Idiopathic Macular Hole Preferred Practice Pattern®

AMERICAN ACADEMY OF OPHTHALMOLOGY® Protecting Sight. Empowering Lives.® © 2019 by the American Academy of Ophthalmology Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ophtha.2019.09.026 ISSN 0161-6420/19 Secretary for Quality of Care Timothy W. Olsen, MD Academy Staff Ali Al-Rajhi, PhD, MPH Andre Ambrus, MLIS Meghan Daly Flora C. Lum, MD Medical Editor: Susan Garratt Approved by: Board of Trustees September 7, 2019 © 2019 American Academy of Ophthalmology® All rights reserved AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners. Preferred Practice Pattern® guidelines are developed by the Academy's H. Dunbar Hoskins Jr., MD Center for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication. Correspondence: Ali A. Al-Rajhi, PhD, MPH, American Academy of Ophthalmology, P. O. Box 7424, San Francisco, CA 94120-7424. E-mail: [email protected]. The Retina/Vitreous Preferred Practice Pattern® Panel members wrote the Idiopathic Macular Hole Preferred Practice Pattern® (“PPP”) guidelines. The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document. Retina/Vitreous Preferred Practice Pattern Panel 2018–2019 Gurunadh A. Vemulakonda, MD, American Society of Retina Specialists Representative Ron A. Adelman, MD, MPH, MBA, FACS Steven T. Bailey, MD, Retina Society Representative Amani Fawzi, MD, Macula Society Representative Jennifer I. Lim, MD Gui-shang Ying, MD, PhD, Methodologist Christina J. Flaxel, MD We thank our partners, the Cochrane Eyes and Vision US Satellite ([email protected]), for identifying reliable systematic reviews that we cite and discuss in support of the PPP recommendations. The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in June 2019. The document was edited in response to the discussion and comments. Preferred Practice Patterns Committee 2019 Robert S. Feder, MD, Chair Roy S. Chuck, MD, PhD Steven P. Dunn, MD Christina J. Flaxel, MD Steven J. Gedde, MD Francis S. Mah, MD Randall J. Olson, MD David K. Wallace, MD, MPH David C. Musch, PhD, MPH, Methodologist The Idiopathic Macular Hole PPP was then sent for review to additional internal and external groups and individuals in July 2019. All those returning comments were required to provide disclosure of relevant relationships with industry to have their comments considered (indicated with an asterisk below). Members of the Retina/Vitreous Preferred Practice Pattern Panel reviewed and discussed these comments and determined revisions to the document. In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at http://one.aao.org/CE/PracticeGuidelines/PPP.aspx). A majority (88%) of the members of the Retina/Vitreous Preferred Practice Pattern Panel 2018–2019 had no financial relationship to disclose. Retina/Vitreous Preferred Practice Pattern Panel 2018–2019 Christina J. Flaxel, MD: No financial relationships to disclose Ron A. Adelman, MD, MPH, MBA, FACS: No financial relationships to disclose Steven T. Bailey, MD: No financial relationships to disclose Amani Fawzi, MD: No financial relationships to disclose Jennifer I. Lim, MD: Alcon Laboratories—Consultant/Advisor Gurunadh A. Vemulakonda, MD: No financial relationships to disclose Gui-shang Ying, MD, PhD: No financial relationships to disclose Preferred Practice Patterns Committee 2019 Robert S. Feder, MD, Chair: No financial relationships to disclose Roy S. Chuck, MD, PhD: Novartis—Consultant/Advisor Steven P. Dunn, MD: No financial relationships to disclose Christina J. Flaxel, MD: No financial relationships to disclose Steven J. Gedde, MD: No financial relationships to disclose Francis S. Mah, MD: Novartis—Consultant/Advisor & Lecture Fees Randall J. Olson, MD: No financial relationships to disclose David K. Wallace, MD, MPH: No financial relationships to disclose David C. Musch, PhD, MPH, Methodologist: IRIDEX, Notal Vision—Consultant/Advisor Secretary for Quality of Care Timothy W. Olsen, MD: No financial relationships to disclose Academy Staff Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose Andre Ambrus, MLIS: No financial relationships to disclose Meghan Daly: No financial relationships to disclose Flora C. Lum, MD: No financial relationships to disclose The disclosures of relevant relationships to industry of other reviewers of the document from January to October 2019 are available online at www.aao.org/ppp. OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P190METHODS AND KEY TO RATINGS P191HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P192INTRODUCTION P193Disease Definition P193Patient Population P193Clinical Objectives P193BACKGROUND P193Epidemiology P193Natural History P193CARE PROCESS P196Patient Outcome Criteria P196Diagnosis P196History