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Resolution of an Absolute Scotoma and Improvement of Relative Scotomata After Successful Macular Hole Surgery
Resolution of an Absolute Scotoma and Improvement of Relative Scotomata After Successful Macular Hole Surgery Raymond N. Sjaarda, M.D., Deborah A. Frank, B.S., Bert M. Glaser, M.D., John T. Thompson, M.D., and Robert P. Murphy, M.D.
Visual loss in eyes with full-thickness macular holes is thought to be caused by the absence of retinal function in the area of the neurosensory defect as well as reduction in retinal function in the surrounding area of neurosensory retinal detachment. To improve characterization of the visual function of eyes after successful macular hole surgery, we studied six eyes preoperatively and postoperatively with macular microperimetry using the scanning laser ophthalmoscope. Best-corrected visual acuity was improved postoperatively in all eyes. Microperimetry performed preoperatively demonstrated an absolute scotoma that corresponded to the neurosensory defect in all eyes, with surrounding concentric isopters of relative scotomata. No detectable absolute scotoma was found in any eye postoperatively. All eyes showed partial or complete resolution of the surrounding relative scotomata. Improvements in visual acuity after successful macular hole surgery may be related to disappearance of a detectable absolute scotoma as well as improvement in the surrounding retinal function. EVES with idiopathic macular holes usually have marked symptoms of central metamorphopsia and reduction of visual acuity to the range of 20/60 to 20/200. 1-4 Visual acuity has been correlated with the size of the macular
Accepted for publication April 14, 1993. From the Retina Center at Saint Joseph Hospital, Baltimore, Maryland. This study was presented in part at the annual meeting of the Vitreous Society, Laguna Niguel, California, Oct. 20, 1992; and at the annual meeting of the Association for Research in Vision and Ophthalmology, May 4,1993. Reprint requests to Raymond N. Sjaarda, M.D., The Retina Center at Saint Joseph Hospital, O'Dea Medical Arts Bldg., 7505 Osler Dr., Suite 103, Baltimore, MD 21204.
hole, and stability of vision over time is typica1.3,4 However, spontaneous closure of macular holes has been reported, with some eyes gaining marked improvements in visual acuity.v" By using vitreous surgical techniques, the macular hole has been flattened and vision has been improved in some patients.?" Flattening of the edges of the macular hole and resolution of the surrounding neurosensory retinal detachment are thought to contribute to this improvement. However, the retinal function has not been characterized precisely. Recently, by using macular microperimetry techniques in which the scanning laser ophthalmoscope was used, we found that eyes with macular holes have an absolute scotoma that corresponds to the neurosensory defect, as well as concentric surrounding relative scotomata that correspond to the surrounding neurosensory retinal detachment/ and that the scotomata were correlated with the best-corrected visual acuity." To improve the understanding of the precise visual changes after successful macular hole surgery, we performed macular microperimetry preoperatively and postoperatively on six eyes of six patients.
Material
and Methods
Six eyes of six patients were examined before and after pars plana vitrectomy, fluid-gas exchange/ and instillation of transforming growth factor-beta 2. Preoperative and postoperative best-corrected visual acuity was obtained by protocol refraction and measurement by a trained clinical coordinator who used the logarithmic eye chart that was used in the Early Treatment of Diabetic Retinopathy Study." All patients underwent examination including slitlamp biomicroscopic, ophthalmoscopic, and fundus biomicroscopic examination with a contact lens or 78-D condensing lens. Fundus pho-
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tography and fluorescein angiography were performed. A macular hole was diagnosed by the presence of a full-thickness neurosensory defect.on clinical examination and the presence of a window defect on fluorescein angiography. Holes were staged according to the classification as proposed by Gass" and Johnson and Cass." The operation was performed according to the protocol that has been described previously." Briefly, a pars plana vitrectomy was performed with careful attention to creating a posterior vitreous detachment. The retina that s~rrou?ded the holes was not manipulated with picks or forceps. A fluid-gas exchange was performed and the transforming growth factorbeta 2 was then injected onto the surface of the retina overlying the macular hole. Tamponade was provided with air (one patient in this series) or 16% perfluoropropane (five of six patients in this series), according to the protocol into which the patient was enrolled. Patients were asked to maintain a supine position for 24 ~ours and then the .appropriate face-down position for the duration of the intravitreal gasbubble tamponade. Macular microperimetry in which a scanning laser ophthalmoscope was used was performed preoperatively and postoperatively on all six patients. The technique, as previously descri~ed, 10 uses a kinetic stimulus and stationary fixation cross. The patient is asked to fixate on the cross and signal the examiner when the test stimulus is seen. The examiner is able to view the real-time image of the macula and assess fixation. A 6 x 6-pixel square test stimulus was used. Test stimulus intensities were controlled by the software to create isopters of scotomata. A log 2 incremental scale of test stimuli, (2"-1), was used with intensities of 15,31,63,127, and 255 actual (He Ne laser output of 0.03, 0.06, 0.58, and 1.39 MW, respectively). The 255 intensity was the brightest stimulus possible and was used to determine the size of an absolute scotoma, if present. The size of the absolute scotoma has been shown to represent the size of the neurosensory defect in macular holes.":" Tests were performed with 40-degree fields on all patients with macular holes. Postoperatively, if no absolute scotoma was present w~th a 40-degree field test, the test was repeated with a 20-degree field test, which is capable of detecting a scotoma as small as seven minutes of arc in radius." Absolute and relative scotomata were mapped and the software was used to convert the mapped areas into pixels. Statistical and mathematical calculations were per-
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formed with the pixel units and later converted to micrometers for anatomic correlation (1 pixel represents approximately 3.28 minutes of arc or 16 IJ.m on the retinal surface). Case 1 A 65-year-old pseudophakic white woman with a 48-week history of painless loss of vision and metamorphopsia in her left eye was referred to our institution. On examination, her best-corrected visual acuity was 20/80 +2. On slit-lamp biomicroscopy the anterior segment was normal and included a well-positioned posterior-chamber intraocular lens with a central capsular opening. Ophthalmoscopy disclosed a full-thickness macular hole with surrounding neurosensory retinal detachment. No overlying operculum was seen. No remnant of ~eiss' ring ~as seen, although the posterior vitreous cavity was optically empty. The hole was graded as stage 3 (vitreofoveal separation). Macular microperimetry was performed with the s.canning laser ophthalmoscope (Fig. 1). Her fixation was good and was positioned on the neurosensory detachment at the inferior edge of the macular hole. The sizes of the scotomata wer~ determined. (Table). After a thorough disCUSSlOn of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient desired to have the operation. Four days after examination, the patient underwent the operation as described previously. A stage 3 hole was confirmed at the time of the operation. Postoperative tamponade was provided with perfluoropropane. Six weeks postoperatively, her best-corrected visual acuity improved to 20/63 + 1. The edges of the macular hole were completely flat with resolution of the neurosensory detachI?ent. Microperimetry was performed and did not show any scotoma in the 40or 20-degree field tests. Fixation was stable and was positioned over the center of the fovea, where the preexisting hole had been. Three months postoperatively, her best-corrected visual acuity improved to 20/40. Results of slitla~p b~omicroscopic and ophthalmoscopic examinatrons were unchanged. Microperimetry was performed and showed no scotomata (Fig. 1) to the 40- or 20-degree fields. Case 2 A 75-year-old white woman with a history of painless loss of vision and symptoms of metamorphopsia in her right eye beginning 24 weeks earlier was referred to our institution.
