High Posterior Vitreous Separation Height Associated With Macular Hole Progression

When full-thickness macular holes develop, foveal inner tears are more likely wherever the posterior vitreous separation height is highest, usually on the temporal side.

High posterior vitreous separation height (PVSH) is associated with a strong likelihood of progression to macular hole (MH) stage 2, especially in women, according to a study published in Ophthalmology Science. In patients who are at the onset of full-thickness macular hole (FTMH), a foveal inner tear is likely to occur on the temporal side or the side with a high posterior vitreous separation height value, according to the report. 

Researchers retrospectively reviewed the medical records of 742 patients with FTMH or impending MH in at least 1 eye, as confirmed by ophthalmoscopy and optical coherence tomography (OCT) performed in a single center between January 2008 and June 2015. 

MHs were staged based on OCT findings. The study included patients with MH stages 1 through 3 whose posterior vitreous membrane was clearly identifiable on OCT images and who had vitreoretinal adhesion size of 1500 µm or smaller. The study also included contralateral eyes in the analysis if they exhibited the focal type of vitreomacular adhesion (VMA). 

Researchers defined the posterior vitreous separation height as the distance between the posterior vitreous membrane and the surface of the retina.

Using OCT images, the research team calculated the PVSHs of each eye in 4 directions (nasal, temporal, superior, and inferior) at 1 mm from the center of the MH or fovea. They included a total of 311 eyes (median age, 66.25 years; 62.1% women, 37.9% men) in the statistical analysis. 

Ophthalmologists must be aware that as PVSH increases, the odds ratio of progression to MH stage 2 increases more in female than in male patients.

The analysis defined initial MH stage 2 (onset of FTMH) as the presence of a gap in only 1 of the 4 directions from the center of the MH.

The researchers explain that their research shows eyes with a higher PVSH have a higher likelihood of foveal inner tearing upon initiation of MH stage 2. Tears are also more likely on the temporal side with the fovea as the center, and since PVSH is typically higher on the temporal side, foveal inner tearing is more likely on that side as well.

The study also notes that progression from MH stage 1 to stage 2 can occur, even in the absence of significant changes to the PVSH.

Previous research shows the frequent occurrence of MH in women with thin retinas. The report explains that the data in the current study also shows that foveal inner tear is more likely to occur in women than in men with high posterior vitreous separation height.

“Special attention should be paid to the direction with the highest PVSH as it is associated with a high probability of foveal inner tears and progression to MH stage 2,” according to the researchers. “Ophthalmologists must be aware that as PVSH increases, the odds ratio of progression to MH stage 2 increases more in female than in male patients.” 

Study limitations include the retrospective nature, lack of follow-up, failure to use radial scanning to evaluate patients, and the exclusion of patients with secondary or traumatic MH, and patients with large adhesions of the vitreous cortex on the macular surface and patients with high myopia were also excluded. 


Sakaguchi H, Kabata D, Sakimoto S, et al. Relationship between full-thickness macular hole onset and posterior vitreous detachment: a temporal onset theory. Ophthalmol Sci. Published online May 26, 2023. doi:10.1016/j.xops.2023.100339