Macular Hole Surgery in the Presence of Prominent Macular Drusen

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.

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).

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).

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.

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.

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