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Fig. 1 (Sjaarda and associates). Case 1. Top left, Preoperative scanning laser ophthalmoscope photograph of the stage 3 macular hole with neurosensory defect (hole) and surrounding darker area of the neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127 and 63 (same area), 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment and resolution of all scotomata.
TABLE SCOTOMA SIZE (PIXELS) INTENSITY
VISUAL CASE NO.
ACUITY'
1 2 3 4 5 6
20/80 +2 20/125 +2 20/100 -2 20/63 -1 20/63 -2 20/100 +2
1 2 3 4 5 6
20/40 20/80 +1 20/63 -2 20/32 20/40 -2 20/40 -2
255
127
Preoperative 1,487 741 1,010 2,823 1,089 1,890 1,481 665 234 234 1,747 968 Postoperative (3 mos) 0 0 0 0 0 0 0 0 0 0 0 0
63
31
15
1,487 5,707 3,428 3,136 1,675 4,083
2,633 7,058 5.920 4,196 3,259 7,536
8,115 16,980 15,058 23,233 15,027
0 0 65 0 0 0
0 0 65 0 0 0
0 7,187 1,760 0 56 21
'According to the logarithmic eye chart used in the Early Treatment of Diabetic Retinopathy Study."
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On examination her best-corrected visual acuity was 20/125 +2. Results of slit-lamp biomicroscopic examination of the anterior segment were normal except for mild nuclear sclerosis (graded mild, moderate, moderately severe, and severe). Ophthalmoscopy and fundus biomicroscopy showed a stage 2 (small, early) full-thickness macular hole with a crescentshaped break at the temporal edge of the fovea and mild radiating striae around the edge of the hole. Macular microperimetry was performed with the scanning laser ophthalmoscope (Fig. 2). Fixation was superonasal to the center of the fovea. The sizes of the scotomata were determined (Table). After a thorough discussion of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient desired to have the operation. Five days after examination, the patient underwent the operation as described previously. A stage 2 hole
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with an attached posterior hyaloid was confirmed at the time of the operation. Tamponade was provided with air and the patient was asked to maintain the appropriate face-down position. Six weeks postoperatively, her best-corrected visual acuity was 20/100 -2. Slit-lamp examination showed mild nuclear sclerosis. The edges of the macular hole were completely flat. Three months postoperatively, her best-corrected visual acuity was 20/80 + 1. Slit-lamp examination showed mild nuclear sclerotic change. The edges of the macular hole remained completely flat. Microperimetry was performed, which showed fixation to be steady and central (Fig. 2). There were no scotomata to the 31, 63, 127, or 255 intensity stimuli in the 40- or 20-degree fields. In a 40-degree field test there was a scotoma to the 15 intensity stimulus with an area of 7,187 pixels (approximately 157 minutes of arc in radius or 776 urn in radius on the retinal surface).
Fig. 2 (Sjaarda and associates). Case 2. Top left, Preoperative scanning laser ophthalmoscope photograph of eccentric macular hole and surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment; only a scotoma to the 15 intensity remains.
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Case 3 A 63-year-old white woman with a history of sudden onset of blurred vision and metamorphopsia in her left eye starting ten weeks earlier was referred to our institution. On examination the best-corrected visual acuity was 20/8 -1. Results of slit-lamp biomicroscopic examination of the anterior segment were normal except for mild nuclear sclerosis. Ophthalmoscopy showed a stage 3 full-thickness macular hole with a surrounding rim of neurosensory retinal detachment and an overlying operculum. After a thorough discussion of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient considered an
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operation. The patient returned nine weeks later for the operation. Her best-corrected visual acuity at that time was 20/100 -2. Results of slit-lamp examination and ophthalmoscopy were unchanged. Macular microperimetry was performed (Fig. 3). Her fixation was stable and was positioned on the neurosensory detachment at the temporal edge of the macular hole. The sizes of the scotomata were determined (Table). The patient underwent the operation as described previously six days later. Postoperative tamponade was provided with perfluoropropane. Six weeks postoperatively, her bestcorrected visual acuity had improved to 20/80 +2. On ophthalmoscopy the edges of the macular hole were completely flat with complete
Fig. 3 (Sjaarda and associates). Case 3. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph showing flattening of the macular hole and resolution of the neurosensory detachment. Bottom right, Postoperative micro perimetry showing residual isopters of scotomata; from inner to outer, the intensities are 63 and 31 (same area) and 15.
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resolution of the surrounding neurosensory detachment. At her three-month visit the bestcorrected visual acuity was 20/63 - 2. Slitlamp examination showed moderate nuclear sclerosis. The edges of the macular hole remained flat without a surrounding neurosensory detachment on ophthalmoscopy. Macular microperimetry was performed (Fig. 3). Fixation was stable and was located centrally in the area of the previous hole. There was no scotoma to the 127 or 255 intensity stimulus in the 40- or 20-degree fields. In a 40-degree field test, to the 31 and 63 intensity stimuli, there was a small scotoma of 65 pixels (approximately 14.9 minutes of arc in radius or 74 urn in radius on the retinal surface). To the 15 intensity stimuli, there was an area of 1,760 pixels (approximately 77.6 minutes of arc in radius or 384 urn on the surface of the retina). Case 4
A 64-year-old white woman with symptoms of sudden loss of vision and onset of metamorphopsia in her right eye beginning 11 weeks earlier was referred to our institution. Her bestcorrected visual acuity was 20/50. Results of slit-lamp examination were normal. There was mild nuclear sclerosis. Ophthalmoscopy showed there to be a stage 2 macular hole with an eccentric break along the nasal margin of the fovea and radiating striae of the retina. The patient was counseled as to the diagnosis and natural progression of her condition. The patient returned as scheduled nine weeks later, at which time her best-corrected visual acuity was 20/63 +2. The examination showed progression of the macular hole to a stage 3 hole with development of a surrounding neurosensory retinal detachment. The patient again returned 16 weeks later, at which time her visual acuity was 20/63 -1. Results of slit-lamp examination remained unchanged with mild nuclear sclerosis. There remained a full-thickness macular hole with a surrounding neurosensory retinal detachment. Macular microperimetry was performed (Fig. 4). At this examination the natural progression of the disease, as best known, was reviewed again with the patient and the risks and benefits of surgical treatment were discussed. The patient desired to proceed with the operation. The next day the operation was performed as described previously. Postoperative tamponade was provided with perfluoropropane. At the six-week postoperative visit the best-corrected visual acuity was 20/4 -1. There remained mild nuclear sclerosis of the
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lens. Ophthalmoscopy showed the edges of the macular hole to be completely flat with complete resolution of the surrounding neurosensory detachment. Three months postoperatively, the best-corrected visual acuity was 20/ 32. Results of slit-lamp examination were normal except for mild to moderate nuclear sclerosis. Ophthalmoscopy showed the edges of the hole to be flat without a surrounding neurosensory detachment. Macular microperimetry was performed, at which time fixation was stable and positioned centrally. There was no scotoma to stimuli of any intensity in the 40- or 20degree visual field tests (Fig. 4). Case 5
A 60-year-old white woman with sudden loss of vision and onset of metamorphopsia occurring 15 weeks earlier in her left eye was referred to our institution. The best-corrected visual acuity was 20/63 -1. Results of slit-lamp biomicroscopy of the anterior segment were normal and the lens was clear. Ophthalmoscopy disclosed a stage 3 macular hole with a small central hole and surrounding neurosensory retinal detachment. After a thorough discussion of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient considered the operation. The patient returned two weeks later for the operation. At that time her best-corrected visual acuity was 20/63 - 2. The results of the remainder of her examination were unchanged. Macular microperimetry was performed (Fig. 5). Fixation was stable and was positioned on the neurosensory detachment at the inferonasal margin of the hole. The sizes of the scotomata were determined (Table). The next day the operation was performed as described previously. Postoperative tamponade was provided with perfluoropropane. Six weeks postoperatively the best-corrected visual acuity had improved to 20/40 - 2. Results of slit-lamp biomicroscopy of the anterior segment were normal except for mild nuclear sclerosis. Ophthalmoscopy disclosed the edges of the macular hole to be completely flat without any surrounding neurosensory detachment. Macular microperimetry was performed (Fig. 5). Fixation was stable and positioned on the center of the fovea. There was no scotoma to the 31 through 255 intensity stimuli in the 40- or 20-degree visual field test. There was a relative scotoma to the 15 intensity stimulus of 56 pixels in size (approximately 13.8 minutes of arc in radius or 68 urn in radius on the retinal
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Fig. 4 (Sjaarda and associates). Case 4. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment and resolution of all scotomata.
