A 'Macular Hole' That May Not Be a Hole
A 63-year-old woman is referred with a diagnosis of 'macular hole, right eye.' Acuity is 20/40 and she reports mild distortion but no central scotoma. The referring optometrist saw a round reddish lesion at the fovea. A macular cube shows a round hyporeflective space at the fovea with a hyperreflective band extending from the inner retina toward the lesion edge on the temporal side. On the displayed B-scan the outer retinal layers appear continuous beneath the lesion. The automated central thickness is 210 µm. The referral asks whether she should be scheduled for vitrectomy.
1. How do you distinguish a full-thickness macular hole from a pseudohole or lamellar hole on these scans, and what additional imaging would you obtain?
Read the worked answer
The distinction rests on layer-by-layer integrity through the foveola, not on the presence of a 'hole-looking' shape.
Features to assess
- Full-thickness macular hole: a defect interrupting all layers from the ILM to the RPE, with elevated, cystic, thickened edges, often a operculum, and a visible base at the RPE. The outer retina is absent within the defect.
- Pseudohole: no full-thickness defect. There is an epiretinal membrane causing centripetal contraction, a steepened 'punched-out' foveal contour, and the outer retina remains intact. The lesion can look red on fundoscopy because the fovea is thinned and steepened, not because it is open.
- Lamellar hole: an irregular foveal contour with a defect limited to the inner retinal layers; the photoreceptor layer is preserved, and there is often epiretinal proliferation.
Additional imaging
- High-resolution horizontal and vertical line scans through the lesion, not just the cube, to confirm outer retinal continuity.
- En face OCT to map the defect and the ERM.
- A check for vitreomacular traction, ERM, or both at the margins.
The current scan shows a hyperreflective band consistent with ERM and continuous outer retina, which argues against a full-thickness hole.
2. What are the management implications, and how would you communicate the uncertainty?
Read the worked answer
The management pathways diverge sharply:
- Full-thickness hole: vitrectomy with ILM peel and gas tamponade is time-sensitive; delay reduces closure rates.
- Pseudohole or lamellar hole: observation is usual; surgery is reserved for significant metamorphopsia or progression, and ERM peeling may be considered. Operating on a pseudohole exposes the patient to cataract, infection, and reoperation risk for little gain.
The referral question ('should she have vitrectomy?') cannot be answered from a cube alone with borderline-quality images. The appropriate response is a targeted report: 'Findings suggest epiretinal membrane with foveal steepening and intact outer retina, consistent with a pseudohole rather than a full-thickness macular hole. Recommend dedicated high-resolution line scans and clinical correlation before surgical planning.' Prompt the referring clinician to compare acuity, Watzke–Allen, and Amsler findings. Document that the automated 210 µm thickness is unreliable near a foveal contour abnormality, and route the images to a retina specialist for review rather than scheduling surgery.