P196Examination P197Ancillary Tests P197Management P197Prevention and Early Detection P197Early Stages P197Later Stages P198Surgical Management P200Preoperative Discussion P200Vitrectomy P200Detaching the Posterior Vitreous P201Internal Limiting Membrane Removal and Dyes P201Seal P203Positioning P204Outcomes of Surgery P204Predictors of Visual Results P205Complications of Vitrectomy P205Follow-up Evaluation after Surgery P207Vitreopharmacolysis P208Provider and Setting P210Counseling and Referral P210Socioeconomic Considerations P210APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA P211LITERATURE SEARCHES FOR THIS PPP P213RELATED ACADEMY MATERIALS P214REFERENCES P215 Background: An idiopathic macular hole (or macular hole) is an anatomic discontinuity of the neurosensory retina that develops in the center of the macula or fovea. The formation of a macular hole typically evolves over a period of weeks to months through the clinically defined stages. Macular holes are more common in females than in males and usually manifest in adults 55 years of age or older. Most investigators believe that macular holes are caused by pathologic vitreoretinal traction at the fovea. There is a high rate of macular hole formation in the fellow eye (10% to 15%) in the 5-year period after a macular hole occurs in the first eye. The recommendations of this Preferred Practice Pattern (PPP) are based on Cochrane-identified reliable systematic reviews. Rationale for treatment: The patient outcome criteria and rational for treatment include the prevention of visual loss and functional impairment, improvement of visual function, and maintenance or improvement of quality of life. It should be noted that early detection of a macular hole is associated with both a higher closure rate after vitrectomy surgery as well as better postoperative visual acuity. Care Process: The care process for a patient with symptoms and signs suggestive of a macular hole starts with all the elements of a comprehensive adult eye evaluation, with attention to those aspects relevant to macular hole. For each patient, physicians are recommended to examine their medical history, conduct an ophthalmologic examination (e.g., slit-lamp biomicropscopy, an indirect peripheral retinal examination, Amsler grid test and/or Watzke-Allen test), and complete ancillary tests including OCT. Diagnosis and management of macular hole requires expertise, skills, and specialized equipment to detect alterations in the retina and then select, perform, and/or monitor the appropriate treatment regimen. Referral to an ophthalmologist who has expertise and experience in managing this condition is recommended. Management of an early or later stage macular hole is detailed in this PPP, which includes surgical management and follow-up evaluation. At the time of this published PPP, there are no known preventive measures for the development of a macular hole. As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care. The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved US Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration. All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the approved by date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-patterns) to comply with the Code. The intended users of the Idiopathic Macular Hole PPP are ophthalmologists. Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1Shinoda K Hirakata A Hida T et al.Ultrastructural and immunohistochemical findings in five patients with vitreomacular traction syndrome.Retina. 2000; 20: 289-293Crossref PubMed Google Scholar (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American College of Physicians.3Shiono A Kogo J Klose G et al.Photoreceptor outer segment length: a prognostic factor for idiopathic epiretinal membrane surgery.Ophthalmology. 2013; 120: 788-794Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar ♦All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.♦Tabled 1I++High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of biasI+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of biasI-Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of biasII++High-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causalII+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causalII-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causalIIINonanalytic studies (e.g., case reports, case series) Open table in a new tab ♦Tabled 1Good qualityFurther research is very unlikely to change our confidence in the estimate of effectModerate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimateInsufficient qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain Open table in a new tab ♦Tabled 1Strong recommendationUsed when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do notDiscretionary recommendationUsed when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced Open table in a new tab ♦The Highlighted Findings and Recommendations for Care section lists points determined by the PPP Panel to be of particular importance to vision and quality of life outcomes.