surface). At her three-month postoperative visit her best-corrected visual acuity was 20/40 - 2. Results of slit-lamp examination and ophthalmoscopy were unchanged. Results of macular microperimetry were unchanged, with the small persistent relative scotoma to only the 15 intensity stimulus. Case 6 A 54-year-old white man with a 20-week history of metamorphopsia and progressive decrease in vision in his left eye was referred to our institution. On examination his best-corrected visual acuity was 20/100 +2. Results of slit-lamp biomicroscopy were normal and the lens was clear. Ophthalmoscopy disclosed a stage 3 macular hole with a surrounding neurosensory retinal detachment and overlying operculum. Macular microperimetry was performed (Fig. 6). Fixation was stable and was positioned on the superonasal margin of the macular hole overlying the neurosensory detachment. The patient could not consistently identify the 15
intensity stimulus in the central macular area to allow plotting of this isopter. After a thorough discussion of the diagnosis, the natural progression as best known, and the risks and benefits of possible surgical treatment, the patient desired to have an operation. The next day the operation was performed as described previously. Postoperative tamponade was provided with perfluoropropane. Six weeks after the operation, the best-corrected visual acuity was 20/63 -2. Results of slit-lamp biomicroscopy were normal and the lens remained clear. Ophthalmoscopy showed the edges of the macular hole to be completely flat with resolution of the surrounding neurosensory detachment. At the three-month postoperative visit the best-corrected visual acuity was 20/4 - 2. The patient was judged to have mild nuclear sclerosis, but otherwise results of slit-lamp biomicroscopy of the anterior segment were unchanged. The ophthalmoscopic appearance was unchanged and the edges of the macular hole were flat with
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Fig. 5 (Sjaarda and associates). Case 5. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 and 127 (absolute), 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment and the small residual relative scotoma to the 15 intensity stimulus only.
no recurrence of the neurosensory detachment. Macular microperimetry was performed (Fig. 6). Fixation was stable and was centered in the area of the previous macular hole. There was no scotoma to the 31 through 255 intensity stimuli in the 40- or 20-degree field test. There was a small relative scotoma to the 15 intensity stimulus with an area of 21 pixels (approximately 8.5 minutes of arc in radius or 42 J.Lm in radius on the surface of the retina).
Results All patients reported preoperative symptoms of reduced vision and metamorphopsia. Their visual acuities averaged 20/80 - 2 (range, 20/63 -1 to 20/125 +2). Preoperative macular microperimetry demonstrated an absolute scotoma in the area of the neurosensory defect in
all six patients, as described previously.P" There were surrounding isopters of relative scotomata in all patients. The size of the absolute scotoma averaged 784.5 pixels in surface area (range, 741 to 1,089) or 15.8 pixels in radius, which would be equivalent to 51.8 minutes of arc in radius or 256 J.Lm in radius on the surface of the retina. Three months postoperatively, all patients had improvement of visual acuity. Of six patients, five (Cases 1, 3, 4, 5, and 6) had at least two lines of improvement, and two patients (Cases 4 and 6) had halving of the visual angle as shown by improvement of the equivalent of three lines on the logarithmic eye chart." Postoperative macular microperimetry disclosed no detectable absolute scotoma by using the 40- or 20-degree field test in all patients. Two patients with 20/32 and 20/40 visual acuity showed no detectable relative scotoma to any intensity stimuli (Cases 4 and 1, respective-
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Fig. 6 (Sjaarda and associates). Case 6. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, and 31. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole and small residual relative scotoma to the 15 intensity stimulus.
ly}. Two patients (Cases 5 and 6) with visual acuity of 20/40 - 2 showed a small persistent relative scotoma to the 15 intensity stimulus only. In each patient the scotoma was markedly smaller than the respective scotoma during the preoperative examination. One patient (Case 2) had a large residual scotoma to the 15 intensity stimulus, although it was markedly smaller than the preoperative scotoma. The postoperative visual acuity in this eye was 20/80 + 1. One patient (Case 3) had relative scotomata to the 15, 31, and 63 intensity stimuli. The patient attained a best postoperative visual acuity of 20/63 -2.
