What Is a Macular Hole?

A macular hole refers to a tissue defect that occurs from the inner limiting membrane of the retina to the photoreceptor cell layer, which severely impairs the patient's central vision. Knapp and Noyes first reported traumatic macular retinal fissures in 1869 and 1871, respectively. Kuhnt first reported non-traumatic macular fissures in 1900. Since then, macular fissures of various causes have been recognized.

Zhao Mingwei

(Chief physician)

Department of Ophthalmology, Peking University People's Hospital

A macular hole refers to a tissue defect that occurs from the internal limiting membrane of the retina to the photoreceptor cell layer, which seriously damages the patient's central vision. It often occurs in healthy women over the age of 50 (mean 65 years, female: male = 2: 1). The onset of the disease is concealed and is often discovered when the other eye is covered. Patients often complain of blurred vision, dark central spots, and deformed vision.

Western Medicine Name: Macular hole
Affiliated Department: Department of Ophthalmology-Ophthalmology
Disease site: Eye
The main symptoms: Blurred vision, dark center point, distortion of vision

Main cause: Trauma, high myopia, cystoid macular edema, inflammation, retinal degenerative diseases, premacular and solar ecchymosis, etc.
Contagious: Non-contagious

Introduction to macular hole disease

A macular hole refers to a tissue defect that occurs from the inner limiting membrane of the retina to the photoreceptor cell layer, which severely impairs the patient's central vision. Knapp and Noyes first reported traumatic macular retinal pores in 1869 and 1871, respectively. Kuhnt first reported non-traumatic macular pores in 1900. Since then, macular pores of various causes have been recognized.

The prevalence of this disease is not high, accounting for about 3.3 of the population. Among them, idiopathic macular holes with unknown causes are the most common (about 83%), and often occur in healthy women over 50 years of age (average 65 years, female : Male = 2: 1), 6% to 28% of patients with binocular disease. Some also occur in younger patients.

Macular hole disease classification

Macular holes are classified according to the cause

(1) Idiopathic macular hole

(2) Traumatic macular hole

(3) Macular hiatus in high myopia

(4) secondary macular hole

Macular hole according to the morphology of macular hole

(1) Full-thickness macular hole

(2) Lamellar macular hole

Causes of macular holes

Except for idiopathic macular holes, the etiology of other causes is relatively clear, such as trauma, high myopia, cystoid macular edema, inflammation, retinal degenerative diseases, anterior macular membrane, and solar retinal retinopathy.

The understanding of idiopathic macular holes has gone through a long period of time. Until 1988, Gass proposed that the tangential direction of the retinal surface of the macular area was the main reason for the formation of idiopathic macular holes. In order to use vitreous surgery to treat the macula Cracks provide a theoretical basis. The theory is proposed based on the anatomic relationship of the vitreoretinal interface, which is due to the liquefaction of vitreous body and detachment of vitreous body during the aging process. The retina surface often has a residual portion of the vitreous cortex. Due to the increase in the vitreous cells in these remnant cortex, a tensile force parallel to the retinal surface is formed on the retinal surface in the central foveal area of the macula. Disengagement, eventually forming a full-thickness macular hole. ^[1]

Macular hiatus pathogenesis

The pathogenesis of macular holes is not fully understood. The earliest literature reported that trauma was the main cause of macular hole formation. However, as case reports increased, it was found that only about 5% to 15% of macular holes were caused by trauma. At the beginning of this century, some authors suggested that cystoid macular degeneration is the main cause of macular holes, and some people believe that age-related vascular changes lead to macular atrophy and eventually form macular holes, but these views cannot explain the pathogenesis of idiopathic macular holes. . In 1924, Lister first proposed that vitreous traction is closely related to macular hole formation. Since then, people have noticed the important role of vitreous body in the occurrence of macular hole, and gradually think that the longitudinal stretching of the retina by the vitreous body is the macular hole. Cause of the disease. In 1988, Gass provided a revolutionary insight into the pathogenesis of idiopathic macular holes, and considered that the tangential traction of the vitreous in front of the macular fovea is the main reason for the formation of idiopathic macular holes, providing a vitreous surgery for macular holes. The theoretical basis is established (Figure 31-3). Since then, reports of vitrectomy for macular holes have been increasing. Through vitreous cutting, especially the removal of the posterior vitreous cortex and anterior retinal membrane, the vitreous macular traction is loosened, and the rupture hole is closed in most cases. The visual acuity of some cases is significantly improved after surgery. In 1995, through clinical pathological studies and based on the fact that vision can be improved after vitreous surgery, Gass further pointed out that the formation of idiopathic macular hole is not accompanied by loss of central fossa retinal nerve tissue, which explains why vision can be restored after surgery. . ^[2]

Macular hole pathophysiology

The clinical pathology of macular hole can be expressed as: The size of macular hole is 400 ~ 500m. The "detachment" range around the macular hole is 300-500 m. Atrophy of photoreceptor cells. Macular cyst-like changes. A yellow dot-like deposit similar to a glass wart is attached to the surface of the RPE. Pre-retinal stellate cell membrane appears.

