DiVerentiating full thickness macular holes from impending macular holes and macular pseudoholes

Aims—The reliability of scanning laser ophthalmoscope (SLO) microperimetry in diVerentiating full thickness macular holes from macular pseudoholes and impending macular holes was evaluated. Methods—106 eyes with the clinical diagnosis of full thickness macular holes, macular pseudoholes, and impending (stage 1) macular holes were examined for the presence of deep or relative scotoma using SLO microperimetry. The relation between these scotomas and the clinical diagnosis was studied. Results—Deep and relative scotomas were detected in all 57 eyes with clinically defined full thickness macular holes. In contrast, among 49 eyes diagnosed with macular pseudoholes or impending macular holes, no deep and only one relative scotoma was observed. The sensitivity of the presence of a deep scotoma as an indicator of the clinical diagnosis of a full thickness macular hole was 100% (57 of 57), and the specificity was 100% (49 of 49). The sensitivity of the presence of a relative scotoma was 100% (57 of 57) and the specificity was 98.0% (48 of 49). Conclusion—With SLO microperimetry, full thickness macular holes can be precisely and objectively distinguished from other conditions that mimic macular holes. (Br J Ophthalmol 1997;81:117–122) Full thickness macular holes are a common cause of visual loss in middle aged and elderly patients. They usually result in a visual acuity of between 20/80 and 20/200. The pathogenesis of this disease is hypothesised to be a result of tangential traction exerted by a thin layer of cortical vitreous. Continued traction causes the macular hole and cuV to enlarge with a progressive decrease of visual acuity in most cases. Recently, surgical techniques have been developed to release the tangential traction, and a macular hole has come to be regarded as a treatable condition. Several studies demonstrated the success of surgical treatment in this disease. 9 Because of the increased surgical intervention for patients with full thickness macular holes, accurate diagnosis of this disease has become extremely important. Several conditions resemble macular holes, including epimacular membranes with pseudoholes, impending macular holes, age-related macular degeneration, vitreomacular traction syndrome, and others. In particular, epimacular membrane with pseudoholes and impending (stage 1) macular holes are often misdiagnosed as full thickness macular holes on conventional examination. Since the treatment of these disorders is often quite diVerent from that of full thickness macular holes, and ranges from conservative to invasive, a reliable means of distinguishing them from macular holes is sorely needed. We used the scanning laser ophthalmoscope (SLO), a device that has been applied to macular diseases in the past, to examine patients with clinical macular holes and other lesions with a similar clinical appearance. The purpose of this study was to determine if SLO microperimetry can reliably diVerentiate full thickness macular holes from macular pseudoholes and impending macular holes. Patients and methods A total of 106 eyes of 94 consecutive patients who were diagnosed with full thickness macular holes, impending macular holes, or macular pseudoholes by the five members of the retina faculty at a university teaching hospital from October 1994 to September 1995 was studied. The best corrected visual acuity was measured by ophthalmic technicians in standard fashion. All patients received detailed fundus examinations using slit-lamp biomicroscopy with a 90 dioptre lens. In most patients, other ocular examinations including fluorescein angiography, the slit-beam test (Watzke–Allen sign), Amsler grid testing, and automated static threshold perimetry using the Humphrey field analyser program 10-2 (Allergan-Humphrey Medical Instruments, Irvine, CA, USA) were also performed. The diagnosis was made based on the results of these conventional examinations. The cases diagnosed by fluorescein angiography as a choroidal neovascularisation, a cystoid macular oedema, or an idiopathic juxtafoveal telangiectasis were excluded from our study. Idiopathic macular holes were graded according to the criteria described by Gass. After an initial diagnosis was assigned, SLO microperimetry was performed. We used a confocal scanning laser ophthalmoscope (Rodenstock, Germany), equipped with a static microperimetry program. MicroBritish Journal of Ophthalmology 1997;81:117–122 117 Department of Ophthalmology, Osaka University Medical School, Japan