• Pros and Cons of Surgery for Lamellar Macular Holes


    Surgery for lamellar macular holes (LMHs) has long been controversial, with some critics wondering if the risks are worth the potential gains in function. Experts do agree on one thing, however: Better definitions are needed to distinguish between types of lamellar holes. With improved classification comes improved management.

    An international panel of vitreoretinal specialists—chaired by Jean-Pierre Hubschman, MD, and Ramin Tadayoni, MD, PhD—has crafted new criteria to differentiate between LMHs and similar conditions such as macular pseudoholes or epiretinal membrane foveoschisis. The panel expects to publish their findings later this year, said Stanley Chang, MD, speaking at the Retina Subspecialty Day on Friday.

    Dr. Chang contrasted the new definitions of LMH versus some similar conditions and shared findings from his own clinical practice.

    Epiretinal membrane foveoschisis. This condition is also known as a tractional LMH or a macular pseudohole with stretched edges.

    • Must have: Contractile preretinal epiretinal membrane (hyperreflective) and foveoschisis at the Henle fiber layer.
    • Optional: Microcystoid spaces in the inner nuclear layer, retinal thickening, retinal wrinkling.
    • Outcomes: Vitrectomy with membrane peeling improves the best-corrected visual acuity (BCVA)

    Lamellar macular hole. LMH is also referred to as degenerative lamellar macular hole.

    • Must have: Irregular foveal contour, foveal cavitation with undermined edges, and another sign of loss of foveal tissue (e.g., pseudo-operculum, thinning of central fovea).
    • Optional: Epiretinal proliferation, foveal bump, ellipsoid layer disruption.
    • Outcomes: Lamellar holes may show ellipsoid layer interruption, spontaneously resolve, or progress to full-thickness macular holes—of which 8% to 25% have epiretinal proliferation.

    Conflicting data. In Dr. Chang’s experience, progressive vision loss is uncommon. Lamellar holes tend to have stable visual acuity, and surgery does not improve vision in patients with LMH. His clinic performed a retrospective review of 340 eyes with macular epiretinal membrane or macular hole. Of these, 11 underwent vitrectomy with a modified Shiraga approach due to progressive, disabling vision loss. Although all of the 11 vitrectomized eyes experienced restoration of foveal architecture, none showed significant gains in visual acuity.

    However, past studies have produced conflicting results, he noted. “If we search the literature, we see a disparity in the improvement versus no improvement [data], and it’s not clear if the selection of cases has something to do with the poor definition of lamellar macular hole,” said Dr. Chang.

    At least one study found that an embedding technique for LMH corrected ellipsoid zone defects in 50% of eyes and improved mean BCVA by 0.3 to 0.1 logMAR units. “So the question is,” he said, “in eyes with a low risk of progressive visual loss, should we operate earlier?”

    Vitrectomy indications, techniques, and outcomes must be more closely examined to determine if early surgical intervention could improve retinal function and protect patient vision, he said. —Anni Delfaro, PhD

    Financial disclosures. Dr. Chang: Alcon Laboratories: L; Genentech: C; Lowy Medical Foundation: C.

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.

    Read more news from AAO 2019 and the Subspecialty Day meetings.