Optometry case study: OCT diagnosis of a macular hole

393
Figure 4. Vertical OCT scan of LE macula

By Yue Zhang, Specsavers Mill Park, VIC

History

Px: 50-year-old Caucasian female
Reason for visit: Sudden blurry central vision in the LE for 4 days (with a flower pattern seen in the central vision). RE unremarkable
GH: Unremarkable
POH: Unremarkable
FOH: Unremarkable

Clinical Assessment

Unaided vision: RE 6/7.5+2     LE 6/9+2
IOP: RE 16mmHg     LE 18mmHg @ 14:16 with NCT
Pupils: PERRL. No RAPD
Amsler grid: RE no distortion seen. LE central distortion

Slit lamp examination:
Anterior segment: Unremarkable OU, anterior chamber clear and quiet, no cells or flare
Posterior segment: Vitreous clear OU, distinct margins ONH, vitreomacular traction (macular hole) in LE

OCT findings:

Diagnosis & Management

Diagnosis: LE vitreomacular traction (macular hole)

Differential diagnosis:

  • Epiretinal membrane with a pseudohole
  • Lamellar hole
  • Cystoid macular oedema
  • Central serous chorioretinopathy
  • Adult vitelliform macular dystrophy

Management: A semi-urgent referral was made to the local retinal specialist.

Discussion

A macular hole is a small break in the macula. Risk factors for macular holes include age, female gender, myopia, trauma or ocular inflammation.

The introduction of OCT has allowed for a more accurate visualisation of the macular anatomy. It is the gold standard cross-sectional imaging test used for diagnosing and managing macular holes. A study by The International Vitreomacular Traction Study Group (IVTS) developed an OCT-based classification for the macular hole1 as shown in Table 1 and in Figure 52. It can be compared with the more commonly used clinical macular hole stages defined by Gass2.

Gass classification OCT findings Classification IVTS
Stage 0 Minimal changes in the foveal contour with detachment of the perifoveal vitreous cortex without traction. VMA
Stage 1A: Imminent MH Foveal cysts and sensory foveolar detachment associated with perifoveal detachment with traction of the posterior vitreous on the foveal internal limiting membrane. VMT
Stage 1B Cyst in the outer retina causing rupture of the cones layer. Perifoveal detachment of posterior vitreous. VMT
Stage 2: Small MH Full-thickness MH of small diameter, with partial rupture of the internal wall of the cyst. Partial detachment of the posterior vitreous, which remains adhered to the operculum. FTMH small / medium with VMT
Stage 3: Large MH MH of a larger size. Total detachment of the posterior vitreous at the level of the macular area, which persists adhered to the papillae. Occasionally, a free operculum adhered to the posterior vitreous can be seen. FTMH medium / large with VMT
Stage 4: Full-thickness MH with PVD Total detachment of the posterior vitreous. In some cases, the vitreous is not observed on OCT scans. Larger diameter of the hole with halo of outer retinal detachment in many occasions. FTMH small / medium / large without VMT

Table 1. Comparison of Gass and IVTS classification from Garcia-Lavana et al 20152 (FTMH: full-thickness macular hole; MH: macular hole; PVD: posterior vitreous detachment; VMA: vitreomacular adhesion; VMT: vitreomacular traction2)

Figure 5. Different stages of a macular hole as defined by the Gass classification. Retrieved from http://macularholesurgery.blogspot.com/2014/02/macular-hole-stages.html

Vitreomacular traction can be treated with vitrectomy surgery using a membrane peel and a gas tamponade3. Patients would usually be asked to adopt a face-down posture for a period of time to achieve a better treatment outcome4.

This case highlights the clinical benefits of using OCT for the diagnosis of retinal conditions. In this presentation, it can be classified as VMT using the IVTS Classification, in comparison to Stage 1A: Imminent MH using Gass classification. Both classifications have a presentation of foveal cysts and sensory foveolar detachment associated with perifoveal detachment with traction of the posterior vitreous on the foveal internal limiting membrane. With the use of OCT, the optometrist can accurately diagnose the condition of patient, allowing for a more effective referral.


REFERENCES

  1. The International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Hole. Duker, Jay S., et al. 12, 2013, American Academy of Ophthalmology, Vol. 120, pp. 2611-2619.
  2. A Review of Current Management of Vitreomacular Traction and Macular Hole. Garcia-Layana, Alfredo, et al. 2015, Journal of Ophthalmology, Vol. 2015, pp. 1-14.
  3. Optimal management of idiopathic macualar holes. Madi, H., Masri, I. and Steel, D. 10, 2015, Clinical Ophthalmology, Vol. 2016, pp. 97-116.
  4. Macular hole surgery with air tamponade and optical coherence tomography-based duration of face-down positioning. Eckardt, C., Eckert , T. and Tckartdt, U. 8, 2008, Retina, Vol. 28, pp. 1087-1096.
Print