Discussion
In a series of six patients we demonstrated that successful surgical treatment of macular
holes can improve visual function as assessed by macular microperimetric analysis, as well as by visual acuity. Small, central scotomata have been demonstrated in 30% to 40% of patients with full-thickness macular holes by using Amsler grid testing.v" However, there were no reports of surgically induced or spontaneous healing of holes in these series. In a pilot series of 52 patients undergoing pars plana vitrectomy and fluid-gas exchange for macular holes, one patient had postoperative resolution of a preoperative central scotoma as detected on visual field testing in which an automated perimeter and macular field software (Humphrey 10-2, Humphrey Instruments, Inc., San Leandro, California) were used." The percentage of patients either preoperatively or postoperatively who had a central scotoma was not stated. The technique of macular visual field testing used in that series has a spatial resolution of 2 degrees, which is less accurate than that of
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Amsler grid testing, in which each square subtends 1 degree in arc. Such gross macular testing was considered inadequate in detecting a central scotoma in over 60% of eyes with macular holes in a previous report, because the predicted scotoma was less than 1 degree .13 With the use of macular microperimetry techniques with the scanning laser ophthalmoscope, Acosta and associates'! demonstrated an absolute scotoma in 26 of 26 eyes with macular holes. However, they detected a surrounding relative scotoma relating to the surrounding neurosensory detachment in only two of 26 eyes. In their series, there were no reports of spontaneous or surgically induced healing of macular holes. In a previous series of 30 patients, we demonstrated that kinetic macular microperimetry using the scanning laser ophthalmoscope can detect and quantitate absolute and relative scotomata in eyes with a macular hole, and that these scotomata were correlated with best-corrected visual acuity." The absolute scotoma exactly corresponded to the area of neurosensory defect in those eyes, whereas surrounding relative scotomata corresponded to the surrounding neurosensory retinal detachment. In the current study, preoperative macular microperimetry showed similar absolute and relative scotomata. Postoperatively, all patients had partial or complete resolution of the relative scotomata, which indicated improved in retinal function. Although our series was small, there was a definite correlation between the postoperative residual relative scotomata and the postoperative visual acuity. Patients with the best postoperative visual acuity had minimal or no residual relative scotomata, whereas those patients with the worst final visual acuity had persistent large, relative scotomata (Table). Nuclear sclerosis was equivalent in all patients and, therefore, did not appear to be an important contributing factor to the differences in postoperative visual acuity. Although postoperative improvement was not unexpected in the relative scotomata with resolution of the surrounding neurosensory retinal detachment, as demonstrated, interestingly all of our patients showed complete resolution of a detectable absolute scotoma. The resolution of the absolute scotoma would imply that after a successful operation, not only does the neurosensory detachment resolve, but the hole can become smaller as well. As described previously, we estimated that our technique
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should be able to detect reliably a scotoma of 7 minutes of arc in radius, or approximately 68 urn in diameter, on the surface of the retina." Therefore, postoperatively in these eyes, the neurosensory defect decreased from an average of 31.6 pixels, or 512 urn in diameter, to less than 7 pixels, or 68 urn in diameter. Thus, after a successful macular hole operation, holes may flatten and close. The processes by which a macular hole could close are not completely understood. However, a decrease in the apparent size of macular holes has been reported in a clinicopathologic correlation." In that report, one patient underwent a successful bilateral macular hole operation, and postmortem pathologic examination disclosed flattening and closure of the hole in each eye. In each eye there was a minute (approximately 50 um) area of photoreceptor absence, which would produce a scotoma smaller than that which we could detect with our microperimetry technique. Closure of the hole in one eye was associated with glial proliferation with possible traction. However, in the other eye, the opposing edges of the macular hole approximated each other without marked glial proliferation. Thus, two mechanisms could be postulated for the closure of macular holes below the threshold of detection of an absolute scotoma. Glial proliferation in the healing hole could exert centripetal contraction, which would pull the edges of the neurosensory retina together. Alternatively, in some eyes flattening of the neurosensory retinal detachment alone could allow reapproximation of the retinal edges and closure of the hole. We found that after successful surgical treatment of macular holes, improvement in visual function can be quantitated with macular microperimetry by using the scanning laser ophthalmoscope. Detectable absolute scotomata can completely resolve, and relative scotomata that correspond to the neurosensory detachment may partially or completely resolve. Resolution of the relative scotomata appears to correlate with better postoperative visual acuity, but it remains uncertain why some patients retain larger areas of residual relative scotomata and poorer postoperative visual acuity. Further studies using microperimetry in patients undergoing surgery for macular holes may alIowa better understanding of the improvement in visual function postoperatively and may help in identifying which candidates may benefit most from an operation.
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References 1. Aaberg, T. M.: Macular holes. A review. Surv. Ophthalmol. 15:139, 1970. 2. Gass, J. D. M.: Idiopathic senile macular hole. Its early stages and pathogenesis. Arch. Ophthalmol. 106:629, 1988. 3. Johnson, R. N., and Gass, J. D. M.: Idiopathic macular holes. Observations, stages of formation, and implications for surgical intervention. Ophthalmology 95:917,1988. 4. Morgan, C. M., and Schatz, H.: Involutional macular thinning. A pre-macular hole condition. Ophthalmology 93:153,1986. 5. Lewis, H., Cowan, G. M., and Straatsma, B. R.: Apparent disappearance of a macular hole associated with development of an epiretinal membrane. Am. J. Ophthalmol. 102:172, 1986. 6. Guyer, D. R., Green, W. R., de Bustros, 5., and Fine, S. L.: Histopathologic features of idiopathic macular holes and cysts. Ophthalmology 97:1045, 1990. 7. Kelly, E. K., and Wendel, R. T.: Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch. Ophthalmol, 109:654, 1991. 8. Glaser, B. M., Michels, R. G., Kuppermann, B. D., Sjaarda, R. N., and Pena, R. A.: Transforming
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growth factor-B, for the treatment of full-thickness macular holes. A prospective randomized study. Ophthalmology 99:1162,1992. 9. Lansing, M. B., Glaser, B. M., Liss, H., Hanham, A., Thompson, J. T., Sjaarda, R. N., and Gordon, A. J.: The effect of pars plana vitrectomy and transforming growth factor-beta 2 without epiretinal membrane peeling on full-thickness macular holes. Ophthalmology. In press. 10. Sjaarda, R. N., Frank, D. A., Glaser, B. M., Thompson, J. T., and Murphy, R. P.: Assessment of vision in idiopathic macular holes with macular microperimetry using the scanning laser ophthalmoscope. Ophthalmology. In press. 11. Early Treatment Diabetic Retinopathy Study Research Group: Early Treatment Diabetic Retinopathy Study design and baseline patient characteristics. ETDRS Report 7. Ophthalmology 98:741,1991. 12. Acosta, F., Lashkari, K., Reynaud, X., Jalkh, A. E., van de Velde, F., and Chedid, N.: Characterization of functional changes in macular holes and cysts. Ophthalmology 98:1820, 1991. 13. Smith, R. G., Hardman Lea, S. J., and Galloway, N. R.: Visual performance in idiopathic macular holes. Eye 4:190, 1990. 14. Funata, M., Wendel, R. T., de la Cruz, Z., and Green, W. R.: Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina 12:289, 1992.
