Pediatric macular hole: etiology-based management and outcomes in 88 eyes

To characterize clinical features, management, and outcomes of pediatric macular hole (MH) and to outline an etiology-guided aid.

A retrospective, consecutive case series.

Pediatric MH patients diagnosed, surgically treated, and followed at a tertiary centre (March 2012 to January 2025).

Clinical data (age, sex, etiology, best-correct visual acuity [BCVA], intraocular pressure, axial length, MH size, and imaging) were reviewed. Etiology was classified as traumatic, secondary, or idiopathic. Vitreoretinal techniques and adjuncts were recorded.

Eighty-eight eyes of 88 patients were included: traumatic 51/88 (58%), secondary 25/88 (28%), and idiopathic 12/88 (14%). At baseline, idiopathic MHs had better BCVA than traumatic (p = 0.05) and secondary (p = 0.003), while secondary MHs had longer axial length than traumatic MHs (p = 0.023). Imaging patterns differed by etiology (acute-injury changes in traumatic; proliferative/tractional features in secondary; relatively "pure" in idiopathic). Surgery reflected these patterns: internal limiting membrane flap/covering in 33% of traumatic MH; multiple adjuncts in secondary eyes (laser 56% with anti-vascular endothelial growth factor/steroid/buckle/oil); and primarily inert-gas tamponade in idiopathic MH (75%). Primary complete closure was 82%; final complete closure after reintervention was 84%. Mean final BCVA improved to 0.90 logMAR (≈20/160; p < 0.001), and the proportion with BCVA >20/200 rose from 47% to 68%. Visual gains were greatest in idiopathic and traumatic.

An etiology-informed, size/edge/traction-guided approach was associated with meaningful-though limited-visual improvement and high closure. These practice-informing data support early recognition, tailored surgery, and proactive complication management; a decision aid is provided. Prospective studies are needed to standardize thresholds and validate outcomes.