Macular hole clinical manifestations

Macular hole symptoms

The onset of the disease is concealed and is often discovered when the other eye is covered. Patients often complain

Blurred, dark center point, and distortion of sight. Vision is generally 0.02 to 0.5, with an average of 0.1.

Macular hole with fundus manifestations and clinical stage

According to the fundus surface in different stages of the formation of idiopathic macular hole.

Now, Gass divides it into four phases:

Stage I: In the early stage of the onset, the macular foveal cortex spontaneously contracts, causing tangential traction of the retina surface, causing the foveal detachment, the foveal foci reflecting away, and small yellow spots on the surface of the retinal pigment epithelium (RPE) in the foveal area ( 100 ~ 200m), this is the stage Ia; the prefrontal foveal cortex further shrinks, the macular fovea detaches, and a yellow ring (200 ~ 350m) appears on the surface of the RPE. Stages Ia and 1b were not accompanied by the separation of vitreous from the fovea, and did not appear a "real" full-layer macular hole. It is clinically called an impending macular hole, and vision decreased slightly to 0.3 ~ 0.8, Fundus fluorescein angiography can show slight hyperfluorescence in the fovea.

Stage II: A few days to several months after the onset of the disease, the tangential direction of the vitreous is further stretched, forming a macular hole at the edge of the central concave, gradually expanding, from crescent to horseshoe, and finally forming a circular hole, often accompanied by a cover . In a few cases, the macular hole begins to form in the center of the fovea and gradually expands to become a capless hole. Recent studies have found that during the formation of idiopathic macular holes, there is no loss of foveal retinal tissue. The so-called "anterior fissure membrane" is a concentrated posterior vitreous cortex. The edge of the subretinal fluid can be seen around the macular hole, and there is a yellow glassy wart-like deposit at the hole, and the vision drops to 0.1 ~ 0.6. Fundus fluorescein angiography can show moderately high fluorescence.

Stage III: After 2 to 6 months of the above lesions, due to contraction of the retinal tissue, the macular hole is enlarged to 400 ~ 500 m with or without the cover film, which is the stage III macular hole. It can be seen that the yellow glassy wart-like deposits and the edge of the subretinal fluid, the cyst-like changes around the central depression, and the vision decreased to 0.02 to 0.5.

Stage IV: Separation of the vitreous from the macula, early manifestation of the macular foramen translocation, and later stage of the complete separation of the vitreous from the macula and the optic nerve papillae. At this stage, the macular hole is 4

Natural course of macular hole

Stage I macular hole (precursor hole): About 50% develop into a full-thickness macular hole, and 50% of cases resolve spontaneously after the vitreous is separated from the fovea.

Stage II macular foramen: Most cases progress to stage 3 foramen after 2-6 months. In most cases, the size of the macular hole develops to more than 400 m.

Stage III macular hole: Less than 40% of cases develop into stage VI macular hole. Vision is relatively stable in 80% of cases. RPE depigmentation usually occurs in the retinal detachment area after 1 year, and the pigmentation dividing line can appear after half a year. Anterior retinal membranes appear in many cases. Occasionally, spontaneous retinal reduction can occur, and retinal detachment can also occur.

Macular hole with contralateral eye symptoms

(1) The vitreous body is separated from the foveal fovea: there is no danger of macular holes.

(2) The vitreous body and the macular fovea are not separated: the possibility of macular hole formation is <15%.

(3) The premacular membrane covers the foveal area, often accompanied by small yellow dots: the probability of macular hole formation is <1%.

(4) Anterior star-shaped opacification with small fovea in the center of the macula with radial retinal folds: no risk of macular hole formation.

(5) If yellow spots or rings appear in the macular area, combined with other manifestations of the threatened macular holes, it is highly dangerous to form macular holes.

Macular hole diagnosis

Diagnosis of macular hole

Since the advent of fundus coherence tomography (OCT), the diagnosis of macular holes has been difficult. An OCT scan can be used to confirm the diagnosis when a suspicious hole in the macular area is found by ophthalmoscope.

Differential diagnosis of macular hole

1. Etiology identification: causes other than idiopathic macular holes, such as secondary causes caused by trauma, inflammation, high myopia, cystoid macular edema, fundus vascular disease, degenerative diseases, and solar retinal disease Macular edema.

