This 49YO female with type 2 diabetes presented with a several-year history of blurred vision in her left eye. Vision was 20/40 OD and 20/60 OS.
Optos RG imaging shows variably fibrosed retinal neovascularization encircling the posterior pole. Fluorescein angiography shows active leakage from these vessels.
An area of small neovascularization is present in the inferior temporal macula, which caused a tractional full-thickness macular hole. A 3D OCT view best shows this diabetic traction.
Vitrectomy surgery was scheduled for her left eye. Primary vitrectomy will be performed for her right eye as well once the left eye has stabilized.
Learning Points:
In 1988, Dr. Gass described his concept for the pathogenesis of idiopathic macular holes (Arch Ophthalmol 1988;106:629-639). His classification system, from stage 1 for an impending macular hole through stage 4 for a fully developed macular hole with complete posterior vitreous detachment, was based on his concept of localized, mostly tangential traction caused by the shrinking foveal vitreous cortex. This classic paper heralded modern macular hole surgery for a previously untreatable condition.
The advent of OCT technology, however, has shown that macular hole development is more often due to focal vitreomacular traction, as our case beautifully illustrates.
The current classification system, described by the International Vitreomacular Traction Study Group, emphasizes the characteristics that determine treatment choice and visual prognosis (Ophthalmology 2013;120:2611-2619). This includes size (small <= 250 microns, medium >250 microns and <= 400 microns, large >400 microns), presence or absence of VMT, and cause (primary from VMT or secondary).
Our patient emphasizes why this new classification system was implemented, since it provides information that guides our treatment. Our patient’s hole is secondary to diabetic traction, which obviously requires a very different vitrectomy procedure compared to a primary hole.
