The ratings of importance to the care process (A-C) and the ratings for strength of evidence (I-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 (American Academy of Ophthalmology Preferred Practice Patterns Committee, 2005). Conditions often mistaken for the various stages of macular hole include cystoid macular edema, central serous retinopathy, a subfoveolar druse, lamellar macular hole, epiretinal membrane with pseudohole, and solar maculopathy (Ho, Guyer, & Fine, 1998; Gass & Joondeph, 1990; Smiddy & Gass, 1995).
History
In general, a complete 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, prolonged gazing at the sun [A:III]
- Medications that may be related to macular cysts (e.g., systemic niacin, topical prostaglandin analogues) [A:III]
Examination
- Slit-lamp biomicroscopy of the macula and the vitreoretinal interface [A:III]
Management
Management Recommendations for Macular Hole
| Stage |
Management |
Follow-up [A:II] |
| 1-A |
Observation (de Bustros,1994) [A:II] |
- Prompt return if new symptoms
- Every 4 to 6 months in the absence of symptoms
|
| 1-B |
Observation (de Bustros,1994) [A:II] |
- Prompt return if new symptoms
- Every 4 to 6 months in the absence of symptoms
|
| 2 |
Surgery (Kim et al.,1996) [A:II]* |
- 1 to 2 days postoperatively, then 1 to 2 weeks
- Frequency and timing of subsequent visits varies depending on the outcome of surgery and the patient's symptoms
- If no surgery, every 4 to 8 months
|
| 3 |
Surgery (Kim et al.,1996; Freeman et al., 1997) [A:I] |
- 1 to 2 days postoperatively, then 1 to 2 weeks
- Frequency and timing of subsequent visits varies depending on the outcome of surgery and the patient's symptoms
|
| 4 |
Surgery (Kim et al., 1996; Freeman et al., 1997) [A:I] |
- 1 to 2 days postoperatively, then 1 to 2 weeks
- Frequency and timing of subsequent visits varies depending on the outcome of surgery and the patient's symptoms
|
*Although surgery is usually performed, observation is also appropriate.
The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery (American Academy of Ophthalmology, "Pretreatment Assessment," 2006; American Academy of Ophthalmology, " An Ophthalmologist's Duties," 2006), and, in particular, of the need for use of intraocular gas or special patient positioning postoperatively. [A:III] Patients with glaucoma should be informed of the possibility of a perioperative increase in intraocular pressure. [A:III] The surgeon is responsible for formulating a postoperative care plan and should inform the patient of these arrangements (American Academy of Ophthalmology, "Pretreatment Assessment," 2006; American Academy of Ophthalmology, "An Ophthalmologist's Duties," 2006). [A:III]
Follow-Up
Components of the follow-up examination should include the following:
- Interval history, including new symptoms [A:III]
- Measurement of intraocular pressure [A:III]
- Slit-lamp biomicroscopy of the retina and indirect binocular ophthalmoscopy to evaluate the peripheral retina [A:III]
Optical coherence tomography is helpful to document the macular anatomy.
Patients who have had a macular hole in one eye should be informed that there is 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 (Ezra et al., 1998; Akiba, Quiroz, & Trempe, 1990; Lewis et al., 1996; Fisher et al., 1994; Guyer et al., 1992; Chew et al., 1999). [A:III]
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 (Dayan et al., 1996; Byer, 1994; Smiddy et al., 1989). [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] Vision rehabilitation restores functional ability (Stelmack et al., 2008) [A:I] and patients with functionally limiting postoperative visual impairment should be referred for vision rehabilitation and social services (American Academy of Ophthalmology Vision Rehabilitation Committee, 2007). [A:III] More information on vision rehabilitation, including materials for patients, is available at http://www.aao.org/smartsight.
Definitions:
Ratings of Importance to Care Process
Level A, defined as most important
Level B, defined as moderately important
Level C, defined as relevant but not critical
Ratings of Strength of Evidence
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.
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
Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)
