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Anatomical Outcomes of Surgery for Idiopathic Macular Hole as Determined by Optical Coherence Tomography
Michael S. Ip, MD;
Brad J. Baker, MD;
Jay S. Duker, MD;
Elias Reichel, MD;
Caroline R. Baumal, MD;
Ronald Gangnon, PhD;
Carmen A. Puliafito, MD, MBA
Arch Ophthalmol. 2002;120:29-35.
ABSTRACT
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Objectives To determine the rate of anatomical closure of idiopathic macular holes
undergoing vitreous surgery with respect to preoperative horizontal diameter
as determined by optical coherence tomography (OCT) and to correlate postoperative
visual acuity, duration of symptoms, and late reopening with initial idiopathic
macular hole diameter by OCT.
Materials and Methods Forty eyes of 40 patients with an idiopathic macular hole were examined
with OCT before and after vitreous surgery. All eyes were treated with pars
plana vitrectomy, peeling of posterior cortical vitreous, and dilute perfluoropropane
or sulfur hexafluoride gas. Face-down positioning was maintained for 7 to
14 days.
Results Twenty-two (92%) of 24 eyes with a preoperative idiopathic macular hole
diameter smaller than 400 µm measured by OCT attained anatomical closure
following surgery. Anatomical closure was observed in 9 (56%) of 16 eyes with
a macular hole diameter of 400 µm or larger measured by OCT (P = .02). The median postoperative visual acuity improvement was 4
Snellen lines in the 31 eyes achieving anatomical closure and no change in
the 9 eyes not achieving anatomical closure (P<.001).
Late macular hole reopening at longer than 6 months occurred in 3 (10%) of
31 eyes with an initially closed macular hole. This event was observed only
in macular holes 400 µm or larger measured by OCT. The preoperative
macular hole diameter (P = .02) and duration of symptoms
(P = .02) were factors predictive of anatomical closure
of the macular hole postoperatively.
Conclusions The postoperative closure of idiopathic macular holes following vitreous
surgery was related to the preoperative macular hole diameter determined by
OCT, with lesions smaller than 400 µm demonstrating higher success rates.
A trend toward greater visual acuity improvement was demonstrated for idiopathic
macular holes smaller than 400 µm. Late reopening was only seen in macular
holes that were 400 µm or larger measured by OCT. Preoperative analysis
and measurement of idiopathic macular holes with OCT may help delineate postoperative
expectations for successful anatomical closure of the macular hole, visual
acuity, and long-term closure.
INTRODUCTION
IDIOPATHIC MACULAR holes have received great attention over recent years
owing to the improved ability to surgically achieve anatomical closure and
regain visual function in many cases.1 Several
authors2-4 have
reported significantly higher rates of anatomical closure and visual rehabilitation
in patients with stage 2 macular holes compared with larger, stage 3 or 4,
macular holes. The staging of macular hole lesions in these studies has largely
been based on clinical biomicroscopic evaluation before and after vitreous
surgery as well as grading of fundus photographs.3-4
Clinical observations based on biomicroscopic observation suggest evolution
of macular holes through several stages as proposed by Gass.5-8
A macular hole may start as a foveal detachment (stage 1) and progress to
a small (<400-µm) full-thickness macular hole (stage 2) then enlarge
to a stage 3 lesion ( 400 µm). When a complete posterior vitreous
detachment is present, the macular hole is defined as stage 4. Surgical intervention
for stage 1 macular holes may not improve the natural history of these lesions
due to spontaneous resolution in some eyes.9
However, vitrectomy with removal of posterior cortical vitreous, complete
air-fluid exchange followed by injection of a dilute concentration of a long-acting
inert gas, accompanied by face-down positioning appears to be effective in
closing full-thickness macular holes.1-4
Recent attempts to use imaging techniques such as the confocal scanning
laser tomograph and the scanning laser ophthalmoscope to predict visual outcome
suggest a correlation between macular hole size and visual recovery.10-12 These studies demonstrated
significant variability in visual recovery based on preoperative volume and
depth of macular holes. This study used optical coherence tomography (OCT)
to measure preoperative macular hole size and correlated this with the postoperative
rate of anatomical closure. To our knowledge, this is the first such study
to use OCT in this manner.
Optical coherence tomography is a noninvasive diagnostic imaging technique
that can help diagnose and quantify macular disease, including idiopathic
macular hole.13-14 Optical coherence
tomography is analogous to ultrasound B-scan except that since light rather
than sound is used, a higher resolution is obtainable. Owing to the precise
resolution of OCT, with an axial definition of 10 µm and a transverse
resolution of 30 µm for a 3-mm scan, it may be a valuable tool to track
anatomical features of idiopathic macular holes longitudinally over time.
