Secondary macular holes: when to jump in and when to stay out

Abstract

In spite of the extensive data on pathogenesis and treatment of idiopathic macular hole in the literature, macular holes secondary to other pathologies have received only fragmented attention. Due to great variation in the nature of pathologies that have been reported to cause a macular hole, the key issues of operability and surgical prognosis are equivocal. The pathogenetic mechanisms for the formation of secondary macular hole are similar to those for idiopathic macular hole, with small variations. The main prognostic parameters are morphology of the secondary macular hole, the extent of visual deficit and the background pathology. With judicious case selection, anatomic and visual outcomes can be satisfactory, though not comparable to those of idiopathic macular holes.

Keywords::

• cystoid macular edema
• epiretinal membrane
• internal limiting membrane
• macular hole
• non-idiopathic macular hole
• secondary macular hole
• trauma
• vitrectomy
• vitreomacular traction

Acknowledgements

Figures used in this manuscript are either sourced from the journal EYE as acknowledged in the figure legends (Figures 1, 3, 4A & B), or derived from the author's work at Aravind Eye Hospital and Postgraduate Institute, Madurai, India (Figure 2, 4E & F), during his tenure there as a Professor of Ophthalmology and Consultant, Retina-Vitreous Service until August 2012.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Secondary macular holes (SMH) are caused either directly by tissue loss due to primary agent: trauma, inflammation, degeneration etc., or indirectly, by the development of an epiretinal membrane (tangential traction), cystoid macular edema or anteroposterior vitreoretinal traction.

• • The default management of SMH is observation, which has diverse implications, waiting for SMH to close spontaneously, treating the cause first, or abandoning any intervention in view of unsalvageable background pathology.

• • The decision to operate is based on two key factors: visual acuity and morphology of SMH. Visual acuity should be neither too good nor too bad, and should correspond to SMH. If an SMH looks like an idiopathic macular hole, it is likely to have similar surgical outcomes.

• • A meticulous pre- and intraoperative evaluation is mandatory, and includes looking for a relative afferent pupillary defect, confounding effects of the primary pathology, and peripheral lesions.

• • The surgical steps are same as for any macular hole with a few riders, for example, internal limiting membrane should be peeled whenever possible, and a long-acting gas (or silicone oil) should be used for tamponade.

Notes