How optical coherence tomography has changed the management of macular holes: A narrative review

Optical coherence tomography (OCT) has revolutionized the diagnosis and management of macular holes (MHs). Before OCT, physicians relied on slit-lamp biomicroscopy and angiographic findings, which were often insufficient for differentiating subtle pathologies. By enabling cross-sectional visualization of the retina, OCT has confirmed vitreomacular traction as a key factor in MH formation and supports the safety of surgical intervention. Quantitative OCT parameters have allowed the development of prognostic biomarkers, while spectral-domain OCT has further improved assessment by revealing postoperative photoreceptor integrity, with restoration of the ellipsoid zone and external limiting membrane correlating with visual recovery. OCT imaging under intraocular gas has enabled early confirmation of MH closure, allowing OCT-guided face-down positioning protocols that reduce postoperative burden without compromising outcomes. En face OCT and three-dimensional volumetric analysis have uncovered new biomarkers, such as preretinal abnormal tissue and inner retinal fluid volume, which aid in surgical planning and visual prognosis. Structural changes, such as dissociation of the optic nerve fiber layer and epiretinal proliferation (EP), are also better understood through OCT, thereby influencing decisions on internal limiting membrane peeling and EP preservation. OCT has not only revolutionized the diagnosis and classification of MHs but also continues to shape their surgical management, bringing us closer to optimizing visual recovery through personalized and data-driven approaches.