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A C T A O P H T H A L M O L O G I C A
61 (1983) 337-342
Department of Ophthalmology (Head: S . Vannar), Helsinki University Central Hospital, Helsinki, Finland
MACULAR HOLE AND RETINAL DETACHMENT
BY
LEILA LAATIKAINEN and HELENA HARJU
Within a 4-year period 6 eyes with a macular hole and rhegmatogenous retinal detachment (1.7% of all rhegmatogenous detachments) were operated on. In 2 eyes no other retinal tears were found, 4 eyes showed additional peripheral tears. Three eyes were myopic (-3.75 to -9.0 D) and one was aphakic. All but one eye were encircled, 3 eyes had a peripheral radial plomb and another 3 had a macular sling procedure using a silastic sponge explant in addition. Cryotherapy was applied on the macular hole in one eye and photocoagulation in one eye. In 5 of the 6 cases the retina reattached. The silastic sponge sling resulted in shallow indentation and caused little distortion at the macula. Coagulation of the macular hole seemed to unnecessary.
Kqi words: retinal detachment - macula - macular hole - retinal surgery.
A full-thickness macular hole is not very uncommon in senile eyes, but rhegma- togenous retinal detachment due to a senile macular hole is rare. Most macular holes which result in retinal detachmenr are associated with high myopia or previous ocular trauma (Marcherio & Schepens 1972a; Leaver & Cleary 1975). The pathogenesis of the retinal detachment in these eyes is not always clear. Most eyes show complete vitreous detachment (Tolentino et al. 1976), and usually n o vitreous traction at the hole can be seen (Leaver & Cleary 1975). In many cases the primary cause of the retinal detachment may be a peripheral tear and the macular hole is a secondary break.
Received on October 13th. 1982.
337 Acta ophthal. 61. 3 22
Laatikainen & Harju Macular hole and retinal detachment
Several methods for treatment of retinal detachment associated with a macular hole have been presented. In cases in which the macular hole is the only break, coagulation of the hole with or without macular buckling procedure, and drainage of subretinal fluid has been recommended (Marcherio & Schepens 1972a; Leaver & Cleary 1975; Tolentino et al. 1976). Treatment of the macular hole in the presence of a peripheral tear has been controversial. Some authors suggest sealing of the peripheral hole as the primary step (Tolentino et al. 1976; Chignell 1980), whereas others have found that treatment of the macular hole is indicated, whether it is the only tear or is associated with other retirial breaks (Leaver & Cleary 1975).
This paper is a report of the management of retinal detachment in 6 eyes in which a macular hole was diagnosed.
Patients and Methods
In 1978- 198 1 6 eyes with rhegmatogenous retinal detachment were seen in which a macular hole was diagnosed. The diagnosis of the macular hole was established by biomicroscopy using the Goldmann contact lens. The mean age of the 4 female and 2 male patients was 66.2 years (range 50-75 years). Three eyes were myopic (-3.75 D or more) and one was aphakic (Table 1). The duration of symptoms varied from one week to several months. In 4 of the 6 eyes peripheral tears were also present, usually in the temporal periphery. The extent of detachment was at least 2 quadrants, in 3 eyes the retina was totally detached. The visual acuity varied from perception of light to counting fingers at 4 m.
The surgical procedure varied. In 3 eyes a radial silastic sponge explant was inserted on the peripheral tear with (2 cases) or without (1 case) encirclement, and in another 3 eyes encirclement was combined with a macular buckling procedure using a silastic sponge sling (Table 1). The macular sling was passed from the upper nasal quadrant, where it was anchored close to the nasal margin of superior rectus muscle in front of the equator, through the insertion of the superior oblique muscle and posterior to the insertion of the inferior oblique muscle to the lower temporal quadrant. After drainage of the subretinal fluid the inferior end of the explant was fixed close to the insertion of the inferior rectus muscle. The peripheral tear was treated by cryocoagulation. In one eye cryotherapy was also applied on the macular hole, and in one eye the macular hole was later surrounded by photocoagulation using argon laser. In the others the macular hole was not treated directly. The follow-up varied from 7 to 25 months except in one case in which the retina remained totally detached.
