• American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Idiopathic macular hole. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p. [138 references]

This is the current release of the guideline.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant.

The ratings of importance to the care process (A, B, C) and the ratings for strength of evidence (I, II, III) are defined at the end of the "Major Recommendations" field.

Diagnosis

The initial evaluation of a patient with symptoms and signs suggestive of macular hole includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to macular hole.

History

In general, a thorough history includes the following items, although the exact composition varies with the patient's particular problems and needs.

• Duration of symptoms [A:III]
• Ocular history: glaucoma or other prior eye diseases, injuries, surgery, or other treatments [A:III]
• Medications that may be related to macular cysts [A:III]

Examination

• Biomicroscopic examination of the macula and the vitreoretinal interface [A:III]

Treatment

Surgery may be considered for patients with stage 3 and stage 4 holes. [A:I] The evidence for the benefits of surgery for stage 2 holes is inconclusive, but surgery is generally considered in these cases to prevent progression to later stages of disease. [A:III]

The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery, and in particular of the need for use of expansile intraocular gas or special patient positioning. [A:III] The surgeon has the responsibility for formulating a postoperative care plan and should inform the patient of these arrangements. [A:III]

Follow-up

The patient should be examined postoperatively within 1 or 2 days and again approximately 1 to 2 weeks after surgery. [A:III] The frequency and timing of subsequent postoperative visits varies, depending on the outcome of surgery and the symptoms the patient has. Components of the follow-up examination should include the following:

• Interval history, including new symptoms [A:III]
• Measurement of intraocular pressure [A:III]
• Biomicroscopic examination of the macula [A:III]

Patients who do not have surgery should be examined at the intervals recommended in the American Academy of Ophthalmology's "Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern." [A:III] They should be advised to contact the ophthalmologist promptly if they develop new symptoms of visual loss. [A:III] For patients with stage 1 holes, follow-up may be conducted more frequently to observe the natural course of these eyes and possibly offer timely surgery if the condition progresses to stage 2. Patients who have had a macular hole in one eye should be informed that they have a 10 to 15% chance over a period of 5 years of macular hole formation in the fellow eye if no posterior vitreous detachment is present and a 2% chance if posterior vitreous detachment is present. [A:III]

Provider

Consultation with or referral to an ophthalmologist who has expertise or experience in managing this condition may be desirable.

Counseling/Referral

Patients should be informed to notify their ophthalmologist promptly if they have symptoms such as an increase in floaters, a loss of visual field, or a decrease in visual acuity. [A:II] Patients should be informed that air travel, high altitudes, or general anesthesia with nitrous oxide should be avoided until the gas tamponade is nearly completely gone. [A:III] Patients with glaucoma should be informed of the possibility of a perioperative increase in intraocular pressure. [A:III] Patients with functionally limiting postoperative visual impairment should be referred for vision rehabilitation and social services. [A:III]

Definitions:

Ratings of Importance to Care Process

Level A, most important
Level B, moderately important
Level C, relevant but not critical

Ratings of Strength of Evidence

1. Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
2. Level II includes evidence obtained from the following:
   • Well-designed controlled trials without randomization
   • Well-designed cohort or case-control analytic studies, preferably from more than one center
   • Multiple-time series with or without the intervention
3. Level III includes evidence obtained from one of the following:
   • Descriptive studies
   • Case reports
   • Reports of expert committees/organization
   • Expert opinion (e.g., Preferred Practice Pattern panel consensus)

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations.")

• American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Idiopathic macular hole. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p. [138 references]

Not applicable: The guideline was not adapted from another source.

2003

American Academy of Ophthalmology - Medical Specialty Society

American Academy of Ophthalmology

Preferred Practice Patterns Committee; Retina Panel

Retina Panel Members: Emily Y. Chew, MD (Chair); William E. Benson, MD; H. Culver Boldt, MD; Tom S. Chang, MD; Louis A. Lobes, Jr., MD; Joan W. Miller, MD; Timothy G. Murray, MD; Marco A. Zarbin, MD, PhD; Leslie Hyman, PhD (Methodologist)

Preferred Practice Patterns Committee Members: Joseph Caprioli, MD (Chair); J. Bronwyn Bateman, MD; Emily Y. Chew, MD; Douglas E. Gaasterland, MD; Sid Mandelbaum, MD; Samuel Masket, MD; Alice Y. Matoba, MD; Donald S. Fong, MD, MPH

No proprietary interests were disclosed by members of the Preferred Practice Patterns Retina Panel for the past 3 years up to and including June 2003 for product, investment, or consulting services regarding the equipment, process, or products presented or competing equipment, process, or products presented.

This is the current release of the guideline.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant.

None available

This summary was completed by ECRI on April 30, 2004. The information was verified by the guideline developer May 20, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Information about the content, ordering, and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500.