September 2007




Reopening macular hole

By Matt Young EyeWorld Contributing Editor


Cataract surgeons beware: operating on a patient with a previously-closed macular hole could reopen it if the patient develops cystoid macular edema (CME).

According to a new study published in the June 2007 online version of the American Journal of Ophthalmology, results differ markedly from previous studies, which often have found no associated between cataract surgery and macular hole reopening. “Our results support the hypothesis that cataract extraction as a subsequent procedure to vitrectomy for macular hole is associated with a higher rate of reopening of previously closed macular holes,” wrote study co-author Jonathan E. Sears, M.D., Cole Eye Institute, Cleveland Clinic Foundation, Cleveland.

A thorough analysis

Dr. Sears and colleagues divided 211 with idiopathic macular holes that were closed via vitrectomy into four groups. Group 1 (56 eyes) had previous cataract extraction. Group 2 (86 eyes) had vitrectomy followed by cataract removal. Group 3 (41 eyes) had only vitrectomy. Group 4 (28 eyes) had a combined vitrectomy and cataract procedure. All in all, 24 macular holes reopened (11%), and the greatest number of reopenings—at 17—were in Group 2 (again with vitrectomy followed by cataract removal). Hence, 20% of Group 2 cases suffered from a macular hole reopening. Comparatively, three eyes in Group 1 (5%), three eyes in Group 3 (7%) and one eye in Group 4 (4%) involved macular hole reopening. “Cox analysis showed a four-fold increased risk of reopening in Group 2 eyes,” Dr. Sears reported. “Eyes with cystoid macular edema after cataract extraction had a seven-fold increased risk of macular hole reopening. Kaplan-Meier analysis showed increased rates of macular hole reopening in Group 2 eyes compared to the other 3 groups combined.”

The period of time between vitreoretinal surgery and cataract removal did not appear to influence reopening. Further, nine cataract surgery cases in which macular hole reopening subsequently developed—the only ones that were available—were performed without complication. What may have influenced the reopening was CME. “CME has been considered both a predisposing factor to macular hole formation, as well as complicit in the reopening of previously closed macular holes,” Dr. Sears noted. “In this report, the highest risk of macular hole reopening occurred when a cataract extraction was followed by CME.”

Still, the existence of CME was not confirmed in all cases by fluorescein angiogram or ocular coherence tomography. Epiretinal membrane, documented in 12 eyes with recurrent macular hole, could have been a complication of cataract surgery after vitrectomy, and also may cause macular hole reopening, Dr. Sears reported. Two patients with uveitis, two with retinal detachment after cataract surgery, and one that underwent ECCE also were among those that developed macular holes, and these attributes also could have had some impact. Hence, the authors suggested that the macular hole may have reopened for different reasons after cataract surgery, but did reopen nonetheless. But the May 2003 issue of the American Journal of Ophthalmology reported that “delayed visual acuity improvement [after macular hole closure] is not attributable to cataract surgery alone.”

Dr. Sears noted that there were, however, 100 eyes of less than 60 months follow-up excluded from that analysis, because the study only reported five-year outcomes.

Other studies also have found no connection between macular hole reopening and cataract surgery, but Dr. Sears appears to be convinced of the correlation. “Although the difference in number of patients who developed late reopening of macular holes with or without sequential cataract surgery is small, the difference is statistically significant,” Dr. Sears wrote. “Patients should be informed of the possibility of reopening of their macular hole after cataract surgery.”

Cataract before vitrectomy

Meanwhile, while Mark Packer, M.D., associate clinical professor, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., said it’s not readily apparent why macular hole would be reopening after cataract surgery, but he said cataract surgery before vitrectomy may be advisable nonetheless. “There has been a trend among retina surgeons to want minimal cataracts operated upon before vitrectomy,” Dr. Packer said. “It makes a lot of sense because we know vitrectomy is going to hasten the development of the cataract anyway.”

Further, Dr. Packer said, vitrectomy is a risk factor for broken-capsule type complications due to fact that no there is no vitreous support to the capsule. Further, the capsule could be mechanically damaged during vitrectomy. Hence for all these reasons, including the fact that the cataract will likely not be as dense before vitrectomy and is easier to extract, pre-vitrectomy cataract surgery might be the best option. Dr. Sears’ study is further evidence that cataract surgery should be performed previous to vitrectomy when possible.

Editors’ note: Dr. Sears has no financial interests related to his study. Dr. Packer has no financial interests related to his comments.

Contact Information


Packer: 541-687-2110,

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