The natural history of lamellar macular holes: a spectral domain optical coherence tomography study.

Abstract

BACKGROUND: To study the evolution of lamellar macular holes (LMHs) using spectral domain-optical coherence tomography (SD-OCT). METHODS: Thirty-four consecutive patients diagnosed with a LMH were followed prospectively at Sacco University Hospital from October 2008 to January 2011. Inclusion criteria were a foveal defect on SD-OCT with residual foveal tissue above the retinal pigment epithelium and corresponding hyperautofluorescence on fundus autofluorescence imaging. Epiretinal membranes (ERMs) were categorized by SD-OCT at baseline as two different types: normal and thicker than normal. Best corrected visual acuity (BCVA) and SD-OCT findings were collected and compared at baseline and every 6 months thereafter. Active eye tracking technology ensured that the same scanning location was identified on follow-up visits. Main outcome measures were visual acuity changes (Early Treatment Diabetic Retinopathy charts) and progression of the lamellar macular defect. The influence of ERM type on disease progression was also evaluated. RESULTS: The patients included 15 males and 19 females with a mean age of 73 years and mean refraction of -0.25 diopters. The mean follow-up period was 18 months (range 6 to 24 months). BCVA at baseline (±standard deviation) was 63 ± 6 letters and did not change significantly during the follow-up period (P = 0.256). Foveal thickness at baseline, 180 ± 29 μm, was also stable (P = 0.592). All eyes had an ERM at baseline. Both thicker and normal ERMs showed similar functional and morphological evolution during follow-up with no significant changes. Two LMHs (5.8 %) developed a full thickness macular hole after 6 and 15 months follow-up respectively. CONCLUSIONS: Lamellar macular holes seem to be a stable macular condition. Vitrectomy should be considered only in the presence of progressive thinning of foveal thickness and/or decrease of visual acuity during the follow-up of the disease.

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123
Graefe's Archive for Clinical and
Experimental Ophthalmology
Incorporating German Journal of
Ophthalmology

ISSN 0721-832X
Volume 251
Number 2

Graefes Arch Clin Exp Ophthalmol
(2013) 251:467-475
DOI 10.1007/s00417-012-2044-2
The natural history of lamellar macular
holes: a spectral domain optical coherence
tomography study
Ferdinando Bottoni, Antonio Peroglio
Deiro, Andrea Giani, Claudia Orini,
Mario Cigada & Giovanni Staurenghi

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RETINAL DISORDERS
The natural history of lamellar macular holes: a spectral
domain optical coherence tomography study
Ferdinando Bottoni & Antonio Peroglio Deiro &
Andrea Giani & Claudia Orini & Mario Cigada &
Giovanni Staurenghi
Received: 1 March 2012 /Revised: 10 April 2012 /Accepted: 16 April 2012 /Published online: 9 May 2012
#Springer-Verlag 2012
Abstract
Background To study the evolution of lamellar macular
holes (LMHs) using spectral domain-optical coherence to-
mography (SD-OCT).
Methods Thirty-four consecutive patients diagnosed with a
LMH were followed prospectively at Sacco University Hos-
pital from October 2008 to January 2011. Inclusion criteria
were a foveal defect on SD-OCT with residual foveal tissue
above the retinal pigment epithelium and corresponding
hyperautofluorescence on fundus autofluorescence imaging.
Epiretinal membranes (ERMs) were categorized by SD-
OCT at baseline as two different types: normal and thicker
than normal. Best corrected visual acuity (BCVA) and SD-
OCT findings were collected and compared at baseline and
every 6 months thereafter. Active eye tracking technology
ensured that the same scanning location was identified on
follow-up visits. Main outcome measures were visual acuity
changes (Early Treatment Diabetic Retinopathy charts) and
progression of the lamellar macular defect. The influence of
ERM type on disease progression was also evaluated.
Results The patients included 15 males and 19 females with
a mean age of 73 years and mean refraction of −0.25
diopters. The mean follow-up period was 18 months (range
6 to 24 months). BCVA at baseline (±standard deviation)
was 63±6 letters and did not change significantly during the
follow-up period (P00.256). Foveal thickness at baseline,
180±29 μm, was also stable (P00.592). All eyes had an
ERM at baseline. Both thicker and normal ERMs showed
similar functional and morphological evolution during
follow-up with no significant changes. Two LMHs (5.8 %)
developed a full thickness macular hole after 6 and
15 months follow-up respectively.
