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Case Reports and Small Case Series
January 2000

Macular Hole Surgery in the Presence of Prominent Macular Drusen

Arch Ophthalmol. 2000;118(1):131-132. doi:

Current vitreoretinal surgical techniques often achieve good visual acuity outcomes in eyes with idiopathic macular holes.1,2 However, the effect of concurrent prominent macular drusen on the outcome of macular hole surgery has not been reported. We describe 3 patients with prominent macular drusen and idiopathic macular holes. Macular hole surgery was performed and a follow-up of at least 3 months was obtained.

Report of Cases
Case 1

An 83-year-old white woman was seen with a 2-month history of decreased vision in her left eye. Best-corrected visual acuity was 20/50 OD and 20/400 OS. The anterior segment examination showed 1+ nuclear sclerosis in both eyes. The posterior segment examination of the right eye showed multiple drusen in the macula. Examination of the left eye revealed multiple drusen with a 200-µm stage 4 macular hole and surrounding cuff of subretinal fluid (Figure 1, A). The Watzke sign was positive. Fluorescein angiogram showed hyperfluorescence corresponding with the hole. The patient underwent pars plana vitrectomy, membrane peeling, fluid-air exchange, and injection of 16% perfluoropropane (C3F8) gas. Two weeks of prone positioning was accomplished and the hole was closed. One year later, her best-corrected visual acuity was 20/30 OS (Figure 1, B).

Figure 1.
Case 1. A, Prominent macular drusen with full-thickness macular hole (arrow). Preoperative visual acuity was 20/400. B, Twelve months after macular hole surgery. The macular hole is closed without progression of macular drusen and the visual acuity is 20/30.

Case 1. A, Prominent macular drusen with full-thickness macular hole (arrow). Preoperative visual acuity was 20/400. B, Twelve months after macular hole surgery. The macular hole is closed without progression of macular drusen and the visual acuity is 20/30.

Case 2

An 82-year-old woman was referred for possible choroidal neovascularization from age-related macular degeneration in her left eye. She had noticed decreased visual acuity in the affected eye for a few weeks and had previous cataract extraction in both eyes 2 years earlier. The best-corrected visual acuity was 20/30−2 OD and 20/200 OS. There were macular drusen in both eyes. Contact lens biomicroscopy of the left eye showed a small macular hole, surrounded by a cuff of subretinal fluid (Figure 2, A). The Watzke sign was positive. There was also evidence of a superonasal branch vein occlusion, which was distant from the macula. Fluorescein angiography revealed a discrete area of hyperfluorescence corresponding with the macular hole (Figure 2, B). Pars plana vitrectomy, membrane peeling, and fluid-gas exchange with 16% C3F8 gas was performed, followed by 2 weeks of prone positioning. The macular hole was closed and the visual acuity improved to 20/60 at the 3-month follow-up examination (Figure 2, C).

Figure 2.
Case 2. A, Prominent macular drusen with stage 4 macular hole (arrows). The foveal area was digitally enhanced to better define the macular hole (inset). Preoperative visual acuity was 20/200. B, Fluorescein angiography revealed a discrete area of hyperfluorescence corresponding to the macular hole (arrow). The area of hyperfluoroscence superotemporal to the fovea corresponded to the cluster of drusen seen in part A. C, Three months following macular hole surgery. The macular hole is closed and the visual acuity is 20/60.

Case 2. A, Prominent macular drusen with stage 4 macular hole (arrows). The foveal area was digitally enhanced to better define the macular hole (inset). Preoperative visual acuity was 20/200. B, Fluorescein angiography revealed a discrete area of hyperfluorescence corresponding to the macular hole (arrow). The area of hyperfluoroscence superotemporal to the fovea corresponded to the cluster of drusen seen in part A. C, Three months following macular hole surgery. The macular hole is closed and the visual acuity is 20/60.

Case 3

A 74-year-old white woman was seen for a 1-month history of decreased vision in her right eye. Six months earlier, she was diagnosed as having prominent macular drusen in both eyes by another retina specialist and had received grid laser treatment in both eyes with partial resolution of the drusen. She also had cataract extraction in both eyes 1 year earlier. Best-corrected visual acuity was 20/200 OU and 20/30 OS. Dilated fundus examination of the right eye showed prominent drusen with a stage 4 macular hole. Examination of the left eye revealed prominent macular soft drusen. Pars plana vitrectomy, membrane peeling, fluid-air exchange, and injection of 16% C3F8 gas was performed on the right eye. The macular hole was closed after 2 weeks of prone positioning. At 18-month follow-up, best-corrected visual acuity was 20/25 OD.

Comment

With current vitreoretinal techniques, anatomic closure rate in macular hole surgery has been reported in up to 91% of cases and the majority of anatomically successful cases achieve 2 or more lines of visual acuity improvement.1,2 After successful surgery, macular hole closure is believed to result from glial proliferation and contraction,3 and the visual acuity may return to near-normal function.

Prominent macular drusen may sometimes mask the presence of a full-thickness macular hole (Figure 2, A). Case 2 was referred with the diagnosis of exudative macular degeneration. The correct diagnosis of macular hole and prominent macular drusen was made with the aid of contact lens biomicroscopy.

The effect of prominent macular drusen on the anatomic and functional success of macular hole surgery has not been previously reported. Banker and associates4 correlated macular retinal pigment epithelium changes with poorer visual outcomes. The described retinal pigment epithelium alterations presumably result from light toxicity or anatomic debridement during macular hole repair.4,5

In the present report, all 3 patients had prominent preoperative macular drusen, which remained essentially unchanged following macular hole surgery. Although these 3 patients represent a limited experience, patients with prominent macular drusen and a macular hole can achieve similar anatomic and visual success compared with patients without drusen. Therefore, the presence of prominent drusen in the macula does not constitute a contraindication to macular hole surgery.

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Article Information

Corresponding author: Harry W. Flynn, Jr, MD, Bascom Palmer Eye Institute, 900 NW 17th St, University of Miami School of Medicine, Miami, FL 33136.

References
1.
Wendel  RTPatel  ACKelly  NE  et al.  Vitreous surgery for macular holes. Ophthalmology. 1993;1001671- 1676Article
2.
Smiddy  WEPimentel  SWilliams  GA Macular hole surgery without using adjunctive additives. Ophthalmic Surg Lasers. 1997;28713- 717
3.
Funata  MWendel  RTde la Cruz  ZGreen  WR Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina. 1992;12289- 298Article
4.
Banker  ASFreeman  WRKim  JW Vision-threatening complications of surgery for full-thickness macular holes. Ophthalmology. 1997;1041442- 1453Article
5.
Park  SSMarcuss  DMDuker  JS  et al.  Posterior segment complications after vitrectomy for macular hole. Ophthalmology. 1995;102775- 781Article
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