[Idiopathic macular foramen: new aspects of staging and possible therapeutic concepts]

Idiopathic macular hole and its early stages raises one of the most fascinating subjects in retinal disease. In this review, we aim to summarize the current knowledge of pathogenesis, the recent classification and the strategies for therapy. Recent evidence strongly suggests tangential traction induced by a thin epiretinal membrane to be the main cause for idiopathic senile macular holes. A thickening of the epicortical vitreous membrane or the internal limiting membrane of the retina could be demonstrated in these cases. When such a precursor situation (stage I) is present, in many cases there will be a progression to a full thickness macular hole (stage II). Further traction usually causes an enlarging of the defect in these eyes and the classic appearance of macular holes (stage III-IV) can then be observed. The clinical appearance, the diagnosis and the strategies of treatment are discussed for all stages of idiopathic senile macular holes. Based on the deeper insight into macular hole development, prophylactic vitrectomy and removal of the epiretinal membrane in cases of stage I macular holes, has been considered in order to prevent a further progression of the disease. There is also evidence that in stages II-IV macular holes, a closure of the hole and a visual improvement can be gained by vitrectomy, removal of the epiretinal membrane and fluid-gas exchange. The additional application of biological modifiers (transforming growth factor-beta, human autologous serum or tissue glue) may enhance the adhesion of the detached retina and therefore lead to better anatomical and functional success rates. The results of the pilot studies are reviewed and the surgical techniques as well as the possible complications are discussed.