Conclusions Lamellar macular holes seem to be a stable
macular condition. Vitrectomy should be considered only in
thepresenceofprogressivethinningoffovealthicknessand/or
decrease of visual acuity during the follow-up of the disease.
Keywords Lamellarmacular hole.Spectral domainoptical
coherencetomography.Naturalhistory
Introduction
Lamellar macular holes (LMHs) are distinct clinical entities,
and as originally described by Gass using biomicroscopy
[1], they have a reddish oval appearance. The description
and pathogenesis of LMHs have been better understood
with the advent of optical coherence tomography
(OCT)[2–9] and fundus autofluorescence (FAF) imaging
[10]. With time domain OCT (TD-OCT), LMHs were
described as partial thickness defects of the macula with
an irregular foveal contour and a schisis between inner
and outer retinal layers, but without any defect of the
photoreceptor layer [2–5, 7]. By definition, LMHs are
macular lesions with loss of foveal tissue [7, 9] as
opposed to pseudo-macular holes. Despite specific criteria,
OCT imaging cannot determine with certainty whether or not
lossoftissuehasoccurred.FAFimagingisofgreathelpinthis
Presented in part at the Association for Research in Vision and
Ophthalmology Annual Meeting, Fort Lauderdale, FL, USA, May
2010 and at the 11th Euretina Congress, London, UK, May 2011
This study had no financial support.
The authors have full control of all primary data and they agree to
allow Graefes Archive for Clinical and Experimental Ophthalmology
to review their data if requested.
F. Bottoni (*):A. P. Deiro:A. Giani:C. Orini:M. Cigada:
G. Staurenghi
Eye Clinic, Department of Clinical Science “Luigi Sacco”,
Sacco Hospital, University of Milan,
Via Andrea Verga 8,
20144 Milano, Italy
e-mail: ferdinando.bottoni@fastwebnet.it
Graefes Arch Clin Exp Ophthalmol (2013) 251:467–475
DOI 10.1007/s00417-012-2044-2
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regard. Any foveal defect, including LMHs, that spare the
photoreceptors, may increase the degree of foveal autofluor-
escence (AF) by decreasing the amount of masking macular
pigment. Thus, the presence offoveal AF is always consistent
with a diagnosis of LMH [10].
LMHs might be the result of abortive development of full
thickness macular holes [2–4]. Alternatively, they may rep-
resent a complication of chronic cystoid macular edema [1],
or they may be related to the contraction of the existing
perifoveal epiretinal membrane (ERM)-internal limiting
membrane (ILM) complex [9, 11, 12]. LMH patients com-
monly have relatively good visual acuity (VA), usually 20/
40 or better.
OCT studies related to LMH investigation are mainly
concentrated on the differential diagnosis [7, 9] and on the
results after surgical intervention [12–16]. There is only one
large series recently published on the natural evolution of
LMHs [17]. However in that study, OCTexaminations were
performed by TD-OCT that is inherently limited to 10 μm
axial resolution, and the low acquisition speed limited the
detailed analysis of pathologic changes. By contrast, spec-
tral domain OCT (SD-OCT), with 5- to 7-μm axial resolu-
tion, allows clear detection of the inner segment/outer
segment (IS/OS) line and the external limiting membrane
(ELM), that is the junction between the inner segments and
Muller cells. The purpose of our investigation was to assess
by SD-OCT the natural course of LMHs in a series of
consecutive patients during a mean follow-up of 18 months.
Material and methods
We studied 34 eyes in 34 consecutive patients diagnosed
with a LMH and followed prospectively at Sacco University
Hospital from October 2008 to January 2011. All examina-
tions and investigations adhered to the tenets of the Decla-
ration of Helsinki. This study was approved by the
Institutional Review Board Committee of Milan University
Medical School at Sacco Hospital.
