seal 90% or more of Stage 2 macula holes but also has complications and involves the use of an intravitreal gas bubble and positioning of the patient.”

     

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