OPHTHALMIC MINIATURE
Her ladyship therefore determined to investigate the woman. The De Conrey's were hereditarily shortsighted, and had been so for thirty centuries at least. So Lady De Courcy, who when she entered the family had adopted the family habits, did as her son had done before her and, taking her glass to investigate the Signora Neroni, pressed in among the gentlemen who surrounded the couch and bowed slightly to those whom she chose to honour by her acquaintance. Anthony Trollope, Barchester Towers Harmondsworth, Middlesex, England, Penguin Books Ltd., 1963, p. 372
Visual loss in eyes with full-thickness macular holes is thought to be caused by the absence of retinal function in the area of the neurosensory defect as well as reduction in retinal function in the surrounding area of neurosensory retinal detachment. To improve characterization of the visual function of eyes after successful macular hole surgery, we studied six eyes preoperatively and postoperatively with macular microperimetry using the scanning laser ophthalmoscope. Best-corrected visual acuity was improved postoperatively in all eyes. Microperimetry performed preoperatively demonstrated an absolute scotoma that corresponded to the neurosensory defect in all eyes, with surrounding concentric isopters of relative scotomata. No detectable absolute scotoma was found in any eye postoperatively. All eyes showed partial or complete resolution of the surrounding relative scotomata. Improvements in visual acuity after successful macular hole surgery may be related to disappearance of a detectable absolute scotoma as well as improvement in the surrounding retinal function. EVES with idiopathic macular holes usually have marked symptoms of central metamorphopsia and reduction of visual acuity to the range of 20/60 to 20/200. 1-4 Visual acuity has been correlated with the size of the macular
Accepted for publication April 14, 1993. From the Retina Center at Saint Joseph Hospital, Baltimore, Maryland. This study was presented in part at the annual meeting of the Vitreous Society, Laguna Niguel, California, Oct. 20, 1992; and at the annual meeting of the Association for Research in Vision and Ophthalmology, May 4,1993. Reprint requests to Raymond N. Sjaarda, M.D., The Retina Center at Saint Joseph Hospital, O'Dea Medical Arts Bldg., 7505 Osler Dr., Suite 103, Baltimore, MD 21204.
hole, and stability of vision over time is typica1.3,4 However, spontaneous closure of macular holes has been reported, with some eyes gaining marked improvements in visual acuity.v" By using vitreous surgical techniques, the macular hole has been flattened and vision has been improved in some patients.?" Flattening of the edges of the macular hole and resolution of the surrounding neurosensory retinal detachment are thought to contribute to this improvement. However, the retinal function has not been characterized precisely. Recently, by using macular microperimetry techniques in which the scanning laser ophthalmoscope was used, we found that eyes with macular holes have an absolute scotoma that corresponds to the neurosensory defect, as well as concentric surrounding relative scotomata that correspond to the surrounding neurosensory retinal detachment/ and that the scotomata were correlated with the best-corrected visual acuity." To improve the understanding of the precise visual changes after successful macular hole surgery, we performed macular microperimetry preoperatively and postoperatively on six eyes of six patients.
Material
and Methods
Six eyes of six patients were examined before and after pars plana vitrectomy, fluid-gas exchange/ and instillation of transforming growth factor-beta 2. Preoperative and postoperative best-corrected visual acuity was obtained by protocol refraction and measurement by a trained clinical coordinator who used the logarithmic eye chart that was used in the Early Treatment of Diabetic Retinopathy Study." All patients underwent examination including slitlamp biomicroscopic, ophthalmoscopic, and fundus biomicroscopic examination with a contact lens or 78-D condensing lens. Fundus pho-
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tography and fluorescein angiography were performed. A macular hole was diagnosed by the presence of a full-thickness neurosensory defect.on clinical examination and the presence of a window defect on fluorescein angiography. Holes were staged according to the classification as proposed by Gass" and Johnson and Cass." The operation was performed according to the protocol that has been described previously." Briefly, a pars plana vitrectomy was performed with careful attention to creating a posterior vitreous detachment. The retina that s~rrou?ded the holes was not manipulated with picks or forceps. A fluid-gas exchange was performed and the transforming growth factorbeta 2 was then injected onto the surface of the retina overlying the macular hole. Tamponade was provided with air (one patient in this series) or 16% perfluoropropane (five of six patients in this series), according to the protocol into which the patient was enrolled. Patients were asked to maintain a supine position for 24 ~ours and then the .appropriate face-down position for the duration of the intravitreal gasbubble tamponade. Macular microperimetry in which a scanning laser ophthalmoscope was used was performed preoperatively and postoperatively on all six patients. The technique, as previously descri~ed, 10 uses a kinetic stimulus and stationary fixation cross. The patient is asked to fixate on the cross and signal the examiner when the test stimulus is seen. The examiner is able to view the real-time image of the macula and assess fixation. A 6 x 6-pixel square test stimulus was used. Test stimulus intensities were controlled by the software to create isopters of scotomata. A log 2 incremental scale of test stimuli, (2"-1), was used with intensities of 15,31,63,127, and 255 actual (He Ne laser output of 0.03, 0.06, 0.58, and 1.39 MW, respectively). The 255 intensity was the brightest stimulus possible and was used to determine the size of an absolute scotoma, if present. The size of the absolute scotoma has been shown to represent the size of the neurosensory defect in macular holes.":" Tests were performed with 40-degree fields on all patients with macular holes. Postoperatively, if no absolute scotoma was present w~th a 40-degree field test, the test was repeated with a 20-degree field test, which is capable of detecting a scotoma as small as seven minutes of arc in radius." Absolute and relative scotomata were mapped and the software was used to convert the mapped areas into pixels. Statistical and mathematical calculations were per-
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formed with the pixel units and later converted to micrometers for anatomic correlation (1 pixel represents approximately 3.28 minutes of arc or 16 IJ.m on the retinal surface). Case 1 A 65-year-old pseudophakic white woman with a 48-week history of painless loss of vision and metamorphopsia in her left eye was referred to our institution. On examination, her best-corrected visual acuity was 20/80 +2. On slit-lamp biomicroscopy the anterior segment was normal and included a well-positioned posterior-chamber intraocular lens with a central capsular opening. Ophthalmoscopy disclosed a full-thickness macular hole with surrounding neurosensory retinal detachment. No overlying operculum was seen. No remnant of ~eiss' ring ~as seen, although the posterior vitreous cavity was optically empty. The hole was graded as stage 3 (vitreofoveal separation). Macular microperimetry was performed with the s.canning laser ophthalmoscope (Fig. 1). Her fixation was good and was positioned on the neurosensory detachment at the inferior edge of the macular hole. The sizes of the scotomata wer~ determined. (Table). After a thorough disCUSSlOn of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient desired to have the operation. Four days after examination, the patient underwent the operation as described previously. A stage 3 hole was confirmed at the time of the operation. Postoperative tamponade was provided with perfluoropropane. Six weeks postoperatively, her best-corrected visual acuity improved to 20/63 + 1. The edges of the macular hole were completely flat with resolution of the neurosensory detachI?ent. Microperimetry was performed and did not show any scotoma in the 40or 20-degree field tests. Fixation was stable and was positioned over the center of the fovea, where the preexisting hole had been. Three months postoperatively, her best-corrected visual acuity improved to 20/40. Results of slitla~p b~omicroscopic and ophthalmoscopic examinatrons were unchanged. Microperimetry was performed and showed no scotomata (Fig. 1) to the 40- or 20-degree fields. Case 2 A 75-year-old white woman with a history of painless loss of vision and symptoms of metamorphopsia in her right eye beginning 24 weeks earlier was referred to our institution.