♦All recommendations for care in this PPP were rated using the system described above. Ratings are embedded throughout the PPP main text in italics.♦Literature searches to update the PPP were undertaken in April 2018 and June 2019 in PubMed and the Cochrane Library. Complete details of the literature searches are available online at www.aao.org/ppp. Macular holes are more common in females than in males and usually occur after age 55. There is a high rate of macular hole formation in the fellow eye (10%-15%) in the 5-year period after a macular hole occurs in the first eye. Patients with vitreous traction and no macular hole (stage 1-A or 1 -B) should be observed without treatment, because they often remain stable or even improve. Currently, there is no evidence that treatment improves the prognosis. Most patients with stage 2 to 4 macular holes will have a poor prognosis without treatment. The visual prognosis is good following successful macular hole closure. The benefits of treatment designed to achieve macular hole closure should be discussed. Studies report that approximately 90% of recent macular holes that are ≤400 μm can be closed with vitrectomy surgery. The early detection of a macular hole is associated with both a higher closure rate after vitrectomy surgery as well as better postoperative visual acuity. Careful removal of the internal limiting membrane (ILM) during vitrectomy surgery increases the macular hole closure rate without adversely affecting the visual acuity. Cataract is a frequent complication of vitrectomy surgery to repair macular holes. This risk should be discussed with patients preoperatively, and postoperative monitoring is advised. A macular hole is a discontinuity of the neurosensory retina, located at the fovea. The patient population consists of adults often 55 years of age or older, most of whom are women, who have idiopathic macular holes. ♦Identify patients at risk for macular hole♦Educate high-risk patients about the reason for periodic monocular self-assessment and follow-up examination, the symptoms of a macular hole, and the need to return promptly should symptoms occur♦Follow patients who are at risk for vision loss from macular hole♦Inform patients of the risks and benefits of the treatment options for macular hole♦Optimize recovery of visual function A macular hole is an anatomic discontinuity of the neurosensory retina that develops in the center of the macula or fovea. Typically, the patient will experience metamorphopsia and decreased visual acuity, which may progress to a central scotoma as the macular hole enlarges.4Colucciello M Evaluation and Management of Macular Holes. Focal Points: Clinical Modules for Ophthalmologists. Module 1. American Academy of Ophthalmology, San Francisco, CA2003Google Scholar, 5Benson WE Cruickshanks KC Fong DS et al.Surgical management of macular holes: a report by the American Academy of Ophthalmology.Ophthalmology. 2001; 108: 1328-1335Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Most investigators believe that macular holes are caused by pathologic vitreoretinal traction at the fovea. Uncontrolled series also suggest that trauma may be responsible for a minority of macular hole cases.6Aaberg TM Blair CJ Gass JD Macular holes.Am J Ophthalmol. 1970; 69: 555-562Abstract Full Text PDF PubMed Google Scholar, 7Kuhn F Morris R Mester V Witherspoon CD Internal limiting membrane removal for traumatic macular holes.Ophthalmic Surg Lasers. 2001; 32: 308-315PubMed Google Scholar It is important to differentiate a full-thickness macular hole (FTMH) from a lamellar macular hole, which is a partial-thickness defect in the neurosensory retina. Another macular abnormality that can simulate an FTMH on clinical examination is a macular pseudohole, a circular or oval configuration of the foveal depression that can result in perifoveal fraction from an epiretinal membrane. A pseudohole has no retinal defect but can give the false clinical appearance of an FTMH. The Beijing Eye Study is a population-based cross-sectional study of 4346 subjects aged 40 or older, that found an FTMH in eight eyes of seven subjects, which corresponds to a prevalence of 1.6 per 1000 Chinese people having a macular hole in this age range.8Wang S Xu L Jonas JB Prevalence of full-thickness macular holes in urban and rural adult Chinese: the Beijing Eye Study.Am J Ophthalmol. 