Full Thickness Macular Hole (FTMH)

Full Thickness Macular Hole (FTMH)
SYMPTOMS Central scotoma, Central vision loss, Metamorphopsia (size of scotoma and severity of vision loss depends on size and extent of macular hole)
SIGNS Gass Classification
Stage 1 (Impending macular hole. Vitreal adhesion present)
Stage 1a: Yellow spot at the fovea (represents increased prominence of xanthophyll pigment), Foveolar detachment, Pseudocyst in the inner retina, Cystic spaces in the inner retina (due to tractional forces)
Stage 1b: Yellow ring at the fovea (due to displacement of photoreceptor and xanthophyll pigment), Foveolar detachment, Pseudocyst enlarges to involve both the inner and outer retina, Cystic spaces in the inner retina due to tractional forces
Stage 2 (Small full thickness macular hole. Vitreal adhesion present)
Stage 2a: Neural retinal defect that is less than 400 microns in diameter, Unroofing of pseudocyst with attached pseudo-operculum, Cystic spaces in the inner retina (due to tractional forces)
Stage 2b: Neural retinal defect that is less than 400 microns in diameter, Unroofing of pseudocyst with pseudo-operculum that is no longer attached, Cystic spaces in the inner retina (due to tractional forces)
Stage 3: Yellow-white dots noted within the hole, Pigmented RPE ring, Grey cuff of edema, Edematous hole margins, Adhesion of the vitreous especially at the foveola, Neural retinal defect is greater than or equal to 400 microns in diameter, Unattached pseudo-operculum, Cystic spaces in the inner retina (due to tractional forces)
Stage 4: Yellow-white dots noted within the hole, Pigmented RPE ring, Grey cuff of edema, Edematous hole margins, Complete detachment of the vitreous from the macula including the fovea and foveola, Neural retinal defect is greater than or equal to 400 microns in diameter, Unattached pseudo-operculum, Cystic spaces in the inner retina (due to tractional forces)
Stage 1: Vitreomacular traction with no evidence of a full thickness macular hole
Stage 1: Vitreomacular traction with no evidence of a full thickness macular hole
Stage 2: Vitreomacular traction with a small (less than or equal to 250 microns in diameter) or medium (greater than 250 microns and less than or equal to 400 microns in diameter) full thickness macular hole
Stage 3: Vitreomacular traction with a large (greater than 400 microns in diameter) full thickness macular hole
Stage 4: Any size full thickness macular hole with a complete PVD
WORK-UP Full eye exam with dilated retinal exam, OCT analysis of the macula (signs of a full thickness macular hole are best seen with an OCT), Fluorescein Angiography, Fundus Autofluorescence, Fundus photos, Infrared retinal imaging, Watzke-Allen test, Macular photostress test, Amsler grid
TREATMENT Stage 1: Typically, no treatment is needed at this stage as there is a 50% chance of spontaneous closure. However, if a patient is symptomatic or has significant vitreomacular traction, the patient should be referred to a retinal specialist for treatment. Give Amsler grid
Stage 2: Refer to a retinal specialist for treatment (90% success rate at this stage when treated)
Stage 3: Refer to a retinal specialist for treatment
Stage 4: If chronic or longstanding, it is highly unlikely that any treatment will improve vision so it would be best to monitor. If new or acute, refer to a retinal specialist for treatment
Treatment includes a Pars plana vitrectomy, ILM peel, Internal gas tamponade (typically the patient needs to lie face down for 14 hours a day for 7-10 days), and Internal ILM flap
FOLLOW-UP Stage 1 (without symptoms or without significant vitreomacular traction): See patient back in 3-4 months
Stage 1/2/3/4 (referred to retinal specialist): If stable after treatment, see patient back in 6 months
Stage 4 (chronic and longstanding): See patient back in 1 year
ADDITIONAL LAB | TESTS None
ETIOLOGY Occurs due to tangential tractional forces and contraction of the vitreous. Intraretinal fluid (due to breaks in the ILM and ELM) can further lead to tractional forces and disruption of foveal integrity
DIFFERENTIAL DX Lamellar macular hole, Pseudohole, Solar retinopathy, Cone dystrophy
NOTES 75% of Stage 2 macular holes progress to Stage 3 macular holes
Inner retinal dimples are common to see on en face imaging following treatment for a macular hole (does not seem to affect vision)
Full Thickness Macular Hole (FTMH): OCT of the macula demonstrating a Stage 4 Macular Hole as there is no visible vitreomacular traction https://webeye.ophth.uiowa.edu/eyeforum/cases/261-FTMH.htm

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