Vitreomacular Traction and Macular Hole

Contents

Aetiology

Posterior vitreous separation and eventual detachment (PVD) is regarded as part of the normal human ageing process. It characteristically occurs initially perifovally with vitreomacular attachment (VMA) before separation. It may be complicated by persistent adhesion and traction at the fovea (VMT), which can lead to full thickness macular hole formation (FTMH) in some cases (termed ‘idiopathic’). 

Macular holes can also be partial thickness and associated with vitreo-retinal interface abnormalities. Several subtypes have been described:

Vitreomacular Traction (VMT)

  • VMT is common and resolves in approx. 50% of cases
  • Only about 5% progress to FTMH (unless the eye is a fellow eye to one with a FTMH where the risk is higher)
  • A number of different stages of macular hole evolution, traditionally based on ophthalmoscopic appearances, have been described. These have more recently been replaced by an OCT-based anatomic classification system describing morphological features and vitreoretinal interface abnormalities.
  • Myopic traction maculopathy is a complication of pathologic myopia in which tractional forces lead to a variety of pathological changes in the eye, including retinoschisis, lamellar or full thickness macular hole, and foveal retinal detachment.

Partial thickness macular holes

A partial thickness discontinuation of the neurosensory retina at the centre of the macula. Can be primary or secondary to a wide variety of conditions

  • Those relating to vitreoretinal interface disorders have been categorised into three subtypes according to their OCT morphology:
    • Lamellar Macular Hole (LMH)
    • Macular Pseudohole (MPH) (appearance of a macular hole but no loss of foveal tissue)
    • Epiretinal membrane (ERM) foveoschisis

Full Thickness Macular Hole (FTMH)

  • interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium
  • Affects 6-8 per 100,000 of the general population per year (with a prevalence of 1 in 200 of those aged over 60 years)
  • Predominantly in those >65 years
  • Female:male predominance = 3:1 (range 17:1) 
  • Unilateral in 90% of cases
  • Spontaneous resolution in 4-6%

Predisposing factors

FTMH

  • ‘Idiopathic’ (i.e. age-related are most common)
  • Risk factors: older age, female gender, myopia ≥-6.0D, retinal detachment, trauma (rare)
  • 10-15% risk of a patient with FTMH developing a FTMH in the fellow eye within five years, unless the fellow eye already has a PVD in which case the risk falls to 1%

Symptoms of macular hole

Macular hole

  • May be asymptomatic depending on ocular dominance
  • Blurred vision, which may be profound
  • Metamorphopsia
  • Micropsia

Signs of vitreomacular traction and macular hole

VMT
The clinical signs and OCT appearances of VMT are tabulated below

Macular hole

  • Reduced visual acuity (typically Snellen 6/24-3/60)
  • Amsler grid test (shows central distortion or scotoma)
  • Watzke-Allen test (narrow slit-beam projected over the macular hole appears to the patient to be thinned or broken up)
  • The International Vitreomacular Traction Study Group has published an OCT-based classification of vitreomacular adhesion, traction and macular hole which can be tabulated along with clinical signs and symptoms (see below)
StageClinical appearance /
symptoms		OCT appearance
1-A
  • Loss of foveal depression and yellowish foveal spot 100-200μm diam
  • Decreased VA (6/7.5 to 6/24)

VMT

  • Localised detachment of perifoveal vitreous cortex with persistent adherence to foveola
  • No foveal shape change or intraretinal changes
  • Vitreofoveolar traction splits retina at fovea (pseudocyst) which corresponds to yellow spot
  • Epiretinal membranes uncommon
1-B
  • Yellow ring 200-350μm diam
  • Decreased VA (6/7.5 to 6/24)

VMT

  • Posterior extension of pseudocyst with disruption of outer retinal layer
  • Retinal ‘roof’ intact with persistent adherence of vitreous cortex
  • Epiretinal membranes uncommon
2
  • Small full thickness macular hole, often eccentric
  • Symptoms include metamorphopsia and decreased VA (6/7.5 to 6/24)

Small or medium FTMH with or without VMT

  • Epiretinal membranes uncommon
3
  • Full thickness macular hole
  • Operculum clinically visible
  • Drusen-like deposits may be seen at base of macular hole
  • Severely decreased VA (6/30 to 6/120); central scotoma may be present

