5. A dehiscence in the Retina at the location of
Fovea.
In Lamellar hole - some layer are intact
Full thickness hole - RPE exposed
6. Older female patients
Younger Myopic patients
Post Traumatic
Chronic cystoid macular edema
Associated with Retinal detachment
Inadvertent exposure to laser therapy
7. Loss of Central Vision
Central Scotoma
Metamorphospia
8. Oblique/anteroposterior traction via a persistent
vitreofoveolar attachment following perifoveal vitreous
separation.
Tangential vitreoretinal traction.
9. Stage O – Premacular hole
- Perifoveal vitreous detachment
- Loss of foveal depression
- Subtle macular topograph changes
- Normal visual acuity
10. Stage 1a: ‘Impending’ macular hole
- flattening of the foveal depression with an underlying
yellow spot.
- Pseudocyst – a perifoveal vitreoretinal detachment
Pathology: inner retinal layers detach from the
underlying photoreceptor layer, with the formation of
a schisis cavity.
11. Stage 1b: Occult macular hole
Signs: a yellow ring with metamorphopsia or a mild
decrease in visual acuity.
- Progression of pseudocyst to outer foveal layer
separation
Pathology: loss of structural support with centrifugal
displacement of photoreceptors.
12. Stage 2: Small /Early full-thickness hole
Signs: full-thickness hole < 400 µm in diameter
The defect may be central, eccentric or crescent-shaped.
Pseudo operculum – prefoveal cortical vitreous
contraction
Pathology: a dehiscence develops in the roof [inner
layer]of the schitic cavity, often with persistent
vitreofoveolar adhesion.
13. Stage 3: Full-size /Established macular hole
Signs: full-thickness hole > 400 µm in diameter
red base with yellow-white dots seen.
Surrounding grey cuff of subretinal fluid
Pathology: Avulsion of the roof of the cyst with an
operculum and persistent parafoveal and optic disc
attachment of the vitreous cortex.
14. Stage 4: Full-size macular hole with complete PVD
Pathology: the posterior vitreous is completely
detached, often suggested by the presence of a Weiss ring.
20. Watzke Allen test
On projecting a thin slit beam of light on to the
macula ,a broken or thinned out appearance is
poistive.
Laser aiming beam test
A spot of laser beam of 50 microns when projected on
macula has disappeared.
21. Surgery not recommended in stage 1 50 % chance
of spontaneous resolution .
Stage 3 and 4 with visual acuity < 6/18 require surgery
Contraindications for surgery
- Coexisting choroidal rupture
- Traumatic RPE rupture
- Chronic Cystoid macular edema
- Optic nerve disorders
22.
Pars Plana Vitrectomy
Anaesthesia is local or general .
Conjunctival peritomy is done.
Three sclerotomies in superotemporal ,superonasal and
inferotemporal at 3.5 mm from limbus .
Induction of Posterior vitreous detachment by suction of cutter
, suction cannula or forceps close to disc.
Use of intravitreal triamcinolone acetonide for improving
visualization.
23. Internal gas tamponade :
A non expansile mixture of C3F8 and air is used and
patient lie down in prone for 14 hours for first 10 days .
Internal Limiting Membrane (ILM) Peeling :
Stains like trypan blue , Brilliant blue , ICG
, Triamcinolone acetonide to improve visualization
of ILM.
Special forceps to grasp ILM membrane in a circular
fashion around macular hole for 2 disc diameters.
25. Following a macular pucker , there is a centripetal pull
of the inner sides of epiretinal membrane – resembles
Macular hole.
26. Partial thickness macular hole where the inner layers
of fovea are involved with traction and detached from
underlying cellular layers.
27.
28.
Gass Atlas of Macular diseases by Anita Agarwal
American Academy of Ophthalmology , Vol 12 ,
Retina and Vitreous
Kanski ,Clinical Ophthalmology , a Systemic Approach
7 th edition