Shruthi Mankal
Introduction
Idiopathic, full-thickness macular holes (iFTMH) are foveal defects involving all neuroretinal layers, accounting for 85% of macular holes (1). They arise from age-related vitreous changes causing vitreomacular traction and subsequent hole formation (2), with peak incidence between the ages 60 to 70, and a 2-3 times greater incidence in women (3). Symptoms include blurred vision, decreased visual acuity, metamorphopsia or central scotoma (2,3). Prompt identification is crucial to ensure appropriate management, as although a minority of cases resolve spontaneously, timely surgical intervention remains the mainstay of treatment to restore anatomy and optimise visual function (4). Advances in vitreoretinal surgery, including pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and emerging techniques such as inverted ILM flaps having improved closure rates, even for chronic or large holes (1,5). This review provides a concise overview of the diagnosis, classification and management of iFTMHs.
Diagnosis
Optical coherence tomography (OCT)
Although macular holes may be visualised with slit lamp and dilated fundus examination, OCT is the gold standard diagnostic modality, as it enables further evaluation of the vitreoretinal interface. Doing so can determine whether a hole is partial or full-thickness and whether an epiretinal membrane is present or the posterior hyaloid is still attached to better guide management (3,6). OCT has also enabled more reliable documentation of macular hole size, namely with documentation of the minimum linear diameter (MLD) of the OCT slice with widest hole diameter (3).
Classification
Although Gass stage (seen in Table 1) has classically been used to report iFTMH stages (7), since the increased availability of OCT, reporting iFTMH size has become important for further classification, as it is a better predictor of postoperative hole closure, especially in larger holes (8,9). Hence, another classification system – the International Vitreoretinal Traction Study (IVTS) system has now been commonly adopted as it incorporates hole size and the presence of vitreomacular traction or posterior vitreous detachment (Table 1).
| Modified Gass’ Classification (biomicroscopic findings) (10) | IVTS Classification (11) |
|---|---|
| – | Vitreomacular adhesion |
| Stage 1: impending macular hole (central yellow spot or yellow ring with bridging interface, indicating serous detachment of foveolar retina) | Vitreomacular traction |
| Stage 2: small FTMH (retinal defect <400 microns inside the yellow ring) | Small (<250 microns) or medium (250-400 microns) MLD FTMH with vitreomacular traction |
| Stage 3: large FTMH (central round retinal defect ≥ 400 microns with no Weiss ring) | Large (>400 microns) MLD FTMH without vitreomacular traction and without complete posterior vitreous detachment |
| Stage 4: FTMH with complete posterior vitreous detachment and separation of the vitreous from the optic disc head (central round retinal defect of any size with Weiss’ ring) | Small, medium or large FTMH without vitreomacular taction and with complete posterior vitreous detachment |
The Royal College of Ophthalmologists’ guidelines suggests both Gass stage and IVTS classification to be used in clinical practice, though emphasise the importance of accurately recording MLD, as macular hole size is the main factor determining management options and surgical outcomes (3).
Management
Standard surgical techniques
Pars plana vitrectomy (PPV) with gas tamponade is the standard surgical approach for treating iFTMH, improving closure rates and visual acuity (1). The most utilised gas tamponade agents are hexafluoroethane (C2F6), sulphur hexafluoride (SF6) and octafluoropropane (C3F8), with no discernible difference in anatomical success (3). General considerations when using gas tamponade agents apply, including the use of face-down / prone postoperative positioning. The impact that face-down positioning has on hole closure rates remains inconclusive (3).
Internal limiting membrane (ILM) peeling may also be employed to remove adherent vitreous cortex remnants, relieving residual traction on the retina (1). Guidance suggests performing ILM peel in all cases of iFTMH regardless of size, due to evidence that the addition of ILM peel results in greater closure rates, lower rates of late hole reopening, and fewer interventions than PPV and gas tamponade alone (3,5,12,13).
Alternative / adjunctive techniques
Standard surgical techniques have reduced efficacy with increasing macular hole size, especially when MLD is over 500-600 microns (3). Hence, adjunctive techniques may be employed, with one such alternative being the formation of an ILM flap. Creating an ILM flap involves inversion of the ILM, placing the flap over the iFTMH defect. The inverted flap acts as a barrier, preventing vitreous fluid migration into the hole whilst also allowing a surface for glial tissue proliferation (1). Evidence suggests the adjunctive use of ILM flap with PPV and gas tamponade to have greater anatomical success rates than PPV, gas tamponade and ILM peel in managing large iFTMHs (14,15).
Ocriplasmin is a form of human plasmin, with proteolytic activity against components of the vitreous including laminin, fibronectin and collagen (1,3). It may be administered via intravitreal injection following PPV for medical management of iFTMH, aiming to relieve vitreomacular adhesion (16). Although it is licensed for use in managing vitreomacular traction in Europe, it is not marketed and hence has limited availability in the UK (3). Additional concerns around its side effect profile have limited its widespread use despite evidence of its efficacy in closing small-medium iFTMHs (3,17,18).
Practical tips
- Document baseline visual acuity and OCT to monitor postoperative success.
- Measure hole size on OCT – specifically MLD, to guide surgical decision-making.
- Recognise that large holes or complex cases may need alternative surgical strategies.
Conclusions
iFTMHs are a common cause of central vision loss. Accurate diagnosis, understanding of staging, and familiarity with standard and emerging surgical techniques are essential for trainees. Early recognition and appropriate surgical planning optimise anatomical and functional outcomes. Further studies should discern the impact of face down positioning on iFTMH closure rates, and whether this is independent of hole size or the use of adjunctive surgical techniques, to better inform future guidelines.
References
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