Saving sight without surgery: Macular holes

BACKGROUND:  A macular hole is a small break in the macula, the center of the eye's light-sensitive tissue called the retina.  The macula is responsible for providing the central vision we need for seeing fine detail, like reading, or driving.  A macular hole will cause blurred and distorted central vision, but they begin gradually.  In the early stage, people might notice a slight distortion or blurriness when they look directly in front of them.  Objects and straight lines may begin to look wavy.  Reading and performing other routine tasks with the affected eye becomes difficult.  There are three stages to a macular hole: stage 1 (foveal detachments), stage 2 (partial-thickness holes), and stage 3 (full-thickness holes).  During stage 1, if left untreated about half of stage 1 macular hole will progress.  In stage 2, if untreated 70% of holes will progress.  When a stage 3 macular hole develops, most central and detailed vision can be lost.  If left untreated, a stage 3 macular hole can lead to a detached retina.  (Source: http://www.nei.nih.gov/health/macularhole/macularhole.asp)

CAUSES AND RISKS:  Eighty-percent of the eye is filled with a gel-like substance that helps it maintain a round shape, called vitreous.  It contains millions of tiny fibers that are attached to the surface of the retina and as we age the vitreous shrinks and pulls away from the retinal surface.  Natural fluids will fill the area where the vitreous has contracted.  In most cases, there are no adverse effects.  Some patients may experience an increase in floaters, or "cobwebs," that seem to float in the field of vision.  If the vitreous is firmly attached to the retina when it pulls away, it can tear the retina and create a macular hole.  In addition, once the vitreous has pulled away from the surface of the retina, some of the fibers can remain on the retinal surface and can contract.   This will increase tension on the retina and lead to a macular hole.  Macular holes can also occur in other eye disorders, such as injury to the eye, retinal detachment, high myopia, and rarely, macular pucker.  (Source: http://www.nei.nih.gov/health/macularhole/macularhole.asp)

TREATMENT:   Some macular holes can seal themselves and do not require treatment.  Surgery is necessary in many cases to improve vision.  It is called vitrectomy, the vitreous gel is removed and replaced with a bubble containing a mixture of air and gas.  The bubble acts as a temporary, internal bandage that holds the edge of the macular hole in place as it heals.  The surgery is done under local anesthesia and often on an out-patient basis. (Source: http://www.nei.nih.gov/health/macularhole/macularhole.asp)

NEW TECHNOLOGY:  In October, 2012 JETREA, an example of a preparation of ocriplasmin, was FDA approved for patients diagnosed with Vitreo Macular Adhesion (VMA).  It is the first nonsurgical alternative to eye surgery for this problem.  Instead of undergoing surgery, the patient gets their eye numbed.  Then the drug is injected into the eye.  The medicine dissolves adhesions that cause the problem in the focus point of the eye.  For small holes, it works 50% of the time.  During clinical trials, 652 eyes were treated: 464 with ocriplasmin and 188 with placebo.  Vitreo Macular Adhesion resolved it in 26.5% of ocriplasmin-injected eyes and in 10.1% of placebo-injected eyes.  Total posterior vitreous detachment was more prevalent among the eyes treated with ocriplasmin (13.4%) than among those injected with placebo (3.7%).  Nonsurgical closure of macular holes was achieved in 40.6% of ocriplasmin-injected eyes, as compared to 10.6% of placebo-injected eyes.  The best-corrected visual acuity was likely to improve by a gain of at least three lines on the eye chart with ocriplasmin than with placebo.  Intravitreal injection closed macular holes in significantly more patients than the injection of placebo.  (Source: http://www.nejm.org/doi/full/10.1056/NEJMoa1110823)

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