Anatomical and visual outcomes in high myopic macular hole (HM-MH) without retinal detachment: a review

To review postoperative anatomical and functional outcomes in high myopic macular hole (HM-MH) without retinal detachment.

In the PubMed database, published articles on myopic macular hole surgery from 2000 to 2013 (present days) were reviewed. Inclusion criteria were high myopia and macular hole (MH). Series with posterior retinal detachment secondary to MH and myopic foveoschisis (MFS) without MH were excluded. Main outcomes included MH closure rate, resolution of the foveoschisis, if present, and postoperative visual acuity. Optical coherence tomography (OCT) features and postoperative evolution were also evaluated when reported.

A total of 131 articles were initially found. After having applied the exclusion criteria, 15 articles were reviewed. Four were focused on HM-MH with concomitant foveoschisis (Schisis Group), and ten included only HM-MH without FS case series (Flat Group). Only one comparative study between these two groups was found. Surgical techniques were observed to be similar for both groups in most series, including vitrectomy with or without internal limiting membrane (ILM) removal, and gas or silicone oil tamponade. However, in one retrospective study, macular buckling was applied together with pars plana vitrectomy in cases of HM-MH with foveoschisis. When available, preoperative and postoperative OCT provided a useful evaluation of the status of the macula. Different prognosis were observed in the two groups in cases of vitreous surgery: anatomical success rate and functional outcomes for HM-MH with foveoschisis were markedly poorer than that for cases of HM-MH without foveoschisis, and multiple procedures might be required. By the contrast, better results seemed to be achieved using the posterior buckle technique for patients with HM-MH and concomitant foveoschisis. Moreover, when compared, final anatomical and functional outcomes seem to be less satisfactory than in emmetropic eyes. Postoperative non-closure or reopening of the macular hole is more common in eyes with HM-MH and concomitant foveoschisis, and possible retinal detachment may occur in these patients.

Despite similar surgical procedures, anatomical and functional results after vitreous surgery in cases of HM-MH may be very different from series to series. The prognosis is generally better in cases involving only HM-MH without foveoschisis than in cases with MH and associated foveoschisis. Persistent MHs are more frequent in eyes with concomitant retinoschisis, and this seems to represent a possible risk factor for late retinal detachment in the case of unsuccessful vitreous surgery. However, although vitrectomy can lead to anatomical and visual improvements, an higher axial length > 30 mm and the presence of a posterior staphyloma seem to remain the two most important risk factors for poor visual outcomes. For these reasons, a different surgical approach, including macular buckling, might be considered in casse of HM-MH and concomitant myopic foveoschisis, in order to counteract the traction exerted by the posterior staphyloma.