338
Cas
e N
o.
Sexl
age
1 F/
73
2 F/
50
3 F/
7 1
4 M
I75
5 M
I69
6 F/
59
Dur
atio
n Pe
riph
eral
E
xten
t of
Coa
gula
tion
Vis
ual a
cuity
Z
Follo
w-
sym
ptom
s (q
uadr
ant3
- {q
uadr
ants
') th
e m
acul
a po
stop
erat
ive
(mon
ths)
Typ
e of
R
efra
ctio
n of
te
ar
deta
chm
ent
of
Fina
l res
ult
preo
pera
tive1
u
p
oper
atio
n
+ 1.
5 2w
eeks
- 8
.0
seve
ral
mon
ths
- 9
.0
3 w
eeks
(m
aCul
ar ho
le
for 3
yea
rs)
+ 1.
5 3w
eeks
+10.
0 1 w
eek
(aph
akia
)
- 3
.75
lmon
th
+S
T
ST
,IT
ra
dial
plo
mb
-
retin
a fl
at,
CF
lm/C
F3
m
23
mac
ular
puc
ker
mac
ular
puck
er
+ S
N
tota
l ra
dial
plo
mb
phot
o-
retin
a fl
at
HM
/CF
1 m
17
enci
rcle
men
t co
agul
atio
n
- IT
, IN
m
acul
ar sl
ing
cryo
- re
tina
flat
H
M/H
M
25
enci
rcle
men
t co
agul
atio
n
+S
T,I
T
tota
l ra
dial
plo
mb
-
tota
l C
F 1 m
/HM
1
- to
tal
mac
ular
slin
g -
retin
a fl
at
PLIO
. 15
7
enci
rcle
men
t de
tach
men
t
enci
rcle
men
t
+ IT
IT
, IN
m
acul
ar sl
ing
-
retin
a fl
at
CF
4m
/CF
3m
14
en
circ
lem
ent
ST =
sup
erot
empo
ral,
IT =
infe
rote
mpo
ral,
SN =
sup
eron
ad,
IN =
infe
rona
sal.
CF
= c
ount
ing
fing
ers,
HM
= h
and
mov
emen
ts,
PL =
per
cept
ion
of li
ght.
h- .-
Ic
Laatikainen & Harju Macular hole and retinal detachment
Results Eyes without peripheral breaks
In 2 eyes no peripheral breaks were found (Table 1). One of the 2 had had a macular hole for 3 years before the retina detached. This eye was myopic (-9.0 D). The other eye had been aphakic for 8 years. Both eyes were treated by encirclement and macular buckling. In spite of a good buckling effect at both ends of the macular sling the indentation at the macula was shallow in both eyes. In the former case the macular hole was treated by cryotherapy. The retina re-attached but the visual acuity remained poor (HM). In the latter case the macular hole was left untreated in order to preserve more macular function because the other eye of this patient was already blind. The retina re-attached and the vision improved to 0.15. Post- operatively the latter eye developed transient choroidal detachment, but no other complications were noticed.
Eyes with peripheral breaks
Three eyes showed one break and one eye two peripheral breaks in addition to the macular hole (Table 1). Two were myopic (-3.75 and -8.0 D) and 2 were hyperopic (f 1.5 D). There was no history of a longstanding macular hole in any of them.
In one eye the peripheral tear was inferior. This eye was treated by encirclement and a macular sling which also sealed the peripheral break. The retina re-attached without coagulation of the macular hole. In the other 3 eyes the peripheral breaks were sealed by radial plombs using silastic sponge explants. In 2 of the 3 encirclement was also performed. None of these macular holes was treated by cryotherapy or diathermy, but in one eye the hole was post-operatively surrounded by mild photocaogulation using argon laser. In 2 eyes the retina reattached, one case failed. One eye (Case 1, Table 1 ) showed some macular pucker pre-operatively. This increased slightly after the operation. No other intra- or post-operative complications were noticed. The post-operative visual acuity varied from hand movements to counting fingers at 3 m.
