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Macular hole vs. Pseudo-hole

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by Brett Wagner on 27 September 2011

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Transcript of Macular hole vs. Pseudo-hole

Case -72 yo Caucasian male
-referred for cataract eval
-Pt has noticed reduced vision over the last year;
esp. the last 6 wks; OS > OD
-Difficulty seeing small print
-Halos around car lights
-(+) Floaters / (-) Flashes Ocular Hx
-K burns secondary to welding
-Multiple K FB's removed
-Bilateral blepharoplasty Demographic and Complaints Meds and Allergies -Vitamins
-PCN and butazolidin VA's and Chairskills +0.75 -2.00 x103 20/25-
+0.25 -0.75 x074 20/50
-BAT VA's: 20/400+
20/400
-EOM's: FROM OU
-CVF: Full OU
-Pupils: PERRLA, (-) APD OU
-Amsler Grid: Central Blur OS
Ant Seg Exam -IOP: 13 mm Hg
12 mm Hg
-Adnexa: Clr OU
-Orbits: Nrml OU
-Conj: Quiet OU
-Cornea: Clear OU
-Ant Chamber: D & Q OU DFE -Lens: 2+ NS, 1+ cort
2+ NS, 2+ cort
-Vitreous: PVD OU
-ON: .2 R; Distinct margins
.2 R; Distinct margins
-Macula: Few Drusen
Hole vs. Pseudohole
-Vessels: Normal OU
-Periph: (-) H, T, D OU OCT OS Referral to Ret. Spec. Differentials: -epiretinal macular membranes
-pseudomacular holes
-lamellar macular holes
-macular cysts
-cystoid macular edema
-adult vitelliform degeneration -Involves the detachment of
the inner macular layers from
the underlying outer retinal layers
-Usually well circumscribed red lesion on DFE
-Detection of early lamellar holes
is difficult
-One study found only 28% of LMH's
are diagnosed clinically s OCT
-VAs often still good bc PR's still intact
(Chen, Jaeger) Lamellar hole Macular Cysts
-Often associated with ret dystrophies
-Tissue loss secondary to disruption of retinal architecture in the macular region
-IVFA shows little leakage (vascular leakage
plays small role)
-CAI's may be useful for treatment
(Ganesh)
CME -Fluid from ret capillaries collects in inner nuclear layers
(Ganesh)
-When in conjunction c sx, usually 4 to 12 wk po
-Associated with wide range of ocular and systemic conditions
-Often treated c NSAID and steroid
(Jaeger) Adult Vitelliform Degeneration -Usually occurs b/w 4th and 6th
decades of life
-VA's typically 20/30 to 20/60
-Clinical appearance of bilateral yellow subretinal
lesions with central pigment spot at fovea
(Jaeger) Macular Pseudohole -ERM contracting can give appearance
of macular hole
-OCT demonstrates steepened foveal pit
c full-thickness retinal tissue at the base
(Jaeger, Schuman) -IVFA was performed
-Determined to be a stage 2
full-thickness macular hole
-R/B of macular hole repair
were discussed and pt
opted to go ahead with surgery Macular Holes Overview -Can be associated c myopia or trauma
-Most are idiopathic
-Often go undetected by pt in cases
of unilateral macular hole
-Vision usually worsens over weeks
and months until it stabalizes around
20/200 to 20/800 if left untreated
-Female predilection
-7th Decade
(Theng) Stages -Stage 1

-Stage 2

-Stage 3

-Stage 4 -Foveal depression either reduced or absent
-Yellow ring or spot is present
-No vitreomacular separation
-Metamorphopsia -Full-thickness macular hole < 400 microns in size
-Almost always progresses to stage 3 with little hope of improvement
-VA's range from 20/50 to 20/400 -Fully-developed macular hole
-> 400 microns in diameter
-Partial vitreomacular traction
-VA's range from 20/200 to 20/800
-Full thickness hole c complete separation of
the vitreous from the ON and macula
Treatment -Many surgeons recommend surgery for symptomatic pts c a stage 2,3, or 4 hole of limited duration with a VA of 20/50 or worse

-Critical component of macular hole repair is the induction of posterior vitreous detachment
(Huang) a) Engage posterior cortical
vitreous c cannula during active
aspiration.
Look for "fish-strike" sign.
b) Strip cortical vitreous
c) Completion of posterior vitrectomy
c vitreous cutter
d) Fluid-air exchange
e) Completion of fluid-air exchange
(Glaser) Prognosis -Good for recent onset holes;
Poor for holes > 1 yr
-Surgery has 60–95% successful
anatomical results and 73% have
improved acuity
- Studies show that improvement of 2 lines or more occurs in about 50% of pts
(Huang, Friedman) CREDITS

Chen, J. C., and L. R. Lee. "Clinical Spectrum of Lamellar Macular Defects including Pseudoholes and Pseudocysts Defined by Optical Coherence Tomography." British Journal of Ophthalmology 92.10 (2008): 1342-346. Medscape.com. WebMD, 4 Nov. 2008. Web. 17 Sept. 2011.

Friedman, Neil J., Peter K. Kaiser, Roberto Pineda, and Peter K. Kaiser. "Macular Holes." The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. [Philadelphia, Pa.]: Saunders/Elsevier, 2009. Print.

Ganesh, Anuradha, Eliza Stroh, George J. Manayath, Sana Al-Zuhaibi, and Alex V. Levin. "Macular Cysts in Retinal Dystrophy." Current Opinion in Ophthalmology (2011). Print.

Glaser, BM, RG Michels, and BD Kupperman. "Transforming Growth Factor-2 for the Treatment of Full-thickness Macular Holes. A Prospective Randomized Study." Opthalmology 1173rd ser. 99.1162 (1992). Print.

Huang, David. Retinal Imaging. 1st ed. Philadelphia, PA: Mosby Elsevier, 2006. Print.
Jaeger, Edward A., Thomas D. Duane, and William Tasman. "Cystoid Macular Edema." Duane's Foundations of Clinical Ophthalmology. Hagerstown, MD: Lippincott Williams & Wilkins, 1998. Print.

Jaeger, Edward A., Thomas D. Duane, and William Tasman. "Optical Coherence Tomography." Duane's Foundations of Clinical Ophthalmology. Vol. 2. Hagerstown, MD: Lippincott Williams & Wilkins, 1998. Print.

Schuman, Joel S., Carmen A. Puliafito, and James G. Fujimoto. Optical Coherence Tomography of Ocular Diseases. Thorofare, NJ: SLACK, 2004. Print.

Theng, Kean, and Hampton Roy. "Macular Hole." Medscape. WebMD, 7 July 2011. Web. 19 Sept. 2011.

Wender, Jon. "Review of Ophthalmology® Revisiting Macular Holes." Review of Ophthalmology® Home. 15 Feb. 2007. Web. 19 Sept. 2011. <http://www.revophth.com/content/d/retinal_insider/i/1296/c/24953/>. (Wender, Jaeger)
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