Differences in the presentation of stage 1 macular holes illustration by optical coherence tomography

Objective: To present two different phases of progression of Gass stage 1 foveolar detachment to lamellar or full-thickness macular holes revealed with spectral domain optical coherence tomography. Design: This is an observational study. Participants: The medical records of four patients (four eyes) with foveolar detachment that had evolved into stage 1 macular holes were compared. The patients manifested neither co-existing myopia nor any other ocular pathology. Methods: At each consultation, best-corrected visual acuity, dilated fundus examination, and spectral domain optical coherence tomography were performed to ascertain whether the foveolar detachment was associated with posterior vitreal detachment. Results: In two of the eyes, and at an early phase of the disease, an incomplete posterior vitreal detachment and vitreal adhesion at the head of the optic nerve were observed. In the other two cases, the traction was not antero-posterior but tangential and had been effected by thickening of the inner limiting membrane or by the presence of a discrete epiretinal membrane in the papillomacular area; the posterior vitreal detachment was complete. In the former two cases and in one of the latter, the foveolar detachments had progressed to full-thickness macular holes. The visual acuities were better in the latter than in the former two eyes. Conclusion: Two different pathological mechanisms appear to underlie the formation of macular holes: The optical coherence tomography–guided classification of Gass stage 1 macular hole as an antero-posterior traction with a triangular foveolar detachment has to be distinguished from a tangential traction and a complete posterior vitreal detachment. Tangential traction is typically associated with a more dome-shaped or irregular foveolar detachment and a hyper-reflective band at the vitreoretinal interface.