Discussion
The 6 cases reported represent 1.7% of all rhegmatogenous detachments operated on. In most studies the overall incidence of macular breaks as a cause of rhegmatogenous retinal detachment was found to be 0.5-0.6% (Howard & Campbell 1969; Marcherio & Schepens 1972a; Feman et al. 1974). The incidence is
340
Laatikainen 8 Harju Macular hole and retinal detachment
higher in high myopia and after trauma (Marcherio & Schepens 1972a; Leaver & Cleary 1975). A greater incidence (8.9%) has been reported among Japanese (Minoda 1979). Two of the present cases had myopia of -8.0 and -9.0 D, respectively, but none had a history of ocular trauma.
In 4 of the present cases the detachment was probably caused by peripheral tears, and the macular hole was secondary. None of these macular holes had been diagnosed before development of retinal detachment. In 2 eyes the retina re- attached by a peripheral buckling procedure. In one of them the macular hole was surrounded by mild photocoagulation which probably did not alter the outcome. In one eye retinal re-attachment was achieved by a macular sling which closed both the peripheral and macular tears. At the macula the indentation was shallow suggesting that sealing of the peripheral tear alone might have been successful. The fourth eye failed. In this eye one of the peripheral tears remained open, and the patient refused re-operation.
In the 2 eyes in which no peripheral tears could be found the detachment was possibly caused by the macular hole. In one of these eyes the macular hole had been diagnosed 3 years earlier. In both cases the macular sling procedure combined with encirclement was successful. This type of macular sling caused little distorsion at the macula, and its insertion was less hazardous than suturing a posterior plomb over the macula (Adams 1961). In one of the 2 eyes cryotherapy was applied on the macular hole, in the other the hole was left untreated. The large atrophic scar of the cryotherapy disturbed macular function considerably as was stated by Chignell (1980). Because re-attachment of the retina was also achieved in the cases in which the macular hole was not treated by coagulation, except the one in which the peripheral tear was open, it seems that treatment of the macular hole by cryo- therapy or photocoagulation was unnecessary.
In order to preserve more of the macular function, Scott (1974) proposed the use of intravitreal silicone oil with or without separation of the retraction membrane from the macula, without destroying the macula with cryotherapy and without the risks of exposing the posterior sclera. More recently Machemer (1982) has shown that closed eye vitrectomy and cutting of vitreoretinal traction on the macular hole alone allowed the retina to re-attach without coagulation of the hole or buckling of the macula. It remains to be seen if this approach will wholly replace conventional procedures for treatment of retinal detachment caused by a macular hole.
References
Adams S T (1961): Retinal detachment due to macular and small posterior holes. Arch
Chignell A H (1980): Retinal Detachment Surgery, pp 92-94. Springer-Verlag, Berlin. Ophthalmol66: 528-533.
34 1
Laatikainen 8 Harju Macular hole and retinal detachment
Feman S S, Hepler R S & Straatsma B R (1974): Rhegmatogenous retinal detachment due to macular hole. Management with cryotherapy and a Y-shaped sling. Arch Ophthalmol91: 371-372.
Howard G M & Campbell C J (1969): Surgical repair of retinal detachments caused by
Leaver P K & Cleary P E (1975): Macular hole and retinal detachment. Trans Ophthalmol
Machemer R (1982): Surgical techniques in the retina and vitreous. George N Wise memorial
Marcherio R R & Schepens C L (1972a): Macular breaks. 1. Diagnosis, etiology, and
Marcherio R R & Schepens C L (1972b): Macular breaks. 2. Management. Am J Ophthalmol
Minoda K (1979): Retinal detachment due to macular hole among Japanese. Jpn J
Scott J D (1974): Macular holes and retinal detachment. Trans Ophthalmol SOC UK 94:
Tolentino F I, Schepens C L & Freeman H M (1976): Vitreoretinal Disorders. Diagnosis and
macular holes. Arch Ophthalmol81: 317-321.
SOC UK 95: 145- 147.
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Management, pp 400-4 12. W B Saunders Co, Philadelphia.
Author’s address:
Dr. Leila Laatikainen, Department of Ophthalmology, Helsinki University Central Hospital, Haartmaninkatu 4 C, SF-00290 Helsinki 29, Finland.
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