Idiopathic macular hole was identified as a unique clinical entity more than 100 years ago.1 2
Most macular holes occur as an age-related primary idiopathic condition unrelated to other ocular problems or antecedent events. The hallmark inciting event of idiopathic macular hole formation is hypothesised to be focal shrinkage of the vitreous cortex in the foveal area.3
The tractional forces of the vitreous can be observed clinically with contact lens examination, with ultrasonography and, most reliably, with OCT.4 5
As suggested and later revised by Gass,6 7
macular holes were commonly classified into four stages. Stage 1, also known as an ‘impending macular hole,’ was characterised by a foveal cyst within the retina. Stages 2–4 included full-thickness macular holes, which were further divided into smaller holes 400 μm in diameter (stage 2), holes larger than 400 μm in diameter (stage 3) and with complete PVD (stage 4).
It has been clinically established that stage 1 impending macular holes have a 50% chance for spontaneous closure with resolution of symptoms8
and are, therefore, observed and not treated surgically. Closure of full-thickness macular holes is less frequent; therefore, these cases are usually treated surgically by pars plana vitrectomy, with or without internal limiting membrane peeling. Spontaneous resolution with hole closure and a restoration of the normal foveal contour is very rare in full-thickness macular holes (stages 2–4). It occurs in 2–4% of eyes, probably secondary to epiretinal membrane formation.9 10
Guyer et al
conducted a retrospective study on the natural history of idiopathic macular holes.11
Resolution, defined as an ophthalmoscopic appearance of a flat, reddish lesion and improved vision, was observed in 15 of 19 (79%) eyes with a stage 1 macular hole, in 3 of 9 (33%) eyes with a stage 2 macular hole and in 3 of 66 (5%) eyes with a stage 3 macular hole. Kakehashi et al
reported this occurrence in 1 of 17 eyes with grade 2 macular hole,12
Hikichi et al
found no such resolution in 48 eyes with grade 2 macular hole,13
and Casuso also reported a series of 15 eyes in which such resolution did not occur during 5 years of follow-up.14
Ezra et al
, comparing the results of treating the complete idiopathic macular hole by surgery versus observation, concluded that 11.5% of idiopathic macular holes type 2 close spontaneously in the 3–6 months after diagnosis, whereas in types 3 and 4 this occurs only in 3–6% of cases. In addition, it is estimated that visual acuity improvement is slight, only in 3–10% of cases, and even worsens in the first months.15
Four explanations have been proposed for the spontaneous resolution of a macular hole: complete detachment of the posterior hyaloid from the foveal area leading to release of traction, cell proliferation at the base of the hole, formation of a contractile epiretinal membrane resulting in shrinkage and closure of the hole, and bridging retinal tissue across the hole.16
In our case, the OCT reveals complete detachment of the posterior hyaloid from the foveal area leading to the release of traction, and the appearance of an epiretinal bridge with some neurosensory retinal external layers over an empty subretinal area results in resolution of the macular hole. Resolution of a macular hole has been demonstrated with OCT in eyes with stage 3 or 4 idiopathic macular holes17 18
and traumatic macular holes.19
We present a rare case of a stage 2 macular hole that resolved spontaneously with good vision documented with OCT. A similar case was presented in 2003.20
We believe that OCT examination is obligatory to study both the development and the resolution of macular holes but not in straightforward cases.
- OCT examination is obligatory to study both the development and the resolution of macular holes but not in straightforward cases.
- OCT follow-up enabled monitoring of the closure mechanisms and complex surgery can be avoided by a short observational period, but the risk of observation versus surgery should be explained to the patient.