Surgery for idiopathic full-thickness macular holes

Idiopathic full-thickness macular holes (FTMH) are an important cause of loss of central vision in the elderly. Improved understanding of the natural history and pathophysiology of FTMH has led to recent advances in the surgical management of patients with this hitherto untreatable condition.

The current concepts of the natural history and surgical treatment are reviewed. Pilot studies of vitrectomy undertaken to relieve the tangential traction at the vitreomacular interface and the role of growth factors as promoters of a limited healing response are reviewed and illustrated by the results of surgical treatment of macular holes obtained by the author and others.

Whereas early pilot studies of vitrectomy of impending (stage I) macular hole suggested beneficial results (80-95% of operated eyes did not progress to FTMH), no such benefit could be demonstrated by a subsequent randomised treatment trial. In a study of early vitrectomy and partial fluid-gas exchange hole closure was achieved in 88% of patients with stage II FTMH with visual improvement in 67%. In other studies of FTMH (stages II-IV) the addition of adjunctive substances such as growth factors, autologous serum, plasma or platelet concentrate has resulted in closure in 77-100% of cases. However, similar results have also been reported with vitrectomy and gas tamponade alone. Histologically the closure of the FTMH is associated with glial proliferation.

Vitrectomy and intraocular tamponade appear to be beneficial in patients with FTMH. The role of adjunctive substances, such as growth factors and other promoters of the healing response, requires clarification by randomised treatment trials.