Dr Watzke's comments are appreciated. Probably assessory glial cells play a significant role in the tangential traction leading to macular holes in at least some cases. One reservation, however, is founded in the results of a histopathology study of specimens removed during surgery for idiopathic epiretinal membranes.1 In that study, retinal pigment epithelial cells were more prevalent than glial cells. On a larger, anatomic scale, the article hypothesizes that instead of the posterior vitreous separation initiating posteriorly, at least in some cases it appeared to initiate peripherally, without changing the vitreoretinal relationships and, presumably, cellular milieu at the macula. Possibly, anatomic variations in the vitreoretinal configuration from one patient to another may account for the susceptibility of some patients to develop a macular hole. Still, the exact mechanism of macular hole formation remains incompletely understood.
Smiddy WE. Atypical Presentations of Macular Holes-Reply. Arch Ophthalmol. 1994;112(4):446. doi:10.1001/archopht.1994.01090160020003