Not Every Full-Thickness Macular Hole Needs Surgical Repair

Not Every Full-Thickness Macular Hole Needs Surgical Repair

NEW YORK (Reuters Health) – Some full-thickness macular holes (FTMH) can close without surgery, according to a new case series.

“We found that small holes – under 200 microns in diameter – can close within a few months, traumatic macular holes can close without treatment, and holes with cystoid macular edema can resolve with topical steroids and nonsteroidal anti-inflammatory agents,” Dr. Hana A. Mansour of the American University of Beirut, in Lebanon, told Reuters Health by email.

“We are taught to perform surgery on everybody with macular holes,” she said. “However, some patients can benefit from conservative treatment rather than jumping straight to vitrectomy, which has complications such as cataract progression in all patients, retinal detachment in 10% of cases, and rarely, endophthalmitis.”

Retina specialists often see patients with FTMH, and several reports of a small percentage of FTMH closures occurring without surgery already exist in the literature, Dr. Mansour and her colleagues note in the British Journal of Ophthalmology.

Over two years, the research team requested retina specialists worldwide to send them data on FTMH cases that had been diagnosed by spectral domain optical coherence tomography (SD-OCT) and had closed without surgery.

They included FTMH cases that were traumatic or idiopathic, acute or chronic, in patients of all ages, genders and races. Among the cases they excluded were those with retinal dystrophy, foveoschisis, neovascular age-related macular degeneration, and vitreous surgery less than one year or phacoemulsification less than six months before FTMH diagnosis.

The researchers analyzed data from 78 patients with a mean age of 58 years. Eighteen patients had blunt ocular trauma, 18 received topical or intravitreal therapies and 42 had idiopathic FTMH. The macular hole reopened in seven eyes (9%) after a mean of 8.6 months.

Cystoid macular edema was found in 49 eyes, perifoveal posterior vitreous detachment in 42, subretinal fluid in 20, vitreomacular traction in 12 and foveal epiretinal membrane in 10.

The average time for closure was 1.6 months for eyes with trauma, 4.3 months for eyes without trauma but with therapy for cystoid macular edema, 4.4 months for eyes without trauma and without therapy with FTMH smaller than 200 um in diameter, and 24.7 months for larger holes.

Dr. Nimesh A. Patel, an ophthalmologist at Massachusetts Eye and Ear Institute in Boston, said by email, “These findings are not surprising. Some prior smaller studies have suggested this, especially in young patients without vitreous detachment.”

“This study was important, to show that intervention is not always required for macular holes,” added Dr. Patel, who was not involved in the research. “A noninvasive approach may solve the issue and improve vision without the risk of surgery.”

He noted that, while the study’s retrospective nature and selection bias are weaknesses, the group’s relatively large size is its strength.

Dr. Ian C. Han, an assistant professor of ophthalmology and visual sciences at the University of Iowa Carver College of Medicine in Iowa City, told Reuters Health by email, “This is a well-compiled retrospective case series from an international group of co-authors.”

“Diagnosis of macular holes has been greatly enhanced by the widespread adoption of advanced retinal imaging, particularly OCT,” he explained. “Monitoring these holes is convenient with longitudinal OCT imaging, which enables visit-to-visit comparisons to determine improvement or worsening.”

“The success rate of macular-hole repair is very high with current surgical techniques and technology, so in the vast majority of cases, per standard care, retina specialists will recommend surgery,” added Dr. Han, who also was not involved in the study. “The potential benefits generally outweigh the minimal risks.”

“Evidence exists to suggest that delayed repair negatively impacts these outcomes,” he advised. “Clinicians need to balance the factors that may be in favor of spontaneous hole closure with the generally modest risks of surgical repair.”

SOURCE: The British Journal of Ophthalmology, online April 29, 2021.

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