Recently, OCT has been used to better establish the sequence of events to
macular hole formation. Anteroposterior forces due to vitreofoveal traction
that result in intraretinal splitting and subsequent full-thickness macular
hole have been documented longitudinally by OCT.15
In this study, OCT was used to document preoperative full-thickness
macular hole size. Preoperative macular hole size was then correlated with
the anatomical success rate of surgery. Evaluation of the anatomical success
rate between macular holes smaller than 400 µm and macular holes larger
than or equal to 400 µm was performed to allow for comparison between
macular hole stages as defined by the widely accepted Gass classification.
Visual outcome and duration of symptoms were also correlated with preoperative
macular hole size as determined by OCT. Late reopening, defined as opening
of a macular hole that had been closed for 6 months or longer, in relation
to initial preoperative OCT measurement was also examined.
MATERIALS AND METHODS
A retrospective review between July 1994 and February 1999 of all eyes
with an idiopathic macular hole that were examined preoperatively and postoperatively
by OCT by the Vitreoretinal Service of the New England Eye Center, Boston,
Mass, was performed. Only eyes diagnosed as having an idiopathic macular hole
were included in this study. Patients with previous and/or coexisting conditions
such as intraocular inflammation, ocular trauma, and retinal detachment were
excluded.
Patients received a complete ophthalmic examination including the following:
complete medical and ophthalmic history, best-corrected Snellen visual acuity,
Amsler grid testing, intraocular pressure measurement, slitlamp biomicroscopy,
indirect ophthalmoscopy, and fundus photography. Optical coherence tomographic
equipment used to obtain fundus images has previously been described by Puliafito
et al13 and Hee et al.14
The lateral resolution is limited by pixel size and determined to be 30 µm
for acquisition of a 3-mm foveal scan performed in a radial fashion centered
on the fovea. Each patient was examined with OCT by an experienced examiner
through a dilated pupil and confirmed to have a full-thickness macular hole.
An idiopathic macular hole was defined by OCT as a full-thickness defect of
neurosensory retina overlying the retinal pigment epithelium and choriocapillaris
reflection. Macular holes were measured in the least horizontal diameter by
OCT (the shortest distance across the full-thickness defect was defined as
the size of the macular hole). Fixation was maintained and readings were repeated
if any question of deviation arose. Fellow eyes were also examined.
Informed consent was obtained prior to surgical intervention in all
patients after the risks and benefits were reviewed. All surgical procedures
were performed by 1 of 3 surgeons (J.S.D., E.R., or C.A.P.) between July 1994
and February 1999. The surgical technique consisted of standard 3-port pars
plana vitrectomy, peeling of the posterior cortical hyaloid, air-fluid exchange,
and injection of either 15% perfluoropropane (25 cases) or 25% sulfur hexafluoride
(15 cases). No attempt was made to remove the internal limiting membrane.
Eight cases included the use of intraoperative autologous serum placed in
the bed of the macular hole. Patients were instructed to maintain strict face-down
positioning for 7 to 14 days. Patients were examined postoperatively at day
1, 1 week, 1 month, 6 months, and when clinically indicated. Postoperative
OCT was obtained when the gas bubble was absorbed superior to the macular
region to confirm macular hole closure and on or after 6 months of follow-up.
Anatomical surgical success was clinically defined as apposition of
the macular hole edges and absence of subretinal fluid cuff. Anatomical success
determined by OCT was restoration of full- or partial-thickness retinal reflection
over the retinal pigment epithelium and choriocapillaris reflections. Visual
success was an improvement of 2 Snellen lines or more with best-corrected
visual acuity or potential acuity meter. Postoperative evaluation of closure
by clinical examination and OCT, late reopening, intraoperative complications,
and macular hole formation in fellow eyes was performed on all patients.
The principal outcome of this study was anatomical closure of the idiopathic
macular hole. Parameters of interest included age, sex, serum use, intraoperative
gas, preoperative macular hole diameter, preoperative visual acuity, and length
of symptoms. For regression analyses, macular hole diameter was dichotomized
as stage 2 (macular hole diameter <400 µm) or stage 3 (macular hole
diameter 400 µm). Length of symptoms was dichotomized as long (6
months) or short (<6 months) duration.
A secondary outcome of this study was visual acuity. Snellen visual
acuities were converted to logMAR equivalents for statistical analysis. Univariate
and multivariate logistic regression analyses were performed. A 2-sided P value of .05 was regarded as statistically significant.
