Purpose
To estimate the rate of macular hole formation in fellow eyes with a perifoveal posterior vitreous detachment (PVD) and early stage 1 intrafoveal lesions in patients with a unilateral idiopathic full-thickness macular hole (MH) using optical coherence tomography (OCT).
Design
Retrospective observational case series.
Methods
Fellow eyes of consecutive patients with a unilateral full-thickness MH were examined on OCT. A subset of fellow eyes with a perifoveal PVD had been followed to investigate the rates of macular hole formation in fellow eyes with early stage 1 intrafoveal lesions.
Results
Of 176 patients with a unilateral full-thickness MH, 42 fellow eyes (42 patients) with a perifoveal PVD were identified. During follow-up, a foveolar detachment was seen in 16 eyes, and 4 eyes had a foveal pseudocyst alone. In the 16 eyes with a foveolar detachment, 9 eyes had concurrent inner foveal splits. Within another 2 years of follow-up, OCT showed that 5 of 16 fellow eyes (31%) with a foveolar detachment developed a second full-thickness MH and 5 of 9 fellow eyes with a foveolar detachment and inner foveal splits developed a second full-thickness MH. Two of 4 eyes with a foveal pseudocyst alone developed vitreofoveal separation without hole formation. The remaining 2 eyes with a foveal pseudocyst alone remained stable at the last follow-up visit.
Conclusions
Fellow eyes with a foveolar detachment and a perifoveal PVD may be at high risk, and fellow eyes with a foveolar detachment and inner foveal splits might be at higher risk for progression to macular hole formation.
During the past 2 decades, the relationship between the vitreofoveal interface and idiopathic macular hole formation has been clarified to a great extent by the tomographic information provided by optical coherence tomography (OCT). Detailed OCT examinations of eyes with a full-thickness macular hole (MH) and normal fellow eyes have provided evidence that anteroposterior traction of a partially detached posterior hyaloid with vitreofoveal attachment seen as a perifoveal posterior vitreous detachment (PVD) is involved in the development of macular holes. Spontaneous resolution of an impending macular hole after release of the vitreofoveal traction also was seen on sequential OCT images. Therefore, a perifoveal PVD with focal vitreofoveal attachment on OCT in fellow eyes of patients with a unilateral idiopathic macular hole is a significant risk factor for the development of a second macular hole.
Before OCT was introduced, the incidence rates of development of a full-thickness MH in the fellow eye had been reported to vary from 2% to 29% in patients with a unilateral full-thickness MH. The wide range is probably attributable to differences in the state of the posterior vitreous hyaloid, the precursor foveal lesions, and the follow-up period. Gass postulated that the probable risk is between 10% and 15% in the fellow eyes and hypothesized based on a biomicroscopic study that macular holes begin as foveolar detachments. After OCT became available, Gaudric and associates reported that an intraretinal split evolved into a cystic space in the fellow eyes of eyes with a macular hole and then to disruption of the outer retinal layer and opening of the foveal floor, forming a full-thickness MH. Therefore, regarding the process of idiopathic macular hole formation on OCT, it has been proposed that an intrafoveal split or pseudocyst starts in the inner retinal layer, while some cases have suggested that a foveal detachment starts. However, the detailed rate of full-thickness MH formation is unknown in the fellow eyes with an intrafoveal split, pseudocyst, or foveolar detachment in patients with a unilateral idiopathic macular hole. In the current OCT study, we evaluated the rate of formation of a full-thickness MH in the fellow eye with a perifoveal PVD, which had early stage 1 intrafoveal lesions during the follow-up period, in patients with a unilateral idiopathic macular hole.
Methods
In this observational case study, we retrospectively reviewed the medical charts and OCT records of consecutive patients diagnosed with a unilateral idiopathic macular hole who first were examined at the Asahikawa Medical University Hospital between November 8, 2002 and October 27, 2006. A total of 176 patients (112 women, 64 men) had a unilateral idiopathic full-thickness MH. The ages of the patients ranged from 45 to 85 years (mean, 66.1 years) at the first visit. All patients underwent bilateral comprehensive ophthalmic examinations, including measurement of the best-corrected visual acuities, binocular ophthalmoscopy, slit-lamp biomicroscopy with a 90-diopter noncontact fundus lens, color fundus photography, and OCT examination. OCT examinations were performed using an OCT3 scanner (Stratus OCT, model OCT3000; Carl Zeiss Meditec, Dublin, California, USA). Experienced operators performed all OCT examinations through a dilated pupil. The OCT examination comprised at least 6 6-mm-long radial scans, centered through the fovea in each eye. We ascertained that the scan intersection point was consistent over time, and each B-scan at that time appeared to show similar retinal status in the region of the macular hole. The horizontal B-scan images were extracted from the radial lines scanned through the center of the fovea. The OCT3 scanner, which is a third-generation time-domain OCT, obtained 10-μm axial high-resolution images and acquired 400 A-scans per second that detected images of weak signals from the posterior hyaloid membrane and detailed cross-sectional images of the intraretinal features and the outer retinal photoreceptor layer in the macular region.