At baseline, each patient underwent a complete ophthal-
mologic examination,including intraocular pressuremeasure-
ment, lens clarity evaluation, refraction, and biomicroscopic
examination of the fovea and vitreous. The best corrected
visual acuity (BCVA) was measured using Early Treatment
Diabetic Retinopathy Study (ETDRS) charts. A combined
confocal scanning laser ophthalmoscope and SD-OCT instru-
ment (Spectralis HRA + OCT, Heidelberg Engineering
GmbH, Heidelberg, Germany) was used for macular exami-
nation.DiagnosisofLMHwasestablishedinthepresenceofa
foveal defect on SD-OCT and corresponding hyperautofluor-
escence on FAF imaging [10]. The OCT definition of “foveal
defect” included 4 criteria: (1) an irregular foveal contour, (2)
a break in the inner fovea, (3) a dehiscence of the inner foveal
retina from the outer retina, and (4) an absence of a full
thickness foveal defect with intact foveal photoreceptors [9].
Incaseofuncertainty,hyperautofluorescence onFAFimaging
was considered decisive (Fig. 1a and b). The size of each
LMH was calculated using the largest diameter recorded in
FAF images.
During the baseline visit, two different types of ERMs
were identified based on OCT images. Normal ERMs
(Fig. 1c) appeared as a thin highly-reflective line immedi-
ately anterior to and separate from the retinal nerve fiber
layer (RNFL). Thicker ERMs (Fig. 1d) appeared as
moderately-reflective material filling the space between the
inner border of the ERM and the RNFL [9]. A complete
posterior vitreous detachment (PVD) was diagnosed using
either the SD-OCT and biomicroscopy. On SD-OCT, the
diagnosis was established when the hyaloid condensation
was visible clearly on the scans. By biomicroscopy, a com-
plete PVD was diagnosed when the Weiss ring was detected.
Patients with current eye disease other than LMH,
opaque media, or refractive error exceeding ± 6 diopters
(D) were excluded. For patients who met the inclusion
criteria, a detailed explanation of the study was provided
at the initial visit, and informed consent was obtained.
Follow-up visits including measurements of BCVA and
SD-OCT evaluations were scheduled every six months.
Confocal scanning laser ophthalmoscopy and SD-OCT by
the Spectralis HRA + OCT provides upto40,000A-scans/sec.
The axial digital resolution is 3.9 μm in tissue and the trans-
versal digital resolution is up to 15 μm (high-resolution mode)
with the superluminescence diode at 870 nm central wave-
length. The instrument combines SD-OCT technology with a
confocal scanning laser ophthalmoscope that provides a refer-
ence fundus image based on infrared and blue reflectance and
blue laser autofluorescence. Using active eye tracking technol-
ogy, the system automatically follows eye movements and
locks each OCT B-scan to the fundus image, ensuring exact
registration. The “AutoRescan” function identifies previous
scan locations and automatically guides the OCT instrument
to scan the same location again for follow-up visits. For the
purpose of this study, the first complete volume scan acquired
at baseline was set as a reference scan. Active real-time eye
tracking and high scanning speed reduce movement artifacts.
For OCTscanning, the software provides an “Automatic Real-
Time” (ART) function to reduce noise and increase image
quality. With ART activated, multiple frames (B-scans) of the
same scanning location are performed during the scanning
process, and images are averaged for noise reduction. In this
study, 20 frames were acquired and averaged for each B-scan
location. For LMH analysis, raster scans of 30°×15° (8.7×
4.3 mm, including the optic disc) and consisting of 19 to 25
line scans were performed. The spacing between the B-scans
rangedfrom119to271μm.Aninternalfixationlightwasused
to center the scanning area on the fovea.
468Graefes Arch Clin Exp Ophthalmol (2013) 251:467–475
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Main outcome measures were VA changes and progres-
sion of the lamellar macular defect. The latter was evaluated
by measuring with software calipers the distance between
the ILM interface and the retinal pigment epithelium at the
thinnest point in the fovea (Fig. 1b). Secondary outcomes
were the influence of ERM type on disease progression and
the correlation between retinal thickness and BCVA at
baseline.
For all computations, commercially available software
was used (R; R Foundation for Statistical Computing,
Vienna, Austria). Changes of VA and OCT findings over
time as well as the influence of ERM type on disease
progression were evaluated using ANOVA for repeated
measures. P<0.05 was considered significant.
Results
Fifteen men and 19 women with a mean age of 73 years
(range, 54 to 87 years) were included in the study. The mean
refraction was −0.25D (range, +2.50D to −5.50D). The
mean follow-up period was 18 months (range, 6 to
24 months). Overall, all patients had at least 6 months of
follow-up, and 31 patients had 12 months, 24 patients had
18 months, and 14 patients had 24 months. The mean LMH
size at baseline was 525 μm (range, 230 to 1010 μm). Four
of the 34 studied cases (12 %) were initially diagnosed as
having LMH only with FAF imaging. All of them showed
an irregular foveal contour and intact foveal photoreceptors
but lacked a clear break in the inner fovea and a dehiscence
of the inner foveal retina from the outer retina (Figs. 2 and
8). After a mean follow-up of 16 months, these four eyes
showed a steady state either functionally and anatomically.
