Traumatic macular hole: observe, operate, or other options

Traumatic macular holes (TMH) represent a distinct subset of macular holes arising from ocular trauma. This review examines controversies in TMH management: whether and when to operate, how to interpret OCT biomarkers as prognostic guides, special considerations in the pediatric population, and the role of emerging surgical and pharmacologic alternatives.

Minimum hole diameter and the presence of intraretinal cysts appears to reliably stratify eyes by likelihood of spontaneous closure. Pediatric TMH generally demonstrates high spontaneous closure rates. Vitrectomy with ILM peeling achieves high anatomical closure rates; while earlier surgery has been associated with better visual outcomes in observational data, this association is likely confounded by the tendency to observe longer in eyes with more extensive comorbidities and poorer baseline prognosis. Topical treatment is an option, and adjuvant maneuvers and plugging material can be considered during vitrectomy for refractory or TMHs at high risk for nonclosure.

The association between earlier surgery and better visual outcomes in the literature requires careful interpretation due to case-mix confounding. A systematic, optical coherence tomography-guided approach integrating hole characteristics, patient age, and associated ocular injuries allows individualized management of TMH. Continued refinement of surgical techniques is promising for large and refractory holes.