Based on a biomicroscopic study, Gass classified a stage 1-A macular hole as a yellow spot in the central fovea and hypothesized that it was a “foveolar detachment” ( Supplemental Figure 1 , available at AJO.com ). Based on an OCT study, Haouchine and associates reported that a “foveal pseudocyst” is a cystoid space that occupies the inner part of the foveal tissue without walls, which results in foveolar thickening, and seems to result from intrafoveal splitting ( Supplemental Figure 1 , available at AJO.com ). Therefore, in the current study, we recognized and defined the term “inner foveal split” as a tiny perifoveolar inner horizontal split without central foveolar involvement with a slight residual foveal depression. The term “perifoveal PVD,” which is a partially detached posterior hyaloid with vitreofoveal attachment, was defined as the reflectivity seen as a thin line by the precipitous posterior dip of the hyaloid face to the fovea or macula in a smooth convex curve on OCT.
Patients whose fellow eye had other diseases, such as an epiretinal membrane, central serous chorioretinopathy, macular degeneration, diabetic retinopathy, or tractional retinal detachment, and eyes with poor-quality OCT scans because of cataract were excluded. Eyes with an intraocular inflammatory disease; those that underwent a previous ocular surgery; eyes with retinal photocoagulation, trauma, solar retinopathy from sun gazing, myopia exceeding -6.0 diopters, or retinal detachment; and eyes that underwent an OCT examination only at the initial visit also were excluded.
The principal outcome in the current study was the rate of formation of a full-thickness MH in fellow eyes with early stage 1 intrafoveal lesions and vitreofoveal attachment seen as a perifoveal PVD in patients with a unilateral idiopathic macular hole. Only patients diagnosed with a unilateral full-thickness MH were included. The other eye was analyzed retrospectively on the first OCT examination at the first visit. Patients with bilateral involvement at the initial visit, including a stage 1-B impending macular hole (ie, a foveal yellow ring accompanied by a large foveal pseudocyst with outer retinal layer separation on OCT; see Supplemental Figure 1 , available at AJO.com ), were excluded for the purpose of reporting the rate of macular hole formation in fellow eyes with early stage 1 intrafoveal lesions and a perifoveal PVD on OCT. The subset of fellow eyes with a perifoveal PVD and no or less severe symptoms was observed, and the features that were documented initially and at various follow-up times were investigated. Patients who completed a follow-up of at least 6 months were eligible for the current study. Patients were followed at least every 3 to 6 months up to 60 months. Eyes with a perifoveal PVD were followed until the need for surgery to treat a second full-thickness MH or until the vitreofoveal attachment was released because the presence of a PVD or vitreomacular separation reduced the risk of macular hole development to 1% or less. Categorical analysis was performed using the 2-tailed Fisher exact test. For analyses, P < .05 was considered significant. Data are reported as the means ± standard deviation.
Results
Of the 176 patients with a unilateral idiopathic full-thickness MH, 42 fellow eyes of 42 patients (42/176 fellow eyes, 23.9%) met the inclusion criteria for this study. The subset of 42 patients had a partially detached posterior hyaloid with attachment at the fovea seen as a perifoveal PVD in the fellow eyes on OCT. The average follow-up period was 18.2 ± 13.0 months (range, 6-60 months). Among the 42 eyes, a foveolar detachment was seen at the initial visit or developed during the follow-up period in 16 eyes. Two eyes with a foveal pseudocyst alone were seen at the initial visit, and 2 eyes progressed to a foveal pseudocyst only during follow-up. The Table shows the characteristics, initial presentation, and evolution of these 20 fellow eyes with these intrafoveal lesions.
