Welcome back to Ready, Set, Retina! In this episode, Daniel Epshtein, OD, FAAO, is joined by Steven Ferrucci, OD, FAAO, to review a case report of full-thickness macular hole (FTMH) that outlines how optometrists can utilize findings from research to inform clinical decision-making.
Dr. Ferrucci is the chief of optometry at Sepulveda VA in North Hills, California, and a professor at the Southern California College of Optometry in Fullerton, California.
Overview of full-thickness macular hole
A macular hole is a vitreomacular interface disease characterized by a partial or full-thickness neurosensory retinal defect in the center of the macula.1 FTMHs tend to be idiopathic but can also be caused by trauma, macular schisis, or cystoid macular edema. Due to central foveal involvement, patients with MHs or FTMHs usually report metamorphopsia and decreased visual acuity.1
The modern classification of MHs utilizes optical coherence tomography (OCT) characteristics to determine the size of the defect, the presence or absence of vitreomacular traction (VMT), and whether the etiology is primary (i.e., idiopathic) or secondary.2 Dr. Ferrucci noted that the size of the MH is determined by the smallest diameter of the hole as measured by OCT.
Macular holes are classified by size as follows:2
- Small MH: < 250μm
- Medium MH: 250 to 400μm
- Large MH: > 400μm
Full-thickness macular hole case report
Baseline
A 65-year-old male patient presented to the clinic with mild blur in his left eye (OS) and noted a “small crater” in his central vision OS. The patient’s best-corrected visual acuity (BCVA) was 20/20 in the right eye (OD) and 20/60 OS. The patient’s medical and ocular history were not remarkable for contributing factors.
Figure 1: Baseline OCT image OD; no significant pathological findings noted.
Figure 1: Courtesy of Steven Ferrucci, OD, FAAO.
Figure 2: Baseline OCT image OS, a very small FTMH can be appreciated.
Figure 2: Courtesy of Steven Ferrucci, OD, FAAO.
Topical therapy for full-thickness macular hole closure
After evaluating the OCT scan, Dr. Ferrucci determined that the patient had a 52μm FTMH OS. Dr. Ferrucci noted that he read a paper recently published in Retina by Wang et al. that changed his approach to treating FTMHs.
In the study, investigators evaluated the efficacy and clinical characteristics of successful FTMH closure with topical therapy (prednisolone 1%, nonsteroidal anti-inflammatory drug [NSAID], and carbonic anhydrase inhibitor [CAI]).3
Consequently, Dr. Ferrucci referred the patient to a retina specialist and started him on topical therapy with:
- Prednisolone 1% QID OS
- Ketorolac QID OS
- Dorzolamide BID OS
Figure 3: Near-infrared reflectance (NIR) and OCT imaging OS of the patient’s 52μm FTMH.
Figure 3: Courtesy of Steven Ferrucci, OD, FAAO.
The patient visited the retina specialist 6 weeks later (while still on the topical therapy), and repeat NIR and OCT imaging demonstrated closure of the FTMH. In addition, the patient’s BCVA improved to 20/25 OS, and he reported resolution of the crater in his vision.
Figure 4: NIR and OCT imaging OS at the 6-week follow-up appointment, resolution of the FTMH can be visualized.
Figure 4: Courtesy of Steven Ferrucci, OD, FAAO.
Research on FTMH closure with topical medical therapy
As mentioned earlier, the retrospective case series titled “Full-Thickness Macular Hole Closure with Topical Medical Therapy” analyzed the results of 49 FTMH patients (mean age 67 years, 59% women) who were treated with a cocktail of topical medications by a single retinal physician from 2017 to 2022.3 In total, 7 of 49 FTMHs (14.3%) were secondary to post-pars plana vitrectomy (PPV) and 42 of 49 (85.7%) were idiopathic.
Overall, 18 patients (36.7%) achieved closure with topical therapy, which was further subdivided into groups based on the FTMH size as follows:3
- FTMH < 200μm: 72% closure
- FTMH 200 to 300μm: 28% closure
- FTMH > 300μm: 0% closure
It is worth noting that of the 18 responders, 13 FTMHs were idiopathic in etiology. In addition, they found that every 10μm decrease in FTMH size increased the odds for closure by 1.2 times (P = 0.001). The average time to closure was 107.2 days (range 20 to 512 days) and did not correlate to FTMH size. The presence of VMT was found to be inversely related to successful closure (P = 0.029).3
Further, if there was no response within 1 to 3 months, then topical therapy was unlikely to cause hole closure and surgical intervention should be considered. There was no significant difference in final BCVA for eyes undergoing primary PPV compared to those trialing drops before undergoing PPV (P = 0.318).3
To see images of responders and nonresponders from the study, watch the full interview!
Additional considerations for FTMHs
A 2021 literature review found that small FTMHs (≤ 250μm) spontaneously close in about 22.2% of cases, though this decreases to 3 to 11% for larger holes (> 250μm), so there is a possibility that the hole closed spontaneously, noted Dr. Ferrucci.4,5 He also emphasized the importance of monitoring the fellow eye, as there is roughly an 11.3 to 22.0% chance of an FTMH developing.6
Dr. Epshtein explained that with this medical approach to FTMH closure, there is some hope that patients may be able to avoid undergoing PPV, which is beneficial because the most frequent complication of PPV is cataract formation.7
One UK-based study found that the risk of cataract surgery following PPV was around 40% (with a mean interval of 399 days), and the following cataract surgery rates per year:7,8
- 1-year post-PPV rate of cataract surgery: 50%
- 2-year post-PPV rate of cataract surgery: 70%
- 3-year post-PPV rate of cataract surgery: 75%
- 4-year post-PPV rate of cataract surgery: 85%
As such, Dr. Epshtein noted that he usually explains to phakic FTMH patients before referring them to a retina specialist that they should expect two surgeries in the future; one to fix the macular hole and a second surgery to remove the cataract that they will likely develop in the next 2 to 3 years.
Conclusion
Prior to reading the study, Dr. Ferrucci referred patients with FTMH for surgery without trying a medical therapy, however, by staying up to date on new research, he is now able to offer a noninvasive treatment approach for FTMH patients.
When treating patients with FTMHs, optometrists can recommend:
- If FTMH is < 300μm, consider topical therapy:
- Prednisolone 1% QID
- NSAID (ketorolac, bromfenac) QID
- CAI (dorzolamide, brinzolamide) BID
- Refer the patient to a retina specialist in ~1 month and send the baseline OCT scan to compare
- If there is no improvement in 1 month, resolution is unlikely, so consider surgery
- If there is improvement in 1 month, continue for 3 months, and then reassess the need for surgery.