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Fig. 1 (Sjaarda and associates). Case 1. Top left, Preoperative scanning laser ophthalmoscope photograph of the stage 3 macular hole with neurosensory defect (hole) and surrounding darker area of the neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127 and 63 (same area), 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment and resolution of all scotomata.
TABLE SCOTOMA SIZE (PIXELS) INTENSITY
VISUAL CASE NO.
ACUITY'
1 2 3 4 5 6
20/80 +2 20/125 +2 20/100 -2 20/63 -1 20/63 -2 20/100 +2
1 2 3 4 5 6
20/40 20/80 +1 20/63 -2 20/32 20/40 -2 20/40 -2
255
127
Preoperative 1,487 741 1,010 2,823 1,089 1,890 1,481 665 234 234 1,747 968 Postoperative (3 mos) 0 0 0 0 0 0 0 0 0 0 0 0
63
31
15
1,487 5,707 3,428 3,136 1,675 4,083
2,633 7,058 5.920 4,196 3,259 7,536
8,115 16,980 15,058 23,233 15,027
0 0 65 0 0 0
0 0 65 0 0 0
0 7,187 1,760 0 56 21
'According to the logarithmic eye chart used in the Early Treatment of Diabetic Retinopathy Study."
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On examination her best-corrected visual acuity was 20/125 +2. Results of slit-lamp biomicroscopic examination of the anterior segment were normal except for mild nuclear sclerosis (graded mild, moderate, moderately severe, and severe). Ophthalmoscopy and fundus biomicroscopy showed a stage 2 (small, early) full-thickness macular hole with a crescentshaped break at the temporal edge of the fovea and mild radiating striae around the edge of the hole. Macular microperimetry was performed with the scanning laser ophthalmoscope (Fig. 2). Fixation was superonasal to the center of the fovea. The sizes of the scotomata were determined (Table). After a thorough discussion of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient desired to have the operation. Five days after examination, the patient underwent the operation as described previously. A stage 2 hole
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with an attached posterior hyaloid was confirmed at the time of the operation. Tamponade was provided with air and the patient was asked to maintain the appropriate face-down position. Six weeks postoperatively, her best-corrected visual acuity was 20/100 -2. Slit-lamp examination showed mild nuclear sclerosis. The edges of the macular hole were completely flat. Three months postoperatively, her best-corrected visual acuity was 20/80 + 1. Slit-lamp examination showed mild nuclear sclerotic change. The edges of the macular hole remained completely flat. Microperimetry was performed, which showed fixation to be steady and central (Fig. 2). There were no scotomata to the 31, 63, 127, or 255 intensity stimuli in the 40- or 20-degree fields. In a 40-degree field test there was a scotoma to the 15 intensity stimulus with an area of 7,187 pixels (approximately 157 minutes of arc in radius or 776 urn in radius on the retinal surface).
Fig. 2 (Sjaarda and associates). Case 2. Top left, Preoperative scanning laser ophthalmoscope photograph of eccentric macular hole and surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment; only a scotoma to the 15 intensity remains.
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Case 3 A 63-year-old white woman with a history of sudden onset of blurred vision and metamorphopsia in her left eye starting ten weeks earlier was referred to our institution. On examination the best-corrected visual acuity was 20/8 -1. Results of slit-lamp biomicroscopic examination of the anterior segment were normal except for mild nuclear sclerosis. Ophthalmoscopy showed a stage 3 full-thickness macular hole with a surrounding rim of neurosensory retinal detachment and an overlying operculum. After a thorough discussion of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient considered an
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operation. The patient returned nine weeks later for the operation. Her best-corrected visual acuity at that time was 20/100 -2. Results of slit-lamp examination and ophthalmoscopy were unchanged. Macular microperimetry was performed (Fig. 3). Her fixation was stable and was positioned on the neurosensory detachment at the temporal edge of the macular hole. The sizes of the scotomata were determined (Table). The patient underwent the operation as described previously six days later. Postoperative tamponade was provided with perfluoropropane. Six weeks postoperatively, her bestcorrected visual acuity had improved to 20/80 +2. On ophthalmoscopy the edges of the macular hole were completely flat with complete
Fig. 3 (Sjaarda and associates). Case 3. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph showing flattening of the macular hole and resolution of the neurosensory detachment. Bottom right, Postoperative micro perimetry showing residual isopters of scotomata; from inner to outer, the intensities are 63 and 31 (same area) and 15.
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resolution of the surrounding neurosensory detachment. At her three-month visit the bestcorrected visual acuity was 20/63 - 2. Slitlamp examination showed moderate nuclear sclerosis. The edges of the macular hole remained flat without a surrounding neurosensory detachment on ophthalmoscopy. Macular microperimetry was performed (Fig. 3). Fixation was stable and was located centrally in the area of the previous hole. There was no scotoma to the 127 or 255 intensity stimulus in the 40- or 20-degree fields. In a 40-degree field test, to the 31 and 63 intensity stimuli, there was a small scotoma of 65 pixels (approximately 14.9 minutes of arc in radius or 74 urn in radius on the retinal surface). To the 15 intensity stimuli, there was an area of 1,760 pixels (approximately 77.6 minutes of arc in radius or 384 urn on the surface of the retina). Case 4
A 64-year-old white woman with symptoms of sudden loss of vision and onset of metamorphopsia in her right eye beginning 11 weeks earlier was referred to our institution. Her bestcorrected visual acuity was 20/50. Results of slit-lamp examination were normal. There was mild nuclear sclerosis. Ophthalmoscopy showed there to be a stage 2 macular hole with an eccentric break along the nasal margin of the fovea and radiating striae of the retina. The patient was counseled as to the diagnosis and natural progression of her condition. The patient returned as scheduled nine weeks later, at which time her best-corrected visual acuity was 20/63 +2. The examination showed progression of the macular hole to a stage 3 hole with development of a surrounding neurosensory retinal detachment. The patient again returned 16 weeks later, at which time her visual acuity was 20/63 -1. Results of slit-lamp examination remained unchanged with mild nuclear sclerosis. There remained a full-thickness macular hole with a surrounding neurosensory retinal detachment. Macular microperimetry was performed (Fig. 4). At this examination the natural progression of the disease, as best known, was reviewed again with the patient and the risks and benefits of surgical treatment were discussed. The patient desired to proceed with the operation. The next day the operation was performed as described previously. Postoperative tamponade was provided with perfluoropropane. At the six-week postoperative visit the best-corrected visual acuity was 20/4 -1. There remained mild nuclear sclerosis of the
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lens. Ophthalmoscopy showed the edges of the macular hole to be completely flat with complete resolution of the surrounding neurosensory detachment. Three months postoperatively, the best-corrected visual acuity was 20/ 32. Results of slit-lamp examination were normal except for mild to moderate nuclear sclerosis. Ophthalmoscopy showed the edges of the hole to be flat without a surrounding neurosensory detachment. Macular microperimetry was performed, at which time fixation was stable and positioned centrally. There was no scotoma to stimuli of any intensity in the 40- or 20degree visual field tests (Fig. 4). Case 5
A 60-year-old white woman with sudden loss of vision and onset of metamorphopsia occurring 15 weeks earlier in her left eye was referred to our institution. The best-corrected visual acuity was 20/63 -1. Results of slit-lamp biomicroscopy of the anterior segment were normal and the lens was clear. Ophthalmoscopy disclosed a stage 3 macular hole with a small central hole and surrounding neurosensory retinal detachment. After a thorough discussion of the diagnosis, the natural progression of the disease as best known, and the risks and benefits of possible surgical treatment, the patient considered the operation. The patient returned two weeks later for the operation. At that time her best-corrected visual acuity was 20/63 - 2. The results of the remainder of her examination were unchanged. Macular microperimetry was performed (Fig. 5). Fixation was stable and was positioned on the neurosensory detachment at the inferonasal margin of the hole. The sizes of the scotomata were determined (Table). The next day the operation was performed as described previously. Postoperative tamponade was provided with perfluoropropane. Six weeks postoperatively the best-corrected visual acuity had improved to 20/40 - 2. Results of slit-lamp biomicroscopy of the anterior segment were normal except for mild nuclear sclerosis. Ophthalmoscopy disclosed the edges of the macular hole to be completely flat without any surrounding neurosensory detachment. Macular microperimetry was performed (Fig. 5). Fixation was stable and positioned on the center of the fovea. There was no scotoma to the 31 through 255 intensity stimuli in the 40- or 20-degree visual field test. There was a relative scotoma to the 15 intensity stimulus of 56 pixels in size (approximately 13.8 minutes of arc in radius or 68 urn in radius on the retinal
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Fig. 4 (Sjaarda and associates). Case 4. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment and resolution of all scotomata.
