Topical Tx for Macular Holes?

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Topical therapy may be able to close small secondary macular holes and potentially eliminate the need for surgery.¹

Study specifics. This retrospective analysis involved nine cases of topically treated, secondary full-thickness mac­ular holes (FTMH). Eight of the eyes (89%) had successful hole closure and resolution of their associated cystoid macular edema. The hole in the ninth eye, in a patient with topically treated bilateral holes, did not close after six weeks of topical therapy, and the pa­tient was then lost to follow-up.

All patients received corticosteroid drops (difluprednate ophthalmic emulsion 0.05%). Six eyes also received a topical carbonic anhydrase inhibitor (dorzolamide 2% or brinzolamide 1%), and two eyes received a nonsteroidal anti-inflammatory drug (bromfenac 0.07%). The average initial hole diame­ter was 79.6 μm (range, 44 to 132 μm), and the average time until closure was six weeks (range, two to 19 weeks).

OCT SEQUENCE. (1) Cystoid macular edema, high retinal surface reflectivity from epiretinal membrane, and a FTMH. The patient was started on difluprednate three times daily. (2) At four weeks, the hole is closed, and the drops are reduced to twice daily. (3) At 22 weeks, the hole remains closed, the outer retinal break is decreased, and treatment is discontinued. (4) At 81 weeks, the hole remains closed without drops.

A paradigm shift? “The standard of care for primary macular holes caused by vitreomacular traction is vitreo­retinal surgery,” said coauthor John Niffenegger, MD, at Retina Associates of Sarasota, Florida. “In cases of small holes (<250 μm) that are secondary to something other than vitreomacular traction, patients often would like to avoid surgery, and interest in address­ing their problem with topical therapy has been increasing.”

The outcomes of this study support a role for comprehensive ophthalmol­ogists to consider medical therapy for patients who have small, secondary macular holes, Dr. Niffenegger said. “With spectral-domain optical coher­ence tomography fairly available now, it’s easier for a comprehensive ophthal­mologist to determine the hole’s size and etiology,” he said. “So, in the ab­sence of vitreoretinal traction, it would be reasonable for them to consider a trial of topical therapy as they refer the patient for vitreoretinal consultation or await scheduling for macular hole surgery. You might be able to spare these patients the expense and possible com­plications of surgery.”

—Linda Roach

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1 Niffenegger JH et al. Ophthalmol Retina. Pub­lished online Jan 28, 2020.  

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Relevant financial disclosures—Dr. Niffenegger: None.

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