Postoperative Macular Hole Outcomes Benefit from Vitrectomy Without Delay

Macular holes in stage 2 progress faster than those in stages 3 and 4, making it beneficial to perform vitrectomy without delay in this population.

Young-Hoon Park, MD, PhD

A new analysis evaluated the progression rate of idiopathic macular hole before vitrectomy using optical coherence tomography (OCT), suggesting the benefit of performing vitrectomy without delay in patients with stage 2 macular hole.

As the relatively small macular hole in stage 2 progresses faster when compared to stages 3 and 4, study investigators noted the shorter the time interval from baseline to operation, the better the postoperative functional and anatomical outcomes.

“Long-term observation without surgery was difficult because all patients needed surgery at the right time,” wrote corresponding author Young-Hoon Park, MD, PhD, Department of Ophthalmology and Visual Science, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea. “Additionally, in patients with small macular holes, the hole may sometimes close spontaneously. However, since this study only included patients who underwent surgery, cases of spontaneous closure were excluded. Whether a small hole should be allowed to close spontaneously or whether surgery should be performed quickly due to the likelihood of rapid growth is controversial; thus, follow-up studies are required.”

The postoperative closure rate of idiopathic macular hole (IMH) is reported to be over 90%, but its anatomical success and visual prognosis can differ depending on macular hole characteristics. Smaller preoperative base diameter (BD) and minimum linear diameter are associated with a higher surgical success rate and better visual prognosis.

It remains important for surgeons to ascertain the appropriate time for surgery in patients with IMH, as immediate surgery before the hole size increases may help visual acuity but emergency surgery is not always possible. The study from Park and colleagues set out to investigate the progression rate of IMH by comparing the hole size on operation day to baseline in patients with IMH and apply the results to determine in which patient it would be beneficial to operate on quickly.

It included patients who underwent vitrectomy for stage 2 or greater full-thickness IMH between January 2015 and December 2020 at Seoul St. Mary’s Hospital and those who were followed up for 6 months or longer. All patients underwent a comprehensive ophthalmological examination and chose the day of operation at baseline. The operation data was then determined by hospital circumstances and a patient’s personal circumstances.

OCT measurements taken at baseline and operation day for patients with stage 2, 3, and 4 IMH helped determine the changes in minimum linear diameter (MLD), base diameter (BD), height, and macular hole index. The difference in OCT parameters was then divided by the time between baseline and operation day to determine the IMH progression rate.

The analysis included a total of 224 eyes of 216 patients. The average time interval from baseline to operation was 35.59 ± 23.43 days. Between baseline and the day of operation for all eyes, the average MLD and BD increased, while macular hole and best-corrected visual acuity (BCVA) decreased (all P <.001) and height did not change significantly (P = .372).

In multiple regression analysis, small MLD (P = .005), small BD (P = .003), good preoperative BCVA (P <.001) and the time interval between baseline and operation (P = .005) were associated with better final visual acuity 6 months after vitrectomy, according to investigators.

The study data show the average progression rates of MLD and BD assessed by simple regression analysis were 0.698 µm (R2 = .066, P <.001) and 1.368 µm/day (R2 = .097, P <.001), respectively.

When classifying patients by macular hole stage, the progression rate of MLD and BD were significantly faster in individuals with stage 2 macular hole than in individuals with stage 3 or 4 macular hole. In patients with stage 3 and 4 macular holes, it was noted that the progression rates of MLD and BD were slow and not statistically significant.

The study, “Progression rate analysis of idiopathic macular hole using optical coherence tomography before vitrectomy: short-term results,” was published in Acta Ophthalmologica.

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