2006; 141: 589-591Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Another population-based cross-sectional study in rural India of 4542 people aged 30 or older found a macular hole in 18 eyes of 13 subjects, which corresponds to a prevalence of 2.7 per 1000 people having a macular hole in this age range.9Nangia V Jonas JB Khare A Lambat S Prevalence of macular holes in rural central India. The Central India Eye and Medical Study.Graefes Arch Clin Exp Ophthalmol. 2012; 250: 1105-1107Crossref PubMed Scopus (4) Google Scholar In the United States, a population-based retrospective study of the largely Caucasian residents (>90%) of Olmsted County, Minnesota, estimated the age- and sex-adjusted incidence of macular holes to be 7.8 people and 8.7 eyes per 100,000 people (all ages) per year.10McCannel CA Ensminger JL Diehl NN Hodge DN Population-based incidence of macular holes.Ophthalmology. 2009; 116: 1366-1369Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In a case-control study, the majority (72%) of idiopathic macular holes occurred in women; more than 50% of holes were found in individuals 65 to 74 years of age and only 3% in those under the age of 55.11Eye Disease Case-Control Study GroupRisk factors for idiopathic macular holes.Am J Ophthalmol. 1994; 118: 754-761Abstract Full Text PDF PubMed Scopus (83) Google Scholar The 5-year risk of a patient with an FTMH of developing an FTMH in the fellow eye was approximately 10% to 15%.12Ezra E Wells JA Gray RH et al.Incidence of idiopathic full-thickness macular holes in fellow eyes. A 5-year prospective natural history study.Ophthalmology. 1998; 105: 353-359Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 13Niwa H Terasaki H Ito Y Miyake Y Macular hole development in fellow eyes of patients with unilateral macular hole.Am J Ophthalmol. 2005; 140: 370-375Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 14Lewis ML Cohen SM Smiddy WE Gass JD Bilaterality of idiopathic macular holes.Graefes Arch Clin Exp Ophthalmol. 1996; 234: 241-245Crossref PubMed Scopus (0) Google Scholar, 15Fisher YL Slakter JS Yannuzzi LA Guyer DR A prospective natural history study and kinetic ultrasound evaluation of idiopathic macular holes.Ophthalmology. 1994; 101: 5-11Abstract Full Text PDF PubMed Google Scholar, 16Guyer DR de Bustros S Diener-West M Fine SL Observations on patients with idiopathic macular holes and cysts.Arch Ophthalmol. 1992; 110: 1264-1268Crossref PubMed Google Scholar, 17Chew EY Sperduto RD Hiller R et al.Clinical course of macular holes: the Eye Disease Case-Control Study.Arch Ophthalmol. 1999; 117: 242-246Crossref PubMed Google Scholar, 18Kumagai K Ogino N Hangai M Larson E Percentage of fellow eyes that develop full-thickness macular hole in patients with unilateral macular hole.Arch Ophthalmol. 2012; 130: 393-394Crossref PubMed Scopus (0) Google Scholar Fellow eyes with a complete posterior vitreous detachment have a lower risk of developing an FTMH. In one study, it was observed that no fellow eye with a complete posterior vitreous detachment developed an FTMH during a median follow-up period of 33 months (range, 9–99 months).15Fisher YL Slakter JS Yannuzzi LA Guyer DR A prospective natural history study and kinetic ultrasound evaluation of idiopathic macular holes.Ophthalmology. 1994; 101: 5-11Abstract Full Text PDF PubMed Google Scholar The formation of a macular hole typically evolves over a period of weeks to months through the clinically defined stages first described by Gass,19Gass JD Idiopathic senile macular hole. Its early stages and pathogenesis.Arch Ophthalmol. 1988; 106: 629-639Crossref PubMed Google Scholar although some macular holes may develop more rapidly. In both cases, macular holes are frequently detected when the patient's symptoms change relatively abruptly.19Gass JD Idiopathic senile macular hole. Its early stages and pathogenesis.Arch Ophthalmol. 1988; 106: 629-639Crossref PubMed Google Scholar, 20Gass JD Reappraisal of biomicroscopic classification of stages of development of a macular hole.Am J Ophthalmol. 1995; 119: 752-759Abstract Full Text PDF PubMed Google Scholar The anatomic findings from optical coherence tomography (OCT) support Gass' original observations, and an updated classification of the stages of development of FTMH is described in Table 1.TABLE 1Clinical Stages and Characteristics of Macular HolesStage*For images of macular hole and abnormalities, please visit https://www.aao.org/image/macular-hole-abnormalitiesCharacteristics1-A (Impending)•Loss of the foveal depression and a yellowish foveal spot (100-200 μm in diameter)•Localized shallow detachment of the perifoveal vitreous cortex with persistent adherence to the foveola•Vitreofoveolar traction may horizontally separate (split) the retina at the fovea (pseudocyst) that corresponds to the yellow spot21Gaudric A Haouchine B Massin P Paques M Blain P Erginay A Macular hole formation: new data provided by optical coherence tomography.Arch Ophthalmol. 