| Patient No. | G/A/E | First Eye OCT Stage a | Initial OCT Presentation | Evolution on OCT | Follow-up Months | ||||
|---|---|---|---|---|---|---|---|---|---|
| Perifoveal PVD | Foveal Features | Foveolar Detachment | Inner Foveal Splits | Foveal Pseudocyst | Foveal Features at the Final Visit | ||||
| 1 | F/67/L | 3MH | + | Normal | + | + | − | Full-thickness MH | 29 |
| 2 | M/73/R | 2MH | + | Normal | + | + | − | Full-thickness MH | 51 |
| 3 | M/69/R | 2MH | + | Foveolar detachment and inner foveal splits | + | + | − | Full-thickness MH | 24 |
| 4 | F/56/R | 2MH | + | Normal | + | + | − | Full-thickness MH | 23 |
| 5 | M/74/R | 2MH | + | Foveolar detachment and inner foveal splits | + | + | − | Full-thickness MH | 11 |
| 6 | F/66/L | 2MH | + | Normal | + | + | − | Foveolar detachment and inner foveal splits | 20 |
| 7 | F/76/L | 3MH | + | Foveolar detachment | + | + | − | Foveolar detachment and inner foveal splits | 12 |
| 8 | F/60/L | 2MH | + | Foveolar detachment | + | + | − | Foveolar detachment and inner foveal splits | 6 |
| 9 | F/78/L | 4MH | + | Foveolar detachment | + | + | − | Resolved foveolar detachment and inner foveal splits | 23 |
| 10 | F/64/L | 2MH | + | Normal | + | − | − | Resolved foveolar detachment | 55 |
| 11 | M/56/L | 2MH | + | Normal | + | − | − | Foveolar detachment | 10 |
| 12 | M/71/L | 4MH | + | Normal | + | − | − | Resolved foveolar detachment | 38 |
| 13 | F/63/L | 2MH | + | Normal | + | − | − | Resolved foveolar detachment | 23 |
| 14 | F/65/L | 2MH | + | Foveolar detachment | + | − | − | Foveolar detachment | 10 |
| 15 | F/69/R | 3MH | + | Foveolar detachment | + | − | − | Resolved foveolar detachment | 9 |
| 16 | M/75/L | 4MH | + | Foveolar detachment | + | − | − | Resolved foveolar detachment | 18 |
| 17 | F/68/R | 4MH | + | Normal | − | − | + | Foveal pseudocyst | 10 |
| 18 | M/72/R | 2MH | + | Normal | − | − | + | Resolved foveal pseudocyst | 34 |
| 19 | F/70/R | 3MH | + | Foveal pseudocyst | − | − | + | Foveal pseudocyst | 16 |
| 20 | F/74/L | 2MH | + | Foveal pseudocyst | − | − | + | Resolved foveal pseudocyst | 25 |
a Stage 2, the posterior hyaloid is still attached to the hole edge; stage 3, the posterior hyaloid is detached from the posterior pole; stage 4, the PVD is complete.
In the 16 eyes with a foveolar detachment, 9 eyes had concurrent inner foveal splits. Five of the 9 eyes developed a second full-thickness MH after an average follow-up of 27.6 ± 14.7 months during a period between 11 to 51 months after the initial visit for the first macular hole ( Table ; Figures 1 and 2 ; Supplemental Figure 2 , available at AJO.com ). The intervals between the development of a full-thickness MH and detection of a foveolar detachment and concurrent inner foveal splits were 2, 6, 8, 11, and 24 months. The mean follow-up period was 10.2 ± 8.4 months. Of the remaining 11 eyes with a foveolar detachment in which a macular hole did not develop, the foveolar detachment spontaneously resolved in 6 eyes after vitreofoveal separation during a period between 9 to 55 months, and the vitreofoveal relationship persisted in the other 5 eyes at the last follow-up visit until patients were transferred to local clinics. The mean follow-up period for those 5 eyes after the initial visit in our hospital was 11.6 ± 5.2 months.
In 2 of the 4 eyes with only a foveal pseudocyst, no macular hole formed because of spontaneous resolution after vitreofoveal separation after an average follow-up of 27.0 ± 4.2 months after the initial visit ( Table , Figure 3 ). The remaining 2 eyes with a foveal pseudocyst alone had not changed at the last follow-up visit (average, 10.5 ± 2.1 months).
Of the remaining 22 eyes with vitreofoveal attachment without a foveolar detachment or a foveal pseudocyst, vitreofoveal separation without macular hole formation occurred in 12 eyes after an average follow-up of 14.2 ± 7.2 months during a period between 6 to 30 months after the initial visit, and the vitreofoveal relationship did not change in the other 10 eyes at the last follow-up visit until patients were transferred to local clinics. The mean follow-up period for those 10 eyes after the initial visit was 15.9 ± 16.0 months.
Five of the 42 fellow eyes (11.9%) with a perifoveal PVD in patients with a unilateral idiopathic macular hole progressed to a full-thickness MH within 5 years. Analysis of the intrafoveal changes seen on OCT showed that 5 of 16 fellow eyes (31%) with a foveolar detachment developed a full-thickness MH within 2 years after its appearance. Five of the 9 eyes with a foveolar detachment with concurrent inner foveal splits developed a full-thickness MH within 2 years from their appearance. Within 2 years, the development of a full-thickness MH in eyes with a foveolar detachment and inner foveal splits in 5 of 9 eyes was significant compared with none of 7 eyes with a foveolar detachment alone (2-tailed P = .0337).
Results
Of the 176 patients with a unilateral idiopathic full-thickness MH, 42 fellow eyes of 42 patients (42/176 fellow eyes, 23.9%) met the inclusion criteria for this study. The subset of 42 patients had a partially detached posterior hyaloid with attachment at the fovea seen as a perifoveal PVD in the fellow eyes on OCT. The average follow-up period was 18.2 ± 13.0 months (range, 6-60 months). Among the 42 eyes, a foveolar detachment was seen at the initial visit or developed during the follow-up period in 16 eyes. Two eyes with a foveal pseudocyst alone were seen at the initial visit, and 2 eyes progressed to a foveal pseudocyst only during follow-up. The Table shows the characteristics, initial presentation, and evolution of these 20 fellow eyes with these intrafoveal lesions.
