Macular Hole

Presents as a full thickness central macular defect or tear.
Mostly occurs in elderly women.
Mechanism:
- Idiopathic, spontaneous focal contraction or shrinkage of the prefoveal vitreous.
- Can be secondary to posterior vitreous separation or severe ocular trauma.

Clinical Features

Symptoms:
- Various degrees of decreased visual acuity
- Metamorphopsia
Signs: depends on the staging of the hole according to Gass's classification.
Stage 1: "Impending" macular hole
- Localized foveal detachment, loss of foveal depression associated with retraction of the retinal receptor (occult hole) and the presence of yellowish macular spot or ring
- Fine radiating retinal striae may be observed
- Visual acuity usually better than 20/50
Stage 2: Small hole begins to develop (<400 µ)
- A 360-degree can-opener type hole may develop
- The hole may be covered by an overlying pseudo-operculum (pre-foveal opacity) which usually larger than the hole
- Visual acuity is in the 20/50 - 20/80 range
Stage 3: Larger macular hole (>400 µ)
- Pseudo-operculum may still present
- Often has a cuff of subretinal fluid
- Drusen-like deposits may be seen at the base of the hole
- Mean visual acuity : 20/200
Stage 4: Complete separation of the vitreous from the entire macular surface and optic disc
Fluorescein angiography in patients starting from stage 2 typically demonstrates early hyperfluorescence in the area of the hole
Optical coherence tomography has proven to be extremely helpful in the diagnosis of macular hole