surface). At her three-month postoperative visit her best-corrected visual acuity was 20/40 - 2. Results of slit-lamp examination and ophthalmoscopy were unchanged. Results of macular microperimetry were unchanged, with the small persistent relative scotoma to only the 15 intensity stimulus. Case 6 A 54-year-old white man with a 20-week history of metamorphopsia and progressive decrease in vision in his left eye was referred to our institution. On examination his best-corrected visual acuity was 20/100 +2. Results of slit-lamp biomicroscopy were normal and the lens was clear. Ophthalmoscopy disclosed a stage 3 macular hole with a surrounding neurosensory retinal detachment and overlying operculum. Macular microperimetry was performed (Fig. 6). Fixation was stable and was positioned on the superonasal margin of the macular hole overlying the neurosensory detachment. The patient could not consistently identify the 15
intensity stimulus in the central macular area to allow plotting of this isopter. After a thorough discussion of the diagnosis, the natural progression as best known, and the risks and benefits of possible surgical treatment, the patient desired to have an operation. The next day the operation was performed as described previously. Postoperative tamponade was provided with perfluoropropane. Six weeks after the operation, the best-corrected visual acuity was 20/63 -2. Results of slit-lamp biomicroscopy were normal and the lens remained clear. Ophthalmoscopy showed the edges of the macular hole to be completely flat with resolution of the surrounding neurosensory detachment. At the three-month postoperative visit the best-corrected visual acuity was 20/4 - 2. The patient was judged to have mild nuclear sclerosis, but otherwise results of slit-lamp biomicroscopy of the anterior segment were unchanged. The ophthalmoscopic appearance was unchanged and the edges of the macular hole were flat with
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Fig. 5 (Sjaarda and associates). Case 5. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 and 127 (absolute), 63, 31, and 15. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole with resolution of the neurosensory detachment and the small residual relative scotoma to the 15 intensity stimulus only.
no recurrence of the neurosensory detachment. Macular microperimetry was performed (Fig. 6). Fixation was stable and was centered in the area of the previous macular hole. There was no scotoma to the 31 through 255 intensity stimuli in the 40- or 20-degree field test. There was a small relative scotoma to the 15 intensity stimulus with an area of 21 pixels (approximately 8.5 minutes of arc in radius or 42 J.Lm in radius on the surface of the retina).
Results All patients reported preoperative symptoms of reduced vision and metamorphopsia. Their visual acuities averaged 20/80 - 2 (range, 20/63 -1 to 20/125 +2). Preoperative macular microperimetry demonstrated an absolute scotoma in the area of the neurosensory defect in
all six patients, as described previously.P" There were surrounding isopters of relative scotomata in all patients. The size of the absolute scotoma averaged 784.5 pixels in surface area (range, 741 to 1,089) or 15.8 pixels in radius, which would be equivalent to 51.8 minutes of arc in radius or 256 J.Lm in radius on the surface of the retina. Three months postoperatively, all patients had improvement of visual acuity. Of six patients, five (Cases 1, 3, 4, 5, and 6) had at least two lines of improvement, and two patients (Cases 4 and 6) had halving of the visual angle as shown by improvement of the equivalent of three lines on the logarithmic eye chart." Postoperative macular microperimetry disclosed no detectable absolute scotoma by using the 40- or 20-degree field test in all patients. Two patients with 20/32 and 20/40 visual acuity showed no detectable relative scotoma to any intensity stimuli (Cases 4 and 1, respective-
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Fig. 6 (Sjaarda and associates). Case 6. Top left, Preoperative scanning laser ophthalmoscope photograph of a stage 3 macular hole with surrounding neurosensory detachment. Top right, Microperimetry showing the isopters of scotomata; from inner to outer, the intensities are 255 (absolute), 127, 63, and 31. Bottom left, Postoperative scanning laser ophthalmoscope photograph and microperimetry showing flattening of the macular hole and small residual relative scotoma to the 15 intensity stimulus.
ly}. Two patients (Cases 5 and 6) with visual acuity of 20/40 - 2 showed a small persistent relative scotoma to the 15 intensity stimulus only. In each patient the scotoma was markedly smaller than the respective scotoma during the preoperative examination. One patient (Case 2) had a large residual scotoma to the 15 intensity stimulus, although it was markedly smaller than the preoperative scotoma. The postoperative visual acuity in this eye was 20/80 + 1. One patient (Case 3) had relative scotomata to the 15, 31, and 63 intensity stimuli. The patient attained a best postoperative visual acuity of 20/63 -2.
