AAO 2023: Causes and care of paediatric macular holes

Reviewed by Ayush Parikh, MD, and Nimesh A. Patel MD

Paediatric macular holes are rare and generally result from blunt trauma. Ayush Parikh, MD, with principal investigator Nimesh A. Patel, MD, and other colleagues from Massachusetts Eye and Ear (MEE), Boston, found that spontaneous macular hole closure and surgical treatment seem to be associated with comparable rates of closure and visual outcomes. He reported the results of a retrospective review of MEE patients at the American Academy of Ophthalmology annual meeting.

The investigators commented, “Given the high rates of spontaneous closure, watchful waiting for 2 to 5 months can be a reasonable approach before an invasive intervention." Image credit: ©rob3000 – stock.adobe.com

The 47 patients reviewed were all younger than 18 years (mean, 13 years); 79% were male and had undergone a retinal examination, had a clinical diagnosis of a full-thickness macular hole and had been followed for 3 months or longer.

In most cases, the macular holes developed as the result of blunt trauma. In the anterior segment, evaluations showed periocular trauma, corneal abrasions hyphema, anterior chamber cells and iris trauma. In the posterior segment, evaluations showed commotio retinae, vitreous hemorrhage, retinal fluid and/or hemorrhages, retinal detachment and tears, according to Parikh.

The median macular hole size available for 25 patients was 222 microns (range, 110-565 microns), with almost two-thirds characterized as under 250 microns, 24% from 250 to 400 microns, and 12% bigger than 400 microns.

The clinical course for the 47 patients was watchful waiting in 41 patients and spontaneous closure in 26, for a closure rate of 63%. Fifteen patients did not have spontaneous closure and of those treatment was deferred in 3. Eighteen patients underwent surgery, which achieved macular hole closure in 13 for a closure rate of 72%; the holes reopened and then closed in 3 patients. Five who underwent surgery did not achieve hole closure and of these, treatment was deferred in 2. Three patients underwent a second surgery and achieved hole closure.

Image courtesy of Ayush Parikh, MD

Surgical closure

The study findings demonstrate that surgical closure was safe and effective for hole closure in 18 patients.The surgeries included pars plana vitrectomy, induction of a posterior vitreous detachment, membrane peeling and fluid-gas exchange with head-down positioning postoperatively, and were performed an average of 134 days from the time of hole diagnosis.

A comparison of surgery and watchful waiting found no difference in closure rates as mentioned, 72% and 63%, respectively.

Both observation and surgery resulted in significant improvements in the best-corrected visual acuity at the final follow-up visit from 20/315 preoperatively to 20/70 in the surgical patients and from 20/230 to 20/50 in the observation group.

The investigators commented on their results, “Given the high rates of spontaneous closure, watchful waiting for 2 to 5 months can be a reasonable approach before an invasive intervention, particularly if no other vision-threatening pathology is present.”

Parikh was joined in this study by Sandra Alhoyek, MD; Bertran Cakir, MD; Shizuo Mukai, MD, and Nimesh Patel, MD.