2. Morphological identification: should be distinguished from the other two vitreous traction macular lesions.

(1) Idiopathic macular membrane: Sometimes with macular holes, fundus and OCT can be diagnosed.

(2) Vitreous macular traction syndrome: often causes macular traction deformation, macular edema, and sometimes coexist with macular holes. OCT examination can confirm the diagnosis.

(3) Lamellar macular hole: OCT inspection can determine whether the macular hole is full or lamellar.

(4) Macular hole retinal detachment: It often occurs in high myopia. Idiopathic macular holes often appear shallow detached halo around the macular hole, but rarely cause retinal detachment.

Macular hole disease treatment

Macular hole treatment principles and progress

1. The surgical treatment of the macular hole was previously a restricted area and should be considered only when there is a large range of peripheral retinal detachment. In recent years, due to the study of the pathogenesis of macular holes, it has been recognized that the formation of macular holes is closely related to the traction of the vitreous body to the direction of the concave tangent of the macular center. Therefore, vitrectomy is widely used to remove the vitreous cortex before the fovea to treat macular holes.

The purpose of surgery is to relieve vitreous macular traction. For stage I patients, the removal of the vitreous body, especially the posterior vitreous cortex in front of the macular area, can restore the detached central fovea of the macular. For patients with a full-thickness macular hole, the purpose of the operation is multifaceted, including relief of vitreous macular traction, stripping of the premacular or retinal boundary membrane associated with the onset of macular hole, and gas filling to close the macular hole Wait. For refractory macular holes (such as large holes or recurrent holes), application of autologous serum, 2 transforming growth factor (TGF-2) or autologous platelets on the macular hole may increase choroidal retinal adhesion in the pore area and promote pore closure. Heal.

2. Indication

(1) Therapeutic vitrectomy: The purpose is to promote the closure of macular hole and superficial retinal detachment around the hole.

A. The diagnosis was idiopathic macular hole with stage II ~ IV, and the visual acuity was significantly decreased (0.05-0.4).

B. Macular holes are formed within one year and are willing to undergo surgery.

(2) In the stage of Gass's macular hole, the stage I macular hole did not form a full-layer macular hole. About half of the patients with stage I macular hole can resolve spontaneously. Therefore, it is not recommended to perform surgery on the stage I macular hole. Patients with high risk of developing a full-thickness macular hole can choose surgery carefully.

Whether vitrectomy can prevent full-thickness macular holes is inconclusive. According to the results of a multicenter, randomized, and controlled clinical study in the United States, for patients with stage I macular hole, the incidence of full-thickness macular holes was 37% and 40% compared with the non-surgical observation group (P = 0.81). The number of cases observed is still small, and the efficacy of preventive surgery is uncertain. Therefore, the proposed prophylactic vitreotomy surgery for stage I macular hole needs to weigh the pros and cons. The "pros" of the surgery is to alleviate the mechanical pull of the vitreous to the macula, and the "disads" are the risks that surgery may bring, including: May cause full-layer macular holes, iatrogenic retinal holes, retinal detachment, infection, lens opacity, etc.

3 Surgical methods and progress

The traditional surgical technique is a standard three-incision transluminal ciliary body vitrectomy, with artificial vitreous detachment, subtotal

The vitreous body is excised, the anterior membrane of the macula or the inner retinal boundary membrane of the macular region is peeled off, or the macular hole is closed by supplementation with biological agents. 20% -25% SF6 gas is used for expansion gas / air exchange. At the end of the operation, the patient was placed in the prone position for about 14 days, and the gas in the vitreous cavity was absorbed and returned to normal position.

(1) Micro-incision vitreous surgery

In 2002, the 25G transconjunctival seamless vitrectomy surgery system was introduced. In 2003, the 23G seamless vitrectomy system was used for vitreous surgery. At present, these two vitreous cutting devices have been used in idiopathic macular hole surgery. Domestic Zhao Mingwei and others proposed that the use of 20G manual small incision vitreous surgery has also achieved good results and reduced the cost of surgery.

(2) Inner boundary membrane staining technique

Internal limiting membrane peeling mostly uses internal limiting membrane dyeing techniques. The dyes include trypan blue, brilliant blue G (BBG), bromphenol blue (BPB), and Chicago blue. , CB), triamcinolone (TA) and indocyanine green (ICG). Triamcinolone cannot stain the inner limiting membrane, but it can be easily identified.