Overall, the mean ± standard deviation BCVA at baseline
was 63±6 letters. After 6, 12, 18, and 24 months, it was 63±
5 letters, 63±6 letters, 64±6 letters, and 64±6 letters re-
spectively. During the follow-up period there was no sign-
ficant change (P00.256, Fig. 3). The foveal thickness at
baseline was 180±29 μm. After 6, 12, 18, and 24 months,
it was 179±27 μm, 175±30 μm, 178±29 μm, and 175±
21 μm respectively. The decrease of foveal thickness from
baseline to 24 months was 3 %, and none of the changes
were statistically significant (P00.592, Fig. 4). We found a
weak correlation between BCVA and thickness of residual
foveal tissue during follow-up (R00.32, P00.000, Fig. 5).
During follow-up, the size of LMH remained stable in 27
eyes (79 %). For the remaining seven eyes, it enlarged in the
largest diameter. In 5 of these 7 eyes, the foveal thickness
did not change; however for two of them the residual outer
retina became thinner.
At baseline, a posterior vitreous detachment was present
in 11 eyes (32 %) as determined by biomicroscopy and
OCT. It developed in four additional eyes during follow-
up. A highly reflective band with the OCT characteristics of
an ERM was identified immediately anterior to the retinal
surface in all cases at baseline. Ten of these were thicker in
appearance in SD-OCT images. A less reflective area was
present between the RNFL and the inner border of the ERM.
Patients with LMHs associated with thicker ERMs had
slightly but not significantly reduced BCVAs at baseline,
Fig. 1 Baseline images of a foveal lesion. a Fundus autofluorescence
image showed a foveal lesion of 330 μm. b The corresponding spectral
domain optical coherence tomography (SD-OCT) revealed only an
irregular foveal contour with intact foveal photoreceptors. Foveal
thickness (arrow) was measured from the retinal pigment epithelium
to the internal limiting membrane. c SD-OCT of a normal epiretinal
membrane (ERM, within circle). d SD-OCT of a thicker ERM with
moderately-reflective material filling the space between the inner bor-
der of the ERM and the retinal nerve fiber layer (within circles)
Graefes Arch Clin Exp Ophthalmol (2013) 251:467–475 469
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60±6 letters, compared with eyes presenting with normal
ERMs, 65±5 letters (P00.149). However, BCVA did not
change significantly during follow-up in either group (P0
0.252; interaction effect P00.564; Fig. 6).
LMHswiththickerERMshadthinnerfovealthicknessesat
baseline, 155.5±33 μm, as compared with eyes presenting
normal ERMs, 190.4±21 μm (P00.003). As with the func-
tional results, the two groups showed similar morphological
evolution during follow-up (interaction effect P00.996) with
no significant changes of foveal thickness (P00.547, Figs. 7,
8, 9 and 10). None of the ERMs changed their appearance
(normal into thicker or vice versa) during follow-up.
Persistent outer foveal hyporeflective defects such as
disruption/interruption of the IS/OS junction were present
at baseline in 3 of the 10 (30 %) LMHs with thicker ERMS.
One eye progressed to a full thickness macular hole after
6 month follow-up (Fig. 11) while the other two eyes
remained stable anatomically and functionally for 24 and
18 months respectively. All of them showed an absent outer
nuclear layer (ONL) at baseline whereas the ELM appeared
Fig. 2 Baseline FAF (a, d, g)
and SD-OCT (b–c, e–f, h–i)
images of 3 cases diagnosed as
having LMH only with FAF
imaging. An irregular foveal
contour and intact foveal pho-
toreceptors are evident. How-
ever, a clear break in the inner
fovea and a dehiscence of the
inner foveal retina from the
outer retina are missing
Fig. 3 Box plot of visual acuity during follow-up. Within boxes: dark
lines, medians; crosses, means
Fig. 4 Box plot of foveal thickness during follow-up. Within boxes:
dark lines, medians; crosses, means
470Graefes Arch Clin Exp Ophthalmol (2013) 251:467–475
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disrupted in only one eye (Fig. 11). By contrast, interruption
of the IS/OS junction was detected at baseline in 3 of the 24
(12.5 %) LMHs with normal ERMS. One eye progressed to
a full thickness macular hole after 15 month follow-up, one
eye remained stable anatomically and functionally
(18 month-follow up) while the last case showed stable
BCVA and reduced foveal thickness after 12 month-follow
up. At baseline, two of these 3 eyes revealed an absent ONL
overlying the IS/OS defect whereas the ELM appeared dis-
rupted in only one eye.
