Lamellar hole-associated epiretinal proliferation: pathophysiology, clinical role and treatment strategies

Lamellar hole-associated epiretinal proliferation (LHEP) is a distinctive clinical entity characterised by a homogeneous, medium-reflective material on optical coherence tomography that is commonly associated with lamellar macular holes (LMH). Since its initial description, significant advances have been made in understanding its histopathological origins, natural progression and clinical implications. Histological studies suggest LHEP likely originates from Müller cells, with immunohistochemical studies consistently demonstrating positivity for glial fibrillary acidic protein and glutamine synthetase. Unlike conventional epiretinal membranes, LHEP does not exhibit tractional properties and is often associated with deeper retinal defects and ellipsoid zone disruption. While early studies yielded conflicting results regarding the impact of LHEP on visual outcomes, recent evidence suggests that LMH with LHEP may represent a distinct clinical entity with potentially different management implications. Surgical approaches have evolved from conventional peeling techniques to LHEP-sparing and LHEP-embedding procedures, with recent innovations including autologous platelet-rich plasma therapy showing promising results. Emerging data suggest improved outcomes with these newer approaches, including the 'no-retina-touch' technique that minimises iatrogenic trauma while achieving high efficacy in foveal defect closure. This review synthesises the current understanding of LHEP, its clinical significance and evolving treatment strategies.