ASRS 2023: Not all full-thickness macular holes require surgery; blunt ocular trauma and hole size may merit observation

The research saw that new-onset full-thickness macular holes (FTMHs), especially those resulting from blunt ocular trauma, might close spontaneously without the need for a surgical intervention. (Image Credit: ©oasisamuel - Adobe.Stock.com)

Reviewed by J. Fernando Arevalo, MD, PhD

J. Fernando Arevalo, MD, PhD, and colleagues reported that new-onset full-thickness macular holes (FTMHs), especially those resulting from blunt ocular trauma, might close spontaneously without the need for a surgical intervention. This scenario also may apply to other macular hole cases depending on their characteristics. Arevalo, the Edmund F. and Virginia B. Ball Professor of Ophthalmology and Chairman of Ophthalmology at Johns Hopkins Bayview Medical Center, and the Wilmer Eye Institute, Johns Hopkins University, Baltimore, reported the observations at the 2023 annual meeting of the American Society of Retina Specialists.

Investigators from multiple centers worldwide collaborated in this retrospective study of FTMHs to identify the anatomic factors that might result in sealing of FTMHs without surgery.

Historically, treatment of FTMHs has depended on vitrectomy, fluid-gas exchange, and internal limiting membrane peeling. However, Arevalo said that several reports have identified a subset of FTMHs that may close without surgery in a small percentage of patients.^1-4

In the study under discussion, MH closure was defined as “a flattened and reattached hole rim along the whole circumference of the hole or type 1 closure (absence of a foveal neurosensory retinal defect).”

The FTMHs included in the study were those diagnosed by spectral-domain optical coherence tomography that sealed on follow-up without surgical intervention. The MHs were classified as traumatic or idiopathic and acute or chronic, Arevalo recounted.

MH findings

Of the 78 eyes of 78 patients (mean age, 57.9 years) with a FTMH, 18 eyes had sustained blunt ocular trauma and 18 were treated with topical or intravitreal therapies. The mean time to FTMH closure following hole diagnosis was 6.2 ± 10.8 months, Arevalo reported.

J. Fernando Arevalo, MD, PhD, the Edmund F. and Virginia B. Ball Professor of Ophthalmology and Chairman of Ophthalmology at Johns Hopkins Bayview Medical Center, and the Wilmer Eye Institute, Johns Hopkins University, Baltimore.
(Image courtesy of J. Fernando Arevalo, MD, PhD)

Following hole closure, the mean logarithm of the minimum angle of resolution corrected visual acuity (VA) at a mean of 33.8 months improved from 0.65 ± 0.54 (20/89 Snellen acuity) to 0.34 ± 0.45 (20/44 Snellen), a difference that reached significance (P<0.001).

The FTMHs closed completely in 74 eyes; 2 eyes had subretinal fluid and 2 eyes had outer retinal defects that persisted at thelast follow-up examination.

A total of 18 patients opted for nonsurgical treatment; in 4 patients that included treatment with intravitreal vascular endothelium growth factor antagonists, 13 received topical corticosteroids, and 7 received topical nonsteroidal anti-inflammatory drugs.

Of the FTMHs that closed initially, seven (9.0%) reopened after a mean of 8.6 months (range, 3-22 months). Of the 7 eyes, 2 FTMHs closed after vitrectomy, 1 stayed open after vitrectomy and closed with topical corticosteroid and topical nonsteroidal anti-inflammatory therapy, and 4 eyes did not undergo surgery.

Hole closure without surgery

Multivariate analysis showed that the initial VA was correlated significantly with the height and narrowest diameter of the MH and the final VA was correlated with the basal diameter (P<0.001 for all comparisons).

Investigators also found that the time to closure of the FTMHs, ie, a median 2.8 months, was correlated with the narrowest diameter (P<0.001) and the presence of subretinal fluid (P=0.001).

The times to hole closure varied considerably based on different factors. In the presence of blunt trauma, the mean time to hole closure was 1.6 months, 4.3 months for eyes without trauma but with therapy for cystoid macular edema, 4.4 months for eyes without trauma and without therapy but less than 200 μm in size, and 24.7 months for hole sizes exceeding 200 μm.

In commenting on their findings, the investigators said, “Our data suggested that is reasonable to observe recent-onset macular holes for nonsurgical closure, particularly in the setting of blunt ocular trauma. In FTMH cases with associated cystoid macular edema, a trial of nonsurgical therapy and frequent periodic observation should be considered and offered to the patient as an alternative to early surgical intervention. This also applies to idiopathic FTMHs without cystoid macular edema and with shole size less than 200 μm.”

References

1. Uwaydat SH, Mansour A, Ascaso FJ, et al. Clinical characteristics of full thickness macular holes that closed without surgery. Br J Ophthalmol. 2022;106:1463-1468. doi: 10.1136/bjophthalmol-2021-319001.

2. Zhang W, Grewal DS, Jaffe GJ, Mahmoud TH, Fekrat S. Spontaneous closure of full-thickness macular hole with epiretinal membrane in vitrectomized eyes: case series and review of literature. Ophthalmic Surg Lasers Imaging Retina. 2017;48:183-190; doi: 10.3928/23258160-20170130-15.

3. Alsakran WA, Alsulaiman SM, Ghazi NG. Delayed spontaneous closure of blue laser-induced full thickness macular hole. Am J Ophthalmol Case Rep. 2019;13:154-156. doi: 10.1016/j.ajoc.2019.01.003.

4. Sharpless M, Hogden M. Full-thickness macular hole closure following a single intravitreal injection of aflibercept in an eye with diabetic macular edema. J Vitreoretin Dis. 2022;6:457-460. doi: 10.1177/24741264221083415.

J. Fernando Arevalo, MD, PhD

E: arevalojf@jhmi.edu

Arevalo is the Edmund F. and Virginia B. Ball Professor of Ophthalmology and Chairman of Ophthalmology at Johns Hopkins Bayview Medical Center, and the Wilmer Eye Institute, Johns Hopkins University, Baltimore. He has no financial interest in this subject matter.