Three-dimensional observations of developing macular holes.

PURPOSE

To describe the morphologic features of idiopathic macular holes and vitreous traction during macular hole evolution.

METHODS

We prospectively examined 89 eyes of 82 patients with idiopathic macular holes (stage 1, 15 eyes; stage 2, 16 eyes; stage 3, 50 eyes; stage 4, eight eyes) using optical coherence tomography. In addition to optical coherence tomography, scanning laser ophthalmoscopy was performed in all 15 eyes with stage 1 hole, six of 16 eyes with stage 2, and 19 of 50 eyes with stage 3.

RESULTS

In stage 1 eyes, optical coherence tomography revealed retinal split or cystic changes at the fovea in 11 of 15 eyes (73%) and foveal retinal detachment in four eyes (27%). Two eyes with foveal cysts progressed to stage 2, and one developed a stage 3 hole. In one eye with retinal detachment, the detached retina thinned and developed dehiscence. Optical coherence tomography showed a vitreous cortex that was detached in the perifoveal area but attached on the fovea in 11 of the 15 stage 1 eyes. In stage 2 macular holes, retinal tissue extending from the perifoveal retina formed a flap. Scanning laser ophthalmoscopy demonstrated intraretinal radiating striae, which corresponded to a foveal cyst or perifoveal cystic changes.

CONCLUSIONS

Macular holes start as retinal splits or foveal cysts in most cases. The anterior wall of the cyst serves as a flap in stage 2 and an operculum in stage 3 holes. Radiating striae correspond to retinal splits or cysts and presumably represent an elevation of Henle fiber. In a few macular holes, foveal detachment is the initial change. The detached retina thins and eventually develops a hole. In both courses, anterior traction of the slightly detached vitreous cortex appears to be a major contributing factor to macular hole formation.