Medium or large FTMH with or without VMT

  • Posterior vitreous detached from macula but may remain attached to optic disc and more peripherally
  • Operculum visible on posterior vitreous face over macular hole
  • Cuff of subretinal fluid may be present; also intraretinal oedema and cysts
  • Rim of hyper- or hypo-pigmented RPE between detached and non-detached retina in long-standing cases
  • Epiretinal membranes may be present
4
  • Large full-thickness macular hole
  • Complete vitreous detachment with Weiss ring
  • Drusen-like deposits may be seen at base of macular hole
  • Severely decreased VA (6/30 to 6/120); central scotoma may be present

Small, medium or large FTMH without VMT

  • Cuff of subretinal fluid, intraretinal oedema and cysts
  • Epiretinal membranes more likely to be present

VMT = vitreomacular traction; FTMH = full thickness macular hole; ILM = inner limiting membrane. Macular hole size (at narrowest point): small (<250μm); medium (>250μm
 and ≤400μm); large (>400μm)

Differential diagnosis

Macular pseudohole
Cystoid macular oedema
Diabetic macular oedema
Central serous retinopathy
Solar maculopathy
Sub-foveolar drusen

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological 

OCT examination (if not available, consider referring to a colleague who has the equipment). OCT imaging provides information on the size of a macular hole
and the presence of vitreoretinal traction and/or epiretinal membrane formation. OCT images are also helpful in patient education

Careful examination of the fellow eye to identify presence of ‘at risk’ features e.g. vitreous traction at or near the centre of the macula (VMT)
(GRADE*: Level of evidence=low; Strength of recommendation=strong)

Patient education on early warning signs e.g. metamorphopsia and/or change in central vision. Supply Amsler Grid and emphasise importance of using it (a)
monocularly and (b) regularly. Alternatively, ask the patient to regularly read with each eye independently to check for changes in vision (blur or metamorphopsia)

Pharmacological 

None

Management category

B1 (modified): for VMT, Stages 1-A and 1-B, monitoring with OCT
A3: for Stages 2, 3 and 4 macular hole: urgent referral to an ophthalmologist (within one week, or in accordance with local protocols)

Possible management by ophthalmologist

Surgical management results in hole closure in approximately 95% of cases and following successful closure, the majority show some visual improvement, with approx. 50% achieving ≤0.30 logMAR (6/12 or better).

Surgery following OCT confirmation of presence and type of macular hole. Surgery is most likely when the diagnosis is FTMH.

FTMH (Stages 2 and 3)
Pars plana vitrectomy with internal limiting membrane (ILM) peeling and intravitreal gas tamponade, usually performed within one month of diagnosis.

Approximately 95% of patients with a full thickness macular hole achieve complete hole closure following a single surgical procedure, which typically results in improved vision. However, cataract develops within a year following this procedure in 50-65% of patients, when it can be dealt with by conventional surgery. Some surgeons recommend vitrectomy and peeling with cataract surgery as a single combined procedure.

OCRIPLASMIN (Stage 2)
Intravitreal injection of Ocriplasmin, which induces enzymatic vitreolysis. Although this technique has been approved by NICE for patients with VMT with no epiretinal membrane and a macular hole of ≤400μm horizontal width and/or severe visual symptoms, it is no longer commonly used in the UK.

PARTIAL THICKNESS MACULAR HOLES 
A 2021 Cochrane review of surgery for lamellar holes concluded that there is insufficient evidence to support or refute surgery as an effective management option, although this is an evolving area and many surgeons offer surgery depending on symptoms and type of partial thickness hole present.

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation. (see https://www.gradeworkinggroup.org/)

Sources of evidence

Chen JC, Lee LR. Clinical spectrum of lamellar macular defects including pseudoholes and pseudocysts defined by optical coherence tomography. Br J Ophthalmol. 2008;92(10):1342-1346

Cheong KX, Xu L, Ohno-Matsui K, Sabanayagam C, Saw SM, Hoang QV. An evidence-based review of the epidemiology of myopic traction maculopathy. Surv Ophthalmol. 2022;67(6):1603-1630.

Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, Sadda SR, Sebag J, Spaide RF, Stalmans P. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013;120(12):2611-2619

Flaxel CJ, Adelman RA, Bailey ST, Fawzi A, Lim JI, Vemulakonda GA, Ying GS. Idiopathic Macular Hole Preferred Practice Pattern®. Ophthalmology. 2020;127(2):184-222

Hubschman JP, Govetto A, Spaide RF, Schumann R, Steel D, Figueroa MS, Sebag J, Gaudric A, Staurenghi G, Haritoglou C, Kadonosono K, Thompson JT, Chang S, Bottoni F, Tadayoni R. Optical coherence tomography-based consensus definition for lamellar macular hole. Br J Ophthalmol. 2020;104(12):1741-1747.

Jackson TL, Haller J, Blot KH, Duchateau L, Lescrauwaet B. Ocriplasmin for treatment of vitreomacular traction and macular hole: A systematic literature review and individual participant data meta-analysis of randomized, controlled, double-masked trials. Surv Ophthalmol. 2022;67(3):697-711.

Murphy DC, Rees J, Steel DH. Surgical interventions for lamellar macular holes. Cochrane Database Syst Rev. 2021;11(11):CD013678.

National Institute for Health and Care Excellence (NICE). Ocriplasmin for treating vitreomacular traction Technology appraisal guidance. Published: 23 October 2013

Neffendorf JE, Kirthi V, Pringle E, Jackson TL. Ocriplasmin for symptomatic vitreomacular adhesion. Cochrane Database Syst Rev. 2017;10(10):CD011874.

Parravano M, Giansanti F, Eandi CM, Yap YC, Rizzo S, Virgili G. Vitrectomy for idiopathic macular hole. Cochrane Database Syst Rev. 2015;2015(5):CD009080

Steel DH, Lotery AJ. Eye (Lond). Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment. Eye (Lond). 2013;27 Suppl 1(Suppl 1):S1-21

Steel DH, Donachie PHJ, Aylward GW, Laidlaw DA, Williamson TH, Yorston D; BEAVRS Macular hole outcome group. Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort. Eye (Lond). 2020 Mar 30. doi: 10.1038/s41433-020-0844-x. Online ahead of print

Tanner V, Williamson TH. Watzke-Allen slit beam test in macular holes confirmed by optical coherence tomography. Arch Ophthalmol. 2000 Aug;118(8):1059-63. doi: 10.1001/archopht.118.8.1059. PMID: 10922198

Summary

What is Vitreomacular Traction and Macular Hole?

The back of the eye is filled with a gel-like fluid called the vitreous which helps the eye to keep its shape. As people age the vitreous becomes more watery and starts to shrink. It normally pulls harmlessly away from the retina (this is known as posterior vitreous detachment) but sometimes the retina can tear in the process. If this happens at the macula, the centre of the retina, where the vision is sharpest and colour vision is best, a hole can develop. This causes a sudden drop in vision in the affected eye. There are also other, rarer causes of macular hole. Macular hole is not related to age-related macular degeneration.

A special examination known as optical coherence tomography (OCT) has been available since 1990. This works like an ultrasound, but using light rather than sound. It is painless and quick. There is no contact with the eye and no radiation. OCT shows the structures inside the eye, including the retina and macula, in great detail.

How is Vitreomacular Traction and Macular Hole managed?

If an optometrist finds a macular hole, he or she will refer the patient to an ophthalmologist (eye doctor) who will probably recommend an operation, as there are no eye drops, medicines or diets that can help. The most usual operation for macular hole is called a vitrectomy, in which the vitreous pulling on the retina is removed. A bubble of gas is then placed inside the eye to help the retina to settle back into place and the macular hole to seal. In most cases this results in better vision.

An eye that has had a vitrectomy is likely to develop cataract, but this can be dealt with later by a routine operation. Surgeons sometimes perform the two operations at the same time. Some patients will be offered another kind of treatment which involves injecting a substance into the eye. This is Ocriplasmin, an enzyme that liquefies the vitreous, releasing tension on the retina.

Vitreomacular Traction and Macular Hole
Version 2
Date of search 04.04.23
Date of revision 12.07.23
Date of publication 03.08.23
Date for review 03.04.25
© College of Optometrists