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Surgery Surgery for Myopic Macular Hole Without Retinal Detachment J o s e G a r c i a - A r u m i , 1,2 A n n a B o i x a d e r a , 2 V i c e n t e M a r t i n e z - C a s t i l l o , 2 M i g u e l A n g e l Z a p a t a 2 a n d C a r m e M a c i à 2 1. Department of Ophthalmology, Instituto de Microcirugia Ocular; 2. Department of Ophthalmology, Hospital Vall d´Hebron, Barcelona, Spain Abstract The purpose of this paper is to review the indications, surgical technique and surgical outcome of myopic macular holes (MHs). In myopic MH, the use of optical coherence tomography has been very useful both in the diagnosis and follow-up after surgery due to the difficulty in biomicroscopic diagnosis in high myopes. Myopic MH surgery is more difficult than idiopathic MH surgery due to the increased axial length, retinal pigment epithelium and choroidal atrophy, and thinner retina making internal limiting membrane and posterior hyaloid staining more important. Myopic MH vitreoretinal surgery achieves comparable anatomical success rates when compared with idiopathic MHs except in cases with posterior staphyloma and axial lengths equal to or over 30 mm where a macular buckle may be needed. The closure of myopic MH decreases the risk of retinal detachment secondary to MH. Keywords Myopic macular hole, pars plana vitrectomy, optical coherence tomography, high myopia, foveoschisis, internal limiting membrane peeling, macular buckle Disclosure: The authors have no conflicts of interest to declare. Received: 12 October 2011 Accepted: 6 January 2012 Citation: European Ophthalmic Review, 2012;(6)4:204–7 Correspondence: Jose Garcia-Arumi, Department of Ophthalmology, Instituto de Microcirugía Ocular, C/ Josep Maria Lladó no 3, 08002, Barcelona, Spain. E: 17215jga@comb.es Asymptomatic Myopic Macular Hole Secondary macular hole (MH) can occur in eyes with high myopia and the characteristics and demographics of these MHs differ from those of most idiopathic holes. Myopic MHs tend to develop in younger subjects and may be associated with a rhegmatogenous retinal detachment surrounding the hole. 1 The mean age of patients in most myopic MH series is mid-fifties, whereas the mean age in idiopathic MH series is the upper sixties. The earlier onset of myopic MHs may be related to abnormal vitreomacular traction in myopic eyes, premature vitreous liquefaction, or other unknown factors predisposing these eyes to premature MHs – there is a predominance in women. The diagnosis may be difficult because of retinal pigment epithelium (RPE) and choroidal atrophy. Biomicroscopic diagnosis of MH in highly myopic eyes without retinal detachment is sometimes difficult. This could be due to a lack of contrast between the MH and RPE, particularly in the presence of a deep posterior staphyloma and severe chorioretinal atrophy. In asymptomatic myopic eyes with good vision, optical coherence tomography (OCT) has revealed the presence of MH. 2 Asymptomatic MH is more prevalent in eyes with higher degrees of myopia and pronounced posterior staphyloma. In the authors’ experience of macular examination with optical coherence tomography in severely myopic eyes with posterior staphyloma, the authors have found that retinal detachment, retinoschisis, or both, are often seen at the fovea, suggesting that foveal retinal detachment may precede the onset of MH formation. Also, in these patients apparent complete posterior vitreous detachment (PVD) confirmed by biomicroscopy does not prevent vitreous remnants adhering to the retina, since vitreoschisis and a posterior vitreous cortex adherence has been found to persist. It may also be preceded by a foveal detachment causing the fovea to become extremely thin. The action of a tangential tensile force on this thinner retina might explain the occurrence of MH. 204 The exact relationship between retinoschisis and MH formation is not known; it has been suggested that retinoschisis develops before the MH. 3 Myopic foveoschisis, recently described based on OCT, may affect between 9 to 20 % of highly myopic eyes with posterior staphyloma. 4 Foveoschisis may develop in these eyes because of traction by either an epiretinal membrane or posterior vitreous cortex on the retina and it is believed to impair macular function and in some cases, result in MH formation and retinal detachment. 5,6 In many cases foveoschisis is asymptomatic, since initially the foveal detachment may be shallow and allow enough oxygen and nutrient diffusion from the choriocapillaris to the photoreceptors. It has been suggested that the combination of myopic foveoschisis and foveal detachment can lead to a MH. 6,7 Kobayashi et al. evaluated the efficacy of vitreous surgery for highly myopic eyes with foveal detachment and retinoschisis. Vitreous surgery may have a role as a prophylactic treatment for highly myopic eyes with a high risk of MH development. 7 It has been observed by Gaucher et al. 6 that especially when a tractional premacular structure is present on OCT, around 44 % of patients develop MH spontaneously or during follow-up after surgery. Gaucher et al. 6 identified two poor prognostic factors: the presence of a premacular structure and a foveal detachment. The premacular structure is seen as a hyper-reflective line on OCT scans and may represent a partially detached and condensed posterior hyaloid or a hyaloid lined with fibrous membranous proliferations. In addition a tense and rigid internal limiting membrane (ILM) has been described which affects the fit of the retinal boundary to the outer curvature of the eyeball. In developed countries the prevalence of myopia is reported to be between 11 and 36 %. 6 The prevalence of degenerative myopia varies from 0.2 % in Egypt to 9.6 % in Spain 8 and 18 % in Japan. 3,9 © TOUCH MEDICAL MEDIA 2012