A macular hole is a retinal lesion that is typically the result of either abnormal tangential or anterior-posterior vitreoretinal traction. Macular holes progress through 4 stages (std. cases 3a-3d). Stages 2 through 4 represent full thickness macular holes (a full thickness defect through the neurosensory retina). A stage 2 macular hole is a small macular hole measuring less than 400 um in diameter (std. case 3b). A posterior vitreous detachment (a separation of the vitreous body from the surface of the retina) is not present. A stage 3 macular hole is a larger macular hole measuring 400 um or more without a posterior vitreous detachment (std. case 3c). A stage 4 macular hole measures 400 microns or more but a posterior vitreous detachment is present (std. case 3d).
In stage 2 to 4 macular holes the defect in the neurosensory retina often has an anvil shape on cross sectional OCT images with the narrowest portion of the hole surrounded by the middle layers of the retina (10). The widest section of the hole is surrounded by the innermost and outermost layers of the retina. Stage 2 macular holes sometimes have a "lid" that is partially open and is attached to a moderately reflective, linear reflection corresponding to the posterior boundary of the vitreous body. On fundus photography this may correspond to an "eccentric" macular hole where the opening of the hole is not centered on the fovea. This finding is generally not present in stage 3 and 4 macular holes.
A stage 1 macular hole is a pre-macular hole lesion that sometimes is difficult to identify on stereoscopic color fundus photography (std. case 3a). It may appear as either a small yellow dot centered on the fovea or as a small yellow ring surrounding the fovea. On OCT images, a full thickness retinal defect is not present. On OCT images, a stage 1 macular hole appears as a distinct foveal thickening often with a large intraretinal cyst present under the fovea. Linear reflections corresponding to the posterior vitreous face are typically noted inserting at the central fovea.
no evidence
questionable
can't grade
definite
stage 1
stage 2
stage 3
stage 4
Vitreomacular traction syndrome (VMT) is an entity that is similar to a stage 1 macular hole. VMT is the result of abnormal anterior-posterior traction on the fovea/perifoveal retina. Secondary retinal thickening is present both on stereoscopic fundus photography and OCT images. Vitreomacular traction differs from a stage 1 macular hole in that the area of retina involved by traction is generally larger. On clinical examination and/or stereoscopic fundus photography a diffuse, thickened posterior hyaloid can be detected. On OCT images this thickened posterior hyaloid is observed to insert in the foveal/perifoveal area (11). The retinal thickening present is generally greater than stage 1 macular holes and the area of retinal thickening can take on a triangular appearance with the apex pointing in towards the vitreous cavity.
no evidence
questionable
< std. case 4
>= std. case 4
can't grade
Center involvement
no evidence
questionable
definite
An epiretinal membrane (ERM) represents abnormal fibrocellular proliferation on the surface of the retina. Commonly these proliferations occur over the central fovea. OCT images of ERMs can be classified into 2 broad categories: Globally adherent or partially non-adherent (12). Both types of epiretinal membranes are visible on OCT images as reflective tissue contiguous with or anterior to the inner retinal surface. Intraretinal edema with or without retinal cysts may be present under the ERM as a result of traction on the retina by the ERM.
Partially non-adherent ERMs are clearly visible on OCT images as they have sections that are separated from the anterior surface of the retina (std. case 5a). The ERM appears as a linear, thin, reflective band anterior to the retina with focal areas of attachment to the retinal surface. The appearance of such an ERM might be mimicked by a partially detached posterior vitreous surface. However, ERMs tend to be thicker and more reflective than the posterior vitreous. The reflection from an ERM may measure up to 60 um in thickness; this is rarely observed with a partially detached posterior vitreous.
Globally adherent ERMs are visible on OCT images as a contrast in reflectivity between the highly reflective ERM and the less reflective anterior surface of the retina. The adherence between the ERM and the anterior retina is uninterrupted in contrast to partially non-adherent ERMs. Approximately 10% of globally adherent membranes detected clinically cannot be detected by OCT. This is the result of difficulty, in some cases, in distinguishing the highly reflective ERM from the underlying reflective nerve fiber layer of the anterior retina. An adherent ERM edge can sometimes be identified as a small discontinuity in the contour of the inner retinal surface on the OCT image. This can sometimes be mimicked by saccadic eye movements so correlation to stereoscopic fundus photography is important.
Globally adherent ERMs may also present as a macular pseudohole (std. case 5b). The OCT images display an adherent ERM contiguous with the anterior retinal surface. An abnormally steep and narrow foveal contour is present. The appearance on the OCT image is similar to that of a macular hole but in the case of a macular pseudohole, full thickness retinal tissue is present at the base of the steepened foveal contour. This retinal tissue typically is of normal foveal thickness.
no evidence
questionable
definite presence of ERM (any type)
can't grade
Center involvement
no evidence
questionable
definite
Type
partially non-adherent
globally adherent
pseudohole appearance
can't grade
Fundus Photograph Reading Center
Department of Ophthalmology and Visual Sciences
University of Wisconsin - Madison
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