March 2010




Finding retinal holes

by Matt Young EyeWorld Contributing Editor


Female myope aged 20 presents with such a large retinal hole (and RD) Source: Anand Sudhalkar, M.D.

The occurrence of retinal holes after cataract surgery could be more frequent than we realize. A new study reports a retinal hole was inadvertently found after cataract surgery during research measuring the presence of cystoid macular edema. As part of that research, a macular hole was discovered after cataract surgery by OCT (Stratus OCT, Carl Zeiss Meditec, Jena, Germany), which was not present in pre-op OCT imaging. The retinal hole would likely have remained undiscovered were it not for OCT imaging during research because the condition was asymptomatic. “Systematic use of OCT may elevate their true incidence” of retinal holes following cataract surgery, reported study co-author Thekla Papadaki, M.D., Department of Ophthalmology, University of Crete, Heraklion, Greece. The study appeared in the November/ December 2009 issue of Seminars in Ophthalmology.

Better visualization

After uneventful phacoemulsification in her right eye, a 78-year-old Caucasian female presented for follow-up, and it was discovered—via OCT—that she had a lamellar hole in the parafoveal area of the operated eye. Investigators began to analyze the pieces of the puzzle more intricately. “The patient’s history was significant for cardiovascular disease, hypertension, and open angle glaucoma in both eyes treated with latanoprost,” Dr. Papadaki noted. “The preoperative examination revealed a best corrective visual acuity (BCVA) of 20/50 with nuclear and posterior sub capsular cataract in both eyes.”

OCT was being used to detect possible CME at one-, three-, and six-month follow-up intervals. But investigators stumbled onto something much more curious than CME. “The retinal hole was a random finding in our case,” Dr. Papadaki reported. “At six months postoperatively, BCVA was 25/25 OD [right eye], and the retinal hole appeared slightly enlarged.”

There’s good reason that the retinal hole was asymptomatic. “Eccentric holes do not involve the fovea and thus remain asymptomatic,” Dr. Papadaki reported. “Therefore, eccentric, lamellar or full thickness, retinal holes following cataract surgery might be underdiagnosed.”

The retinal hole did not appear in fundus biomicroscopy. “In the literature, it is mentioned that only 28–37% of lamellar holes detected on OCT were also detected on fundus biomicroscopy,” Dr. Papadaki reported. Dr. Papadaki suggested the cause for the retinal hole remained elusive, but speculated as to possible causative factors. “Pathogenesis of a lamellar hole is uncertain, although posterior vitreous detachment, epiretinal membranes, vitreomacular traction syndrome, and CME are considered the most common factors involved,” Dr. Papadaki noted. “Antero-posterior tractional forces causing incomplete vitreous detachment play an important role in the retinal tissue destruction during hole formation at the site of vitreoretinal adhesion.”

For instance, Dr. Papadaki reported, in one study, posterior vitreous detachment coexisted with lamellar holes in 10 of 19 eyes visualized with ultrahigh-resolution OCT. Epiretinal membranes coexisted in 17 of 19 eyes with lamellar holes. Dr. Papadaki also suggested that “mechanical forces during cataract surgery, release of inflammation factors postoperatively, spacing changes due to the replacement of the crystalline lens by a thinner intraocular lens, all influence the vitreoretinal adhesions and interface,” and may be linked to retinal hole formation. This study was the first to document and report the formation of a retinal hole after cataract surgery, the researchers claimed. Nevertheless, Dr. Papadaki still believes that full-thickness macular holes are rare complications after cataract surgery. Some are actually caused by the re-opening of operated macular holes, Dr. Papadaki noted. Although macular holes are rare, James Maisel, M.D., Hauppauge, N.Y., and Hicksville, N.Y., suggested ophthalmologists are seeing more of them. “Macular hole surgery is the third most common operation I do now,” Dr. Maisel said. “I used to think it was a rare condition.” That opinion hasn’t necessarily changed. “I can’t say the incidence is increasing,” said Dr. Maisel, who instead pointed to new technology helping ophthalmologists visualize macular holes better than ever before. “The OCT makes it quite easy to detect and follow lamellar and full-thickness macular holes.” Dr. Maisel said that there are two mechanisms by which macular holes form. In the first scenario, a clean separation of vitreous gel from the macula could occur. Dr. Maisel likened such separation to Scotch Tape being removed from a surface. In the second scenario, the gel separates from the macula but leaves a layer on the surface of the retina called the epiretinal membrane.

“This pulls on the macula like Scotch Tape that would shrink,” he said. “Sometimes it pulls enough on the macula to rip it or spread out a little hole-forming defect.” This can be visualized at the slitlamp or with OCT imaging, “which is better than our eyes at spotting them,” he said.

Editors’ note: Dr. Papadaki has no financial interests related to this study. Dr. Maisel has no financial interests related to his comments.

Contact information

Maisel: 516-939-6100,

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