Variables were included in the multivariate logistic regression model using
a stepwise procedure based on the Akaike Information Criterion.16
Statistical analysis of the data was performed using SAS (SAS Institute, Cary,
NC) and S-PLUS (Insightful Corporation, Seattle, Wash).
RESULTS
The clinical characteristics and demographics of the patients are included
in Table 1. There were 31 women
(78%) and 9 men (22%), with a median age of 65 years (age range, 40-85 years).
Twenty-two right eyes (55%) were included. Preoperative macular hole diameter
ranged from 70 to 810 µm, with a median of 330 µm.
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Demographics of 40 Patients With Idiopathic Macular Hole Undergoing
Vitrectomy Surgery*
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The range of preoperative visual acuity was 20/50 to 20/400, with a
median of 20/100. In 40% (16/40) of eyes, the macular hole diameter was larger
than or equal to 400 µm. Eyes with macular hole diameter larger than
or equal to 400 µm had poorer preoperative visual acuity (median, 20/200)
than eyes with macular holes smaller than 400 µm (median, 20/100) (P = .04, Wilcoxon rank sum test). Twenty-five of the 40
eyes received 15% perfluoropropane, and the remaining 15 eyes received 25%
sulfur hexafluoride. Adjuvant autologous serum was used in 8 cases (20%).
The median length of visual symptoms, such as metamorphopsia, blurring,
or scotoma, was 4 months with a range of 2 weeks to 1 years. Eyes
with macular hole diameter larger than or equal to 400 µm had a longer
length of visual symptoms (median, 6 months) than eyes with macular holes
smaller than 400 µm (median, 3 months) (P =
.02, Wilcoxon test). Sixteen eyes had symptoms lasting at least 6 months.
Of these 16 eyes, 7 had macular hole diameters smaller than 400 µm,
and 9 had macular hole diameters larger than or equal to 400 µm.
Twenty-two (92%) of 24 eyes with an idiopathic macular hole smaller
than 400 µm as determined by preoperative OCT achieved anatomical closure
after 1 surgical intervention. Figure 1 shows a patient with a full-thickness macular hole measuring 70 µm in
horizontal diameter on preoperative OCT that was successfully closed with
vitreous surgery. For the subgroup of macular holes measuring larger than
or equal to 400 µm on OCT, anatomical closure was observed in 9 (56%)
of 16 eyes. Figure 2 shows a patient
with a macular hole measuring 560 µm on preoperative OCT that was successfully
closed with vitreous surgery.
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Figure 1. Fundus photograph (A) and optical
coherence tomographic (OCT) image (B) of preoperative full-thickness idiopathic
macular hole measuring 70 µm in horizontal diameter. Postoperative fundus
photograph (C) showing clinical anatomical closure confirmed by the OCT image
(D) showing reapposition of retinal tissue at the site of previous idiopathic
macular hole.
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Figure 2. Fundus photograph (A) showing
a larger idiopathic macular hole with surrounding cuff of subretinal fluid.
Optical coherence tomographic (OCT) image (B) shows the 560-µm defect
with adjacent thickening of the neurosensory retina. Eight months after undergoing
surgery the 560-µm macular hole appears to be closed on clinical examination
and on the fundus photograph (C). The OCT image (D) shows restoration of retinal
tissue overlying the choriocapillaris reflection.
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In univariate logistic regression analyses, anatomical closure was associated
with macular hole diameters smaller than 400 µm (P = .02) and with a length of visual symptoms for less than 6 months
(P = .02). In a multivariate logistic regression
analysis, the associations between anatomical closure and both a macular hole
diameter smaller than 400 µm and a length of visual symptoms less than
6 months remained statistically significant (P =
.043 and P = .043, respectively). Other variables
such as age, sex, serum use, and gas injection were excluded from the model
based on the Akaike Information Criterion model selection criterion. All 9
eyes in male subjects achieved anatomical closure, while 9 (29%) of 31 eyes
in female subjects did not achieve anatomical closure (P = .09, Fisher exact test).
Overall, a median postoperative visual acuity improvement of 3 Snellen
lines was observed (P<.001, Wilcoxon signed rank
test), resulting in a median postoperative visual acuity of 20/50. The median
postoperative visual acuity improvement was 4 Snellen lines in the 31 eyes
achieving anatomical closure and no change in the 9 eyes not achieving anatomical
closure (P<.001, Wilcoxon rank sum test). For
eyes with macular holes smaller than 400 µm, the median postoperative
visual acuity improvement was 3 Snellen lines; in eyes with macular holes
larger than or equal to 400 µm, the median visual acuity improvement
was 2.2 Snellen lines (P = .27, Wilcoxon rank sum
test). The median visual acuity improvement in eyes with a length of visual
symptoms less than 6 months was 3.8 Snellen lines compared with an improvement
of 0.8 Snellen lines in eyes with visual symptoms for at least 6 months (P = .003, Wilcoxon rank sum test).