4 Surgical complications

The complications of treating idiopathic macular holes are similar to those of ordinary vitrectomy, including nuclear cataracts, transient high intraocular pressure, iatrogenic retinal holes, enlarged macular holes, and phototoxic retinal pigment epithelium. Lesions, vascular obstruction, and endophthalmitis. Among them, the incidence of nuclear cataract is the highest, which can reach 12% -90%. In the literature, about 33% of cases require cataract extraction and intraocular lens implantation 5 to 16 months after the first operation, and the eyes are closed in the macular hole. Vision returned to or better than that before vitreous surgery. About 17.4% of the surgical eyes develop transient high intraocular pressure, which mostly occurs within 3 weeks after surgery, and is mainly caused by gas filling. Generally, symptomatic treatment is sufficient. The iatrogenic retinal hiatus should be avoided during the operation as much as possible. If iatrogenic hiatus occurs, laser sealing should be used instead of condensation sealing to reduce the incidence of postoperative complications such as premacular membrane. ^[3]

Prognosis of macular hole disease

The main reasons for macular hole vision loss are as follows: There are no retinal photoreceptor cells in the hole. Superficial detachment of the retina around the hole. Cyst-like edema around the hole. Cells degenerate to varying degrees around the crack. Vitreous cutting surgery loosens the anteroposterior and tangential traction to eliminate the cause of the disease; gas filling and biological factors close the macular hole to promote retinal neuroepithelial reset, which can improve vision and vision distortion.

The results of different studies on the efficacy of different surgical methods for macular holes are different. Kelly (1991) et al. Used vitrectomy alone (52 cases), with a hole closure rate of 58% and a visual acuity improvement of 2 lines or more was 42.3%. Two years later, the author's case totaled 170 cases. It was 73%, and vision improvement of 2 lines or more was 55%. In recent years, studies have found that using autologous platelets, autologous serum, transforming growth factor 2 (TGF-2), fibrinogen, etc. to fill macular holes during surgery can increase choroidal retinal adhesion healing at the holes, and Effectively improve vision. The literature reported that the use of vitreous cutting combined with TGF-2 to close the macular hole was 91% ~ 100%, and the visual acuity improved more than 2 lines by 83% ~ 90.1%, but some surgeons failed to repeat the same results and found that After the increase in intraocular pressure, the response was obvious. Recently, Thompson et al. Reported that compared with placebo, the use of TGF-2 showed no significant difference in anatomical reduction of macular hole and improvement of vision.

Gaudric (1995) first reported the use of autologous platelets to seal macular holes, and a simple vitreous cut was used as a control (20 cases each). As a result, the platelet group had a 95% closed hole opening, 85% improvement in visual acuity over 2 rows, and pure vitreous The crack closure rate in the cutting group was only 65%. In recent years, with the continuous advancement of surgical technology, more and more evidence shows that using vitrectomy combined with internal limiting membrane peeling can achieve a higher surgical success rate.

The results of a randomized controlled clinical trial by Christensen et al. [10] showed that for phase 2 and phase 3 idiopathic macular holes, the rate of macular hole closure after internal limiting membrane peeling was significantly higher than that without the internal limiting membrane group (2 (Phase macular hole, 100% to 55%, stage 3 macular hole, 91% to 36%).

Factors affecting the prognosis of surgery are as follows: Whether the hole is closed. People with poor pore closure were not satisfied with their vision recovery. Whether the postoperative hole is completely closed may be related to whether the premacular and posterior vitreous cortex is cleared during the operation, whether the membrane around the hole is peeled off, whether there is still tension around the hole, and the patient's head position is maintained after surgery. The appearance of postoperative complications also affects vision recovery, such as cataract formation, pre-retinal hyperplasia after sclera freezing when iatrogenic holes occur. During the operation in the macular hole area, care should be taken to avoid damage to the retinal tissue of the macular area.

With the development of OCT technology, people's understanding of the prognosis of idiopathic macular hole has also deepened. Inoue et al. [11] used frequency-domain OCT to examine 53 patients with macular hole closure after surgery, and found that the connection between the inner and outer segments of the photoreceptor may play an important role in postoperative macular hole vision recovery. The more severe the internal and external intersegmental defect, the worse the visual prognosis. Over time, the internal and external intersegmental connections can be partially restored in some patients, but persist in others. ^[4]

Macular hole disease prevention

For non-idiopathic macular holes with a clear etiology, the occurrence of macular holes can be prevented through treatment of the primary disease and close follow-up inspection. There is no effective prevention method for idiopathic macular holes.

Macular hole disease care

Macular hole surgery is due to the gas filled in the eye, which requires a prone position after surgery. The duration of the prone position depends on the type of gas filled in the eye. Usually 1-2 weeks. At this time, nursing was performed according to the routine intraocular filling nursing after vitreous surgery.