Download - Macular Holes
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Macular HolesNigel Kirkpatrick
SWONSMay 2011
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Macular hole
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History 1st reports in 1869 – Knapp (trauma)
› Related to myopia, inflammation, trauma !970’s and 80’s – most idiopathic 1990’s – reports of surgical treatment
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Incidence & Causes 1 in 3300 of population
› ?overestimation Peak incidence in 50’s and 60’s
› Female >>male
Idiopathic hole› Contraction of vitreous in macular area› Tangential forces causing separation in macula› Pseudo-operculum of glial tissue forms› Photoreceptors remain in retinal layer
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Gass Classification Staged according to appearance
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Stage 1
Yellow Dot, good vision, no distortion
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Stage 2
Tiny slit / hole, good vision (6/12), sl distortion
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Stage 3 (st 4 same with pvd)
Obvious hole, vision 6/24, distortion ++
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Symptoms Vision – variable Distortion (metamorphopsia) Occasionally none (early holes etc)
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Signs Watzke Allen test
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Investigation = OCT
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OCT stagingA = St 1
B= St 2
C= St 3
D=St 4
E= Post op
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Treatment Surgery option vs. conservative
› Dominant vs. non- dominant eye› More right eyes
Vitrectomy› Consent› Risk vs. benefit
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Kelly and Wendel 1991
One of the most quoted VR papers No treatment until this time Gass classification Observed that PVD protected against
macular hole 60% success rate with vitrectomy and gas
Vitreous Surgery for Idiopathic Macular HolesResults of a Pilot Study Neil E. Kelly, MD, Robert T. Wendel, MDArch Ophthalmol 1991 109 654
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1990’s Everyone tried it Variable success
Late 90’s› Bizarre posturing regimes› Platelets› Forceps from Moscow
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Modifications 2000 - 2010 ILM peel
› Not for faint hearted!! – almost invisible› Increased hole closure to >90%
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Dyes ICG – excellent view Safety record in doubt
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Dyes 2 Trypan blue
› Membrane blue – good for erm not ilm› Brilliant peel
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Surgery – vity, pvd, peel, gas
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Surgery – ILM peel
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Results Depends on hole stage / size
› Stage 2-3 = >95% closure› Vision improved by 2 lines in >80%› Amount of vision improvement can be
predicted by OCT
› Larger holes (>400 microns) harder to close
› Stage 4 holes 70-80% closure
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Complications Macular damage Iatrogenic tear Cataract – almost every case Field defect
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Controversy Phaco at same time Posturing Value of ILM peel
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The future
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Microplasmin
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Summary Zero to hero in 1 generation Injection era is upon us Value of OCT in macular disease
Any questions
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The dinosaur