Visual improvement of 2 or more Snellen lines was recorded in 26 (84%)
of 31 eyes in which anatomical closure was achieved; 1 of 9 eyes in which
anatomical closure was not achieved experienced a visual improvement of 2
or more Snellen lines (P<.001, Fisher exact test).
Seventeen of the 31 eyes achieving anatomical closure had a final visual acuity
of 20/40 or better; none of the eyes in which anatomical closure was not achieved
had a final visual acuity of 20/40 or better (P =
.005, Fisher exact test).
Late reopening of an initially closed macular hole after 6 months occurred
in 3 (10%) of 31 eyes between 8 to 18 months (median, 14 months) postoperatively.
The initial preoperative diameter in these 3 eyes by OCT was 460, 470, and
550 µm.
Progression of nuclear sclerosis or posterior capsule opacification
occurred in all patients after the initial macular hole surgery. Two patients
had postoperative intraocular pressures above 30 mm Hg on postoperative day
1 and were treated with aqueous suppressants. Four of the patients had a history
of or developed a macular hole in the fellow eye. Seven patients received
either intraoperative cryotherapy or endolaser to treat a retinal tear.
COMMENT
Surgical treatment of idiopathic macular holes has given vitreoretinal
surgeons and patients an option for visual recovery for this once untreatable
condition. Although often effective, there is controversy regarding the pathogenesis,
surgical timing, verification of macular hole closure, visual recovery, and
long-term complications.
Some conditions such as epiretinal membrane, lamellar hole, cystoid
macular edema, and macular degeneration may be misdiagnosed on occasion as
a full-thickness macular hole on biomicroscopic evaluation.17-18
Optical coherence tomography has been used successfully to demonstrate these
entities and differentiate them from idiopathic full-thickness macular hole.13-14 Confirmation of the diagnosis, monitoring
longitudinally over time, and unequivocal documentation of anatomical success
or failure are possible with OCT.
Timing of surgical intervention, depending on idiopathic macular hole
staging, size, and duration has shown correlation in success rate and visual
recovery.2 Preoperative staging has been traditionally
based on the classification system proposed by Gass,5
judging macular hole diameters on clinical and photographic evaluation using
the peripapillary vein as 125 µm in diameter as a reference. Stage 2
idiopathic macular hole closure based on this system has been reported in
more than 90% of the selected cases.2 The measurement
of macular hole size in these previous studies was performed biomicroscopically,
without the use of OCT. The use of OCT may allow better quantification of
macular hole diameter, as OCT measurements are reproducible with a transverse
resolution of 30 µm. Furthermore, OCT measurements do not rely on the
assumption that a landmark peripapillary vein, which may vary in size between
individuals, is 125 µm.
In this study, 22 (92%) of 24 macular holes smaller than 400 µm
were successfully closed as determined by OCT. The anatomical closure rate
decreased to 56% for idiopathic macular holes equal to or larger than 400
µm in diameter. We suggest that it is possible to use these results
to predict rates of anatomical closure after surgery. Some studies have demonstrated
that a smaller preoperative idiopathic macular hole size attains a higher
rate of closure with surgical intervention.2
This study uses OCT to quantify a measurement at which the success rate appears
higher. Four hundred microns was chosen to allow for comparison between macular
hole staging as defined by the Gass classification. Clinicians may use the
results of this study to more accurately predict postoperative expectations
for initial and long-term anatomical closure.
Ryan and Gilbert2 reported that shorter
duration of macular hole presence had a better prognosis for closure and visual
rehabilitation, separating the groups into symptoms less than 6 months and
those longer than 6 months. In a natural history study of idiopathic macular
hole, it was found that 34% of macular holes increase in size and 45% experience
a loss of 2 or more Snellen lines during a follow-up period of 1 to 6 years.19 In this study, all successfully closed macular holes
smaller than 400 µm by OCT had a short duration of symptoms of less
than 6 months (median, 3 months) with the exception of 1 patient.
Optical coherence tomography may allow the physician to discuss the
rate of possible success if intervention occurs in a timely fashion. Ophthalmologists
are more likely to refer patients with macular hole symptoms at an earlier
time owing to the success rates of surgery. Optical coherence tomography can
provide valuable information in these earlier onset macular holes, many of
which will be of smaller diameter.
