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.

By Vanessa Caceres

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.”

Vitrectomy for a macula hole is typically done with 23- to 25-gauge instrumentation. A core vitrectomy is first performed followed by detachment and removal of the posterior vitreous face from the retina followed by a gas tamponade. Surgeons debate whether the internal limiting membrane (ILM) should be peeled in every case, Dr. Folk said. Peeling of the ILM removes residual epiretinal membranes and cells that can be left behind after the vitreous is removed. This can result in a better initial closure rate and a decreased rate of later reopening of the macula hole.

Most surgeons will use dyes such as indocyanine green or Brilliant Blue to visualize the ILM. Although Brilliant Blue is thought to be safer, most studies showed that the two dyes have been shown to have equivalent results after 6 to 12 months of follow-up,⁴ Dr. Folk said. Brilliant Blue is not available in the U.S. In addition, the closure rate of recent or smaller macular holes is very good, even without ILM peeling, he said.

After surgery for a macular hole, patients were previously told they had to stay face down for 1 to 2 weeks, as that was thought to be important for sealing. “Now, we’ve become a little more relaxed with that face-down recommendation,” Dr. Folk said. Some surgeons will say patients are fine so long as they are not on their back, and others recommend positioning their head down for only 2 to 3 days.

Virtually all phakic patients with a macular hole will go on to develop cataracts. Retinal detachment occurs in up to 1% to 5% of patients, and endophthalmitis occurs in 0.05% of patients.^5-7

“Visual recovery varies with the duration and size of the hole,” Dr. Folk said.

The biggest decision an ophthalmologist must make is to decide if a macula hole is actually present, as well as other retinal disease.

“If it is just vitreous traction without a hole, you should probably follow the patient, depending on the symptoms and acuity. If a hole is present, you should probably recommend surgery,” he said.

References

• Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc. 2005;103:537-657.

• Haller JA, Stalmans P, Benz MS, et al. Efficacy of intravitreal ocriplasmin for treatment of vitreomacular adhesion: subgroup analyses from two randomized trials. Ophthalmology 2015;122:117-22.

• Kaiser PK, Kampik A, Kuppermann BD, et al. Safety profile of ocriplasmin for the pharmacologic treatment of symptomatic vitreomacular adhesion/traction. Retina. 2015 Jun;35(6):1111-27.

• AAO Retina/Vitreous Preferred Practice Pattern Panel. Idiopathic Macular Hole PPP-2014. American Academy of Ophthalmology. http://one.aao.org/preferred-practice-pattern/idiopathic-macular-hole-ppp--2014

• Tarantola RM, Tsui JY, Graff JM, et al. Intraoperative sclerotomy-related retinal breaks during 23-gauge pars plana vitrectomy. Retina 2013;33:136-42.

• Grosso A, Panico C. Incidence of retinal detachment following 23-gauge vitrectomy in idiopathic epiretinal membrane surgery. Acta Ophthalmol 2011;89:e98.

• Le Rouic JF, Becquet F, Ducournau D. Does 23-gauge sutureless vitrectomy modify the risk of postoperative retinal detachment after macular surgery? A comparison with 20-gauge vitrectomy. Retina 2011;31:902-8.

James C. Folk, MD

E: james-folk@uiowa.edu

This article is based on Dr. Folk’s presentation “How Does the Retina Specialist Manage Idiopathic Macular Hole?” at the annual meeting of the American Academy of Ophthalmology last year. He presented on behalf of the 2014 Retina/Vitreous Preferred Practice Pattern Panel.