1999; 117: 744-751Crossref PubMed Google Scholar•Epiretinal membranes are uncommon•Visual acuity ranges from 20/25 to 20/80•Surgical intervention is not recommended1-B (impending)•Yellow ring 200-350 μm in diameter•Posterior extension of the pseudocyst with disruption of the outer retinal layer21Gaudric A Haouchine B Massin P Paques M Blain P Erginay A Macular hole formation: new data provided by optical coherence tomography.Arch Ophthalmol. 1999; 117: 744-751Crossref PubMed Google Scholar, 23Azzolini C Patelli F Brancato R Correlation between optical coherence tomography data and biomicroscopic interpretation of idiopathic macular hole.Am J Ophthalmol. 2001; 132: 348-355Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar•The retinal roof remains intact with persistent adherence of the posterior hyaloid to the retina21Gaudric A Haouchine B Massin P Paques M Blain P Erginay A Macular hole formation: new data provided by optical coherence tomography.Arch Ophthalmol. 1999; 117: 744-751Crossref PubMed Google Scholar, 23Azzolini C Patelli F Brancato R Correlation between optical coherence tomography data and biomicroscopic interpretation of idiopathic macular hole.Am J Ophthalmol. 2001; 132: 348-355Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar•Epiretinal membranes are uncommon•Visual acuity ranges from 20/25 to 20/80•Surgical intervention is not recommended2•Small full-thickness (<400 μm in diameter) retinal defect, often eccentric•Epiretinal membranes are uncommon•Visual symptoms include metamorphopsia and decreased vision•Visual acuity 20/25 to 20/803•Full-thickness hole ≥400 μm in diameter•The posterior hyaloid is separated from the macula but may remain attached at the optic disc and be attached more peripherally21Gaudric A Haouchine B Massin P Paques M Blain P Erginay A Macular hole formation: new data provided by optical coherence tomography.Arch Ophthalmol. 1999; 117: 744-751Crossref PubMed Google Scholar•An operculum or a flap is present on the posterior hyaloid over the hole and is visible clinically or by means of optical coherence tomography•A cuff of subretinal fluid may be detected along with intraretinal edema and cysts•Drusen-like deposits**Drusen-like or yellow deposits may represent macrophages at the level of the retinal pigment epithelium, suggesting chronicity of disease. may be occasionally seen in the base of the hole•A rim of retinal pigment epithelium hyper/hypopigmentation is often present at the junction between edematous or detached retina and normal-appearing attached retina in long-standing cases24Casuso LA Scott IU Flynn Jr., HW et al.Long-term follow-up of unoperated macular holes.Ophthalmology. 2001; 108: 1150-1155Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar•Epiretinal membranes may be present•Visual acuity usually ranges from 20/100 to 20/40017Chew EY Sperduto RD Hiller R et al.Clinical course of macular holes: the Eye Disease Case-Control Study.Arch Ophthalmol. 1999; 117: 242-246Crossref PubMed Google Scholar, 24Casuso LA Scott IU Flynn Jr., HW et al.Long-term follow-up of unoperated macular holes.Ophthalmology. 2001; 108: 1150-1155Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar4•A full-thickness hole with a diameter usually larger than stage 3 (>400 μm in diameter)•A complete posterior vitreous detachment with a Weiss ring20Gass JD Reappraisal of biomicroscopic classification of stages of development of a macular hole.Am J Ophthalmol. 1995; 119: 752-759Abstract Full Text PDF PubMed Google Scholar, 23Azzolini C Patelli F Brancato R Correlation between optical coherence tomography data and biomicroscopic interpretation of idiopathic macular hole.Am J Ophthalmol. 2001; 132: 348-355Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar•A cuff of subretinal fluid, intraretinal edema, and cystoid changes are usually present•Drusen-like deposits*For images of macular hole and abnormalities, please visit https://www.aao.org/image/macular-hole-abnormalities may be occasionally seen in the base of the hole•Epiretinal membranes are more frequent25Blain P Paques M Massin P et al.Epiretinal membranes surrounding idiopathic macular holes.Retina. 1998; 18: 316-321Crossref PubMed Google Scholar•Visual acuity is more profoundly affected to 20/100 to 20/40017Chew EY Sperduto RD Hiller R et al.Clinical course of macular holes: the Eye Disease Case-Control Study.Arch Ophthalmol. 1999; 117: 242-246Crossref PubMed Google Scholar, 24Casuso LA Scott IU Flynn Jr., HW et al.Long-te