Macular hole
 

The macula contains a full thickness hole which is about a quarter of a disc diameter. There may  be an operculum seen in the vitreous. Note: If the macula shows wrinkling, make sure that you  are not looking at a pseudohole which may occur in cellophane maculopathy. Examine the other  eye for similar lesion as macular hole is bilateral in about 15% of cases.  Further examination: when examine the other eye look specifically for the presence of  posterior vitreous  detachment (in the absence of macular hole, the presence of total posterior  vitreous  detachment means that the risk of future macular hole is low) perform a Watzke test. A thin long beam of light is projected through a 78 or 90D  onto the macular hole and the patient is asked if there is a gap in the light. The presence  of a gap is termed positive Watzke's test and occurs in full thickness macular hole.

Questions

1. What are the causes of macular hole?

Answer
idiopathic (most commonly seen in female in the 60s and 70s)
trauma
myopia
solar burn
following cystoid macular oedema

2. What are the stages of macular hole?

Answer
There are four stages in macular hole.
Stage 1:  this appears as a yellow spot in the fovea with loss of the normal foveal depression. It is thought to be the result of tangential traction of cortical vitreous leading to foveolar detachment. Symptoms usually consist of mild visual loss and metamorphopsia.

Stage 2: a full-thickness defect is present with yellow RPE precipitates. The diameter is about 200microns. There is usually a significant visual loss with VA of 6/36 or less.

Stage 3: the hole enlarges to about 500 microns. There is vitreofoveal separation but the remainder of the pre-macular vitreous remains adherent.

Stage 4: there is posterior vitreous separation. Operculum may be seen.

3. How would you manage a patient with stage 1 macular hole?

Answer
Although stage 1 macular hole may progress to stage 2 macular hole causing a loss of vision, it is not uncommon for spontaneously resolution to occur with good visual acuity. As prophylactic vitrectomy may be associated with major complications, the best management is to observe the patient and treat only if the hole progresses.

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