Discussion
In a series of six patients we demonstrated that successful surgical treatment of macular
holes can improve visual function as assessed by macular microperimetric analysis, as well as by visual acuity. Small, central scotomata have been demonstrated in 30% to 40% of patients with full-thickness macular holes by using Amsler grid testing.v" However, there were no reports of surgically induced or spontaneous healing of holes in these series. In a pilot series of 52 patients undergoing pars plana vitrectomy and fluid-gas exchange for macular holes, one patient had postoperative resolution of a preoperative central scotoma as detected on visual field testing in which an automated perimeter and macular field software (Humphrey 10-2, Humphrey Instruments, Inc., San Leandro, California) were used." The percentage of patients either preoperatively or postoperatively who had a central scotoma was not stated. The technique of macular visual field testing used in that series has a spatial resolution of 2 degrees, which is less accurate than that of
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Amsler grid testing, in which each square subtends 1 degree in arc. Such gross macular testing was considered inadequate in detecting a central scotoma in over 60% of eyes with macular holes in a previous report, because the predicted scotoma was less than 1 degree .13 With the use of macular microperimetry techniques with the scanning laser ophthalmoscope, Acosta and associates'! demonstrated an absolute scotoma in 26 of 26 eyes with macular holes. However, they detected a surrounding relative scotoma relating to the surrounding neurosensory detachment in only two of 26 eyes. In their series, there were no reports of spontaneous or surgically induced healing of macular holes. In a previous series of 30 patients, we demonstrated that kinetic macular microperimetry using the scanning laser ophthalmoscope can detect and quantitate absolute and relative scotomata in eyes with a macular hole, and that these scotomata were correlated with best-corrected visual acuity." The absolute scotoma exactly corresponded to the area of neurosensory defect in those eyes, whereas surrounding relative scotomata corresponded to the surrounding neurosensory retinal detachment. In the current study, preoperative macular microperimetry showed similar absolute and relative scotomata. Postoperatively, all patients had partial or complete resolution of the relative scotomata, which indicated improved in retinal function. Although our series was small, there was a definite correlation between the postoperative residual relative scotomata and the postoperative visual acuity. Patients with the best postoperative visual acuity had minimal or no residual relative scotomata, whereas those patients with the worst final visual acuity had persistent large, relative scotomata (Table). Nuclear sclerosis was equivalent in all patients and, therefore, did not appear to be an important contributing factor to the differences in postoperative visual acuity. Although postoperative improvement was not unexpected in the relative scotomata with resolution of the surrounding neurosensory retinal detachment, as demonstrated, interestingly all of our patients showed complete resolution of a detectable absolute scotoma. The resolution of the absolute scotoma would imply that after a successful operation, not only does the neurosensory detachment resolve, but the hole can become smaller as well. As described previously, we estimated that our technique
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should be able to detect reliably a scotoma of 7 minutes of arc in radius, or approximately 68 urn in diameter, on the surface of the retina." Therefore, postoperatively in these eyes, the neurosensory defect decreased from an average of 31.6 pixels, or 512 urn in diameter, to less than 7 pixels, or 68 urn in diameter. Thus, after a successful macular hole operation, holes may flatten and close. The processes by which a macular hole could close are not completely understood. However, a decrease in the apparent size of macular holes has been reported in a clinicopathologic correlation." In that report, one patient underwent a successful bilateral macular hole operation, and postmortem pathologic examination disclosed flattening and closure of the hole in each eye. In each eye there was a minute (approximately 50 um) area of photoreceptor absence, which would produce a scotoma smaller than that which we could detect with our microperimetry technique. Closure of the hole in one eye was associated with glial proliferation with possible traction. However, in the other eye, the opposing edges of the macular hole approximated each other without marked glial proliferation. Thus, two mechanisms could be postulated for the closure of macular holes below the threshold of detection of an absolute scotoma. Glial proliferation in the healing hole could exert centripetal contraction, which would pull the edges of the neurosensory retina together. Alternatively, in some eyes flattening of the neurosensory retinal detachment alone could allow reapproximation of the retinal edges and closure of the hole. We found that after successful surgical treatment of macular holes, improvement in visual function can be quantitated with macular microperimetry by using the scanning laser ophthalmoscope. Detectable absolute scotomata can completely resolve, and relative scotomata that correspond to the neurosensory detachment may partially or completely resolve. Resolution of the relative scotomata appears to correlate with better postoperative visual acuity, but it remains uncertain why some patients retain larger areas of residual relative scotomata and poorer postoperative visual acuity. Further studies using microperimetry in patients undergoing surgery for macular holes may alIowa better understanding of the improvement in visual function postoperatively and may help in identifying which candidates may benefit most from an operation.
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References 1. Aaberg, T. M.: Macular holes. A review. Surv. Ophthalmol. 15:139, 1970. 2. Gass, J. D. M.: Idiopathic senile macular hole. Its early stages and pathogenesis. Arch. Ophthalmol. 106:629, 1988. 3. Johnson, R. N., and Gass, J. D. M.: Idiopathic macular holes. Observations, stages of formation, and implications for surgical intervention. Ophthalmology 95:917,1988. 4. Morgan, C. M., and Schatz, H.: Involutional macular thinning. A pre-macular hole condition. Ophthalmology 93:153,1986. 5. Lewis, H., Cowan, G. M., and Straatsma, B. R.: Apparent disappearance of a macular hole associated with development of an epiretinal membrane. Am. J. Ophthalmol. 102:172, 1986. 6. Guyer, D. R., Green, W. R., de Bustros, 5., and Fine, S. L.: Histopathologic features of idiopathic macular holes and cysts. Ophthalmology 97:1045, 1990. 7. Kelly, E. K., and Wendel, R. T.: Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch. Ophthalmol, 109:654, 1991. 8. Glaser, B. M., Michels, R. G., Kuppermann, B. D., Sjaarda, R. N., and Pena, R. A.: Transforming
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growth factor-B, for the treatment of full-thickness macular holes. A prospective randomized study. Ophthalmology 99:1162,1992. 9. Lansing, M. B., Glaser, B. M., Liss, H., Hanham, A., Thompson, J. T., Sjaarda, R. N., and Gordon, A. J.: The effect of pars plana vitrectomy and transforming growth factor-beta 2 without epiretinal membrane peeling on full-thickness macular holes. Ophthalmology. In press. 10. Sjaarda, R. N., Frank, D. A., Glaser, B. M., Thompson, J. T., and Murphy, R. P.: Assessment of vision in idiopathic macular holes with macular microperimetry using the scanning laser ophthalmoscope. Ophthalmology. In press. 11. Early Treatment Diabetic Retinopathy Study Research Group: Early Treatment Diabetic Retinopathy Study design and baseline patient characteristics. ETDRS Report 7. Ophthalmology 98:741,1991. 12. Acosta, F., Lashkari, K., Reynaud, X., Jalkh, A. E., van de Velde, F., and Chedid, N.: Characterization of functional changes in macular holes and cysts. Ophthalmology 98:1820, 1991. 13. Smith, R. G., Hardman Lea, S. J., and Galloway, N. R.: Visual performance in idiopathic macular holes. Eye 4:190, 1990. 14. Funata, M., Wendel, R. T., de la Cruz, Z., and Green, W. R.: Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina 12:289, 1992.
OPHTHALMIC MINIATURE
Her ladyship therefore determined to investigate the woman. The De Conrey's were hereditarily shortsighted, and had been so for thirty centuries at least. So Lady De Courcy, who when she entered the family had adopted the family habits, did as her son had done before her and, taking her glass to investigate the Signora Neroni, pressed in among the gentlemen who surrounded the couch and bowed slightly to those whom she chose to honour by her acquaintance. Anthony Trollope, Barchester Towers Harmondsworth, Middlesex, England, Penguin Books Ltd., 1963, p. 372