Macular Hole Plus Retinal Elevation in Macula-Off Detachments May Predict Visual Outcomes

Optometrist giving eye exam to senior patient
Foveal changes and macular hole presence play a significant role in vision outcomes of macula-off retinal detachment repairs.

Foveal changes play a significant role in vision loss following macula-off retinal detachment repairs, according to research published in Eye. Macular hole presentation and resulting tension in the fovea with high detachments may also play a significant role in visual outcomes following surgical repair. 

Researchers conducted a retrospective, consecutive, observational case series study to assess which preoperative and surgical factors may correlate with functional outcomes following retinal detachment surgery. 

The cohort included 47 patients with macula-off rhegmatogenous retinal detachments (RRD). Investigators were able to identify the fovea in 44 of 47 patients; in the remaining 3 patients, the fovea could not be imaged through preoperative optical coherence tomography (OCT). All patients completed 6 months of follow-up and 44 eyes from 44 patients (mean age, 57.4 years ± 21.1 years) were included in the final analyses. 

Mean duration of macular detachment was approximately 41.5 days. As measured via OCT, the average detached macula height was 869.36 μm ± 587.71 μm.  

Half of the patients were treated with pneumatic retinopexy; 38.6% were treated with pars plana vitrectomy, and 11.5% were treated with scleral buckling. Within the cohort, 59.1% of patients were phakic at presentation, 7 patients who were phakic at presentation received pars plana vitrectomy and three developed “significant cataracts” during the 6-month follow-up period. 

Secondary surgeries were required in 6 patients first treated with pneumatic retinopexy in order to reattach the retina, and 3 patients who underwent pars plana vitrectomy required repeat surgery (which was unsuccessful in 2 patients). 

On OCT image analysis, 3 characteristic retinal changes were noted: schisis-like changes/fluid in the outer plexiform layer, schisis-like changes/fluid in the inner nuclear layer, and folds in the outer retina. The presence of epiretinal membrane, macular hole, and subretinal depositions were also noted. 

Among patients with fewer than 2 weeks of symptom duration, outer plexiform changes were found in 97% of patients, retinal folds in 18% of patients, and inner nuclear layer changes in 18%. A macular hole, either full-thickness or with a thin residual outer retinal remnant, was noted in 18% of patients. The most common findings in those with symptom duration longer than 2 weeks were outer plexiform changes and subretinal depositions and epiretinal membrane (60% and 30% of patients, respectively). 

Investigates examined the correlations between OCT retinal findings, symptom duration, and retinal detachment height, and preoperative VA. Retinal detachment height was the primary factor that correlated with preoperative VA (r=0.519; P <.0001). Macular hole presence and epiretinal membranes were also correlated with preoperative VA (r=0.311 and r=0.339; P =.047 and P =.037, respectively). No relationship between macula-off duration and preoperative VA was noted. 

Additional correlations between visual acuity at presentation, detachment height, and symptom duration with vinal VA were also noted (P =.001, P =.003, and P =.03, respectively). In a multiple regression analysis, investigators found a statistically significant correlation between macular hole presence, epiretinal membrane presence, and the success of the first surgery and final VA (P =.003, P =.007, and P =.006, respectively). 

The same analyses were performed on a subgroup of patients with symptoms of less than 14 days (n=33). Correlations were noted between visual acuity at presentation, the height of detachment, and final VA (P =.036 and P =.014, respectively), as well as between macular hole presence and final visual acuity (P =.012). No correlation was identified between symptom duration and final visual acuity in this group. 

In a subanalysis of patients with a macular hole at presentation, those with a macular hole had worse visual acuity, higher detachment, and worse visual outcomes. Six patients were treated with pneumatic retinopexy, and five had successful reattachment. 

Study limitations include a lack of validation of the measurement technique used to determine foveal detachment height and the retrospective nature of the research. 

“Our study is the first to demonstrate the significance of foveal changes in the pathogenesis of lost vision in macula-off retinal detachments,” the research says. “The high rate of macular holes and the correlation between the macular hole and the height of the detachment suggest that elevated tension in the fovea in high detachments might play a significant role in the visual outcomes of macula-off RRD following repair.”


Hostovsky A, Trussart R, AlAli A, Kertes PJ, Eng KT. Pre-operative optical coherence tomography findings in macula-off retinal detachments and visual outcome. Eye. Published online January 29, 2021. doi:10.1038/s41433-021-01399