Macular hole
-
Upload
narciso-atienza -
Category
Health & Medicine
-
view
4.745 -
download
39
description
Transcript of Macular hole
Macular hole
Narciso F. Atienza, Jr. MD, DPBOMichael Shea Vitreo-Retina Fellow,
University of TorontoSt. Michael’s Hospital (2002-2004)
Chief Retina Service: Cardinal Santos Medical Center
First described by Knapp (1869) and Noyes (1870)
First coined by Ogilve (1900) Initially thought as untreatable. Patho-physiology unknown.
Factors inciting macular hole formation Vitreous syneresis Posterior vitreous separation Cystoid macular edema
• Previous ocular surgery
• Inflammatory process Traumatic blunt ocular injury
• Accidental laser injury• Lightning• Electrical shock
High Myopia
Theory on Macular hole formation
Lister (1924) Stated the importance of the vitreous in
the pathogenesis.
Tangential traction on the macula• Remnant posterior vitreous membrane on the macula
with contractile cells. Focal shrinkage of foveal vitreous cortex Tractional elevation of the Henle’s nerve fiber
layer. Intraretinal foveolar cyst formation. “Unroofing” of the cyst.
Gass JDM. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol 1988: 106:629-639.
Hydration theory• Together with peri-foveal traction, hydration of
the edges of the hole causes the bridge to expand, increasing the size of the hole.
Tornambe, P. Macular Hole Genesis: The Hydration Theory. Retina: 23 (3) June 2003 421-424
Other theories in macular hole formation
Retinal/choroidal ischemia theory• Affected by RPE dysfunction and possible
intraretinal fluid accumulation in the fovea
Involutional retinal thinning
Incidence and Risk factors (?)
Incidence• 0.05%
• Female predominance
• Lack of Estrogen use
• Bilateral in 3 to 22%
Risk factors• History of glaucoma
• Increased plasma fibrinogen
Gass classification
Stage 1 - localized shrinkage of prefoveal cortical vitreous, tractional shallow detachment of the foveola (loss of the normal foveolar depression and light reflex), retinal striae, Lack of Watzke sign.• Stage 1A - small yellow spot (250-300 mm)
• Stage 1B - foveal detachment progresses, a yellow halo forms
Stage 1
Stage 2 - minute holes form near the center of the detached fovea. This is not an inevitable process. In 50% of cases, the vitreofoveal attachment spontaneously separates.
Followed by restoration of the normal foveal depression and improved visual acuity.
Stage 2
Stage 3 – full thickness macular hole greater than 450 um in size, with no posterior vitreous separation.
Most common presentation in the clinics• Yellow deposits at the level of the retinal pigment
epithelium
• Cuff of subretinal fluid
• Operculum
• Cystoid macular edema
• Positive Watzke’s sign
Stage 3
Stage 4 – full thickness macular hole with a posterior vitreous detachment
Stage 4
The Watzke-Allen test• Slitlamp biomicroscopy
The laser aiming beam test.
Questions asked
(1) Is it possible to reattach the retina around the macular hole?
(2) If it is reattached, will the patient's central vision improve?
Vitrectomy and fluid/gas exchange
Kelly, EK, and Wendel, RT.
Vitreous surgery for idiopathic macular holes: results of a pilot study, Arch Ophthalmol 109:654, 1991
In 30 (58%) of 52 patients, successful reattachment of the detached macula.
In 22 (73%) of the 30 patients in whom the macula was successfully reattached, there was an improvement in visual acuity of two lines or better.
In the 22 patients in whom reattachment of the macular hole was not obtained, there was no significant improvement in visual acuity.
Personal experience
91 cases macular hole surgery (since 7/2004)
76 patients 62 female vs 14 male patients 15 patients (bilateral) VA (CF 4 feet - 20/60)
80 cases – phakic• 68 - PPV alone
• 15 - PPV + phaco IOL
11 cases - pseudophakic Tamponade
• 55 cases - C3F8
• 36 cases - Silicone oil
80 patients (90%) - successful hole closure in one surgery• 71 patients- improvement in BCVA (more than 2 lines)
6 cases - did not close• 2 cases had re-operation (closed after 2nd surgery)
Conclusions
Importance of compliance• (Face down positioning)
Combined surgery • Does not affect closure rate
Tamponade• No direct relationship between gas and oil
(too small for comparison)
Observation
100% of patients will claim compliance • Face down position
Sign of compliance• 41/101 (40%)
Post-operative course
15 developed cataract within 2 years (3 months - 2 years)
No retinal detachments 3 cases of high IOP Failure to close
• 6 cases (1 case still had ILM, 4 cases patients did not position)
Technical modifications
ILM peeling - 91% - 100% No face down requirement - 79%
Surgical adjuncts
Transforming growth factor• 91% vs 53% (Smiddy)
Recombinant TGF-beta• 78% vs 61% (Thompson)
Autologous platelet• 94% vs 81% (Paques)
“If you don’t have complications, then you haven’t operated enough”
Dr. Michael Shea
1st Fellow of Charles Schepens
1st Retina Surgeon in Canada (U of Toronto)