In this study, 78% of eyes had an improvement of 2 Snellen lines or
better. Although a trend toward greater visual acuity improvement was noted
in the group of eyes with macular holes smaller than 400 µm than the
group of eyes with macular holes larger than or equal to 400 µm (mean
of 3 Snellen lines vs 2.2 Snellen lines), this did not reach statistical significance
(P = .27, Wilcoxon rank sum test). This finding may
reflect the fact that visual acuity was performed with a Snellen letter chart
and without the benefit of a standardized refraction protocol. Additionally,
other tests of visual function such as the Bailey-Lovie Word Reading test,
that was found to have a significant benefit from macular hole surgery when
other tests of visual function such as the Early Treatment Diabetic Retinopathy
Study chart had only a marginal benefit from surgery in other studies, were
not used in this study.3 Furthermore, the effect
of cataract was not accounted for in this study as visual acuity data were
a secondary outcome; the primary objective of this study was to correlate
preoperative macular hole size with the rate of anatomical closure following
vitreous surgery.
Complications of vitreous surgery for idiopathic macular holes include
retinal tears, visual field defects, cataract formation, and late macular
hole reopening. Late reopening of initially closed macular holes has been
reported to occur in approximately 5% to 9.5% of eyes in previous studies.20-22 Late macular hole
reopening in this study occurring after 6 months of successful repair was
seen in 10% of eyes. Preoperative macular hole size in these eyes measured
by OCT was 460, 470, and 550 µm, respectively. Two of 3 underwent successful
second pars plana vitrectomy. A larger sample size may reveal a lower rate
of macular hole reopening, but this study suggests that macular holes with
a greater horizontal diameter are at increased risk for late reopening.
Surgical intervention with a standard 3-port vitrectomy and injection
of long-acting intravitreal gas, in combination with proper face-down positioning,
has proven effective in attaining closure of idiopathic macular holes. Recent
multicenter prospective studies have questioned the efficacy of adjuvants
in surgical management and visual recovery of idiopathic macular holes.23-24 Six (75%) of the 8 patients receiving
intraoperative adjuvant autologous serum in our series had closed macular
holes. As only 5 of the 22 macular holes smaller than 400 µm in diameter
that were successfully closed received adjuvant serum, we believe that idiopathic
full-thickness macular holes smaller than 400 µm in diameter by OCT
are likely to be successfully closed without adjuvant serum owing to their
smaller size. Since the mechanism of closure by vitrectomy and gas injection
is not completely known, it is possible that relieving traction from the posterior
hyaloid surgically and preventing vitreous fluid from entering the macular
hole via a gas bubble may be sufficient for successful closure.
Limitations of this study are based in its retrospective nature and
sample size. The lack of a standardized refraction protocol limits the interpretation
of visual acuity data. Although close attention was given to standardization
of image acquisition, patient tracking of the scanning probe can result in
an overestimate of macular hole size.14 Although
reproducible, OCT is limited in the lateral resolution by pixel size, 30 µm,
for acquisition of a 3-mm foveal scan in this study. Consideration of these
factors should be made when applying these results to clinical situations.
CONCLUSIONS
Preoperative measurement of idiopathic macular hole diameter with OCT
may help delineate postoperative expectations for successful initial anatomical
closure of the macular hole, successful long-term closure and possibly visual
function. Stage 2 macular holes, smaller than 400 µm in diameter as
measured by OCT, had a greater likelihood of successful postoperative closure
than stage 3 or 4 macular holes equal to or larger than 400 µm in diameter.
There was also a trend, although this did not reach statistical significance,
toward better postoperative visual acuity in the subgroup of eyes with stage
2 macular holes. Additionally, late reopening of macular holes in this study
occurred only in the subgroup of eyes with preoperative macular hole diameters
larger than 400 µm. When used in conjunction with careful clinical observation,
OCT may be used to confirm the diagnosis of macular hole, verify results of
surgery, and predict in which patients vitrectomy surgery will more likely
be successful based upon preoperative quantitative measurement of macular
hole diameter.
AUTHOR INFORMATION
Accepted for publication September 11, 2001.
Corresponding author and reprints: Michael S. Ip, MD, Department
of Ophthalmology, University of Wisconsin, Clinical Science Center, F4/336,
600 Highland Ave, Madison, WI 53792 (e-mail: msip{at}facstaff.wisc.edu).
From the Departments of Ophthalmology (Drs Ip and Gangnon) and Biostatistics
(Dr Gangnon), University of Wisconsin, Madison; and the Vitreoretinal Service,
New England Eye Center, Tufts University School of Medicine, Boston, Mass
(Drs Baker, Duker, Reichel, Baumal, and Puliafito). Dr Puliafito is a consultant
for Zeiss Humphrey Systems.
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