Management
Stage 1
Î Cautious observation of stage 1 macular holes is recommended. (I+, G, S)
Î In most cases presenting with good central visual acuity, patients with
stage 1-A or 1-B macular holes can be followed and asked to return
promptly should symptoms worsen. (I+, G, S)
Î With OCT imaging and monocular visual acuity testing with Amsler grid,
the physician is able to monitor the progress of early stage macular holes
and make appropriate treatment recommendations. (III, G, D)
Stage 2
Î The consensus of the vitreoretinal community is to recommend surgery
for a stage 2 macular hole, not only because the visual acuity results are
good with surgery, but also to minimize further visual loss that occurs with
progression to a stage 3 or stage 4 macular hole. (I++, G, S)
Stage 3 or 4
Preoperative Management
Î The preoperative discussion should address the risk of poor central
visual acuity and lower anatomic success rate, if untreated. (III, G, S)
Î The preoperative discussion should describe the 10%–15% risk of
developing a macular hole in the fellow eye, especially when the vitreous
remains attached or a lower risk when the vitreous appears detached.
(III, G, S)
Î The preoperative discussion should address that the duration and size of
the macular hole is indicative of the chance for spontaneous macular hole
closure and the associated visual benefit. (III, G, S)
Î The preoperative discussion should include the suitability of intravitreal
ocriplasmin for a macular hole with associated vitreomacular traction
(VMT) or vitreomacular adhesion (VMA) as compared to vitrectomy
surgery, including the risks and benefits of each option. (III, In, D)
Î For surgery, the discussion should include the type of anesthesia required
(usually monitored anesthesia care with a local anesthetic). (III, G, S)
Î Nitrous oxide gas should be avoided during the last 10 minutes of
the air fluid exchange when using general anesthesia because it may
postoperatively result in an unpredictable gas fill. (III, G, S)
Î For surgery, the discussion should include the risks (e.g., cataract, retinal
tears) versus benefits of vitrectomy surgery. (III, G, S)