We just mentioned that two LMHs in our series (5.8 %)
developed a full thickness macular hole after 6 and
15 months follow-up respectively. The LMH in the first
patient (Fig. 11) had a thicker ERM, low foveal thickness
(108 μm), and poor BCVA (47 letters) at baseline. The other
patient who developed a full thickness macular hole had a
normal ERM, a baseline foveal thickness of 165 μm, and a
BCVA of 66 letters. In both cases, a PVD was detected and
the BCVA became smaller after the full thickness macular
hole formed. They were successfully repaired with one
surgical procedure that included vitrectomy, peeling of the
ILM, air/fluid exchange with subsequent injection of 20 %
sulfur hexafluoride gas, and strict face-down positioning for
3 to 5 days. Both cases regained a BCVA of 60 and 57
letters respectively on ETDRS charts.
Fellow eyes showed a normal macular appearance in
62 % of the cases, an ERM in 16 % and a LMH in 19 %
(1 fellow eye was highly myopic, 3 %).
Discussion
There is only one OCTstudy, as far as we know, concerning
the natural course of LMHs. Theodossiadis et al. found that
VA was stable in almost 80 % of patients over a follow-up
period of 37.1 months [17]. They also showed that LMH
patients experienced only a 10.3 % decrease of macular
thickness during that time. Our investigation differs from
their study in many aspects, but we share some of their
findings. We used SD-OCT instead of TD-OCT. The former
allows better detection of the outer nuclear layer, the IS/OS
line, and the ELM compared with TD-OCT. Our mean
follow-up period, 18 months, was shorter than theirs; how-
ever, we performed serial SD-OCT examinations every
Fig. 5 Linear regression to assess the correlation between best cor-
rected visual acuity (BCVA) and thickness of residual foveal tissue
during follow-up
Fig. 6 Visual acuity during follow-up in normal and thicker epiretinal
membranes. Values are means ± standard deviations
Fig. 7 Foveal thickness during follow-up in normal and thicker epi-
retinal membranes. Values are means ± standard deviations
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6 months and not only at the baseline and at final examina-
tions. The aim was to follow the evolution of morphological
changes during the follow-up period. The active eye track-
ing technology of the Spectralis has already proved to be
very effective for monitoring the dynamic healing process of
idiopathic macular holes after surgical repair [18]. The ideal
procedure to evaluate continuous changes in macular mor-
phology is to scan the same location at each follow-up visit.
With active eye tracking this is possible because the system
automatically follows eye movements and locks each OCT
B-scan to the fundus image. In our series, for each patient
the first complete volume scan acquired at baseline was then
setasareference.The“AutoRescan”functionoftheinstrument
ensured that the same scanning location was identified by the
tracking program on follow-up visits. The same scanning loca-
tion during follow-up is not related to the location of the
fixation light but to the eye tracking system and its reference
points. The reference points (landmarks) for the eye tracker are
anatomic structures in the confocal scanning laser ophthalmo-
scope fundus image. As long as there is an overlap of the
fundus image for the first and the follow-up examinations that
allows the identification of enough landmarks to align the two
images automatically, then the automatic re-scan is feasible.
There might be a slight variation of the position of the follow-
Fig. 8 Baseline and follow-up
FAF and SD-OCT images of an
86-year-old male patient. (a–c)
Corresponding FAF (a) and
SD-OCT (b, c) baseline images
showed a LMH of 380 μm. (d–
g) SD-OCT after 6 (d), 12 (e),
18 (f) and 24 (g) months of
follow-up. All of the SD-OCT
sections pass through the lines
displayed in the scanning laser
ophthalmoscope infrared image
obtained at baseline (b). A nor-
mal epiretinal membrane was
evident. This patient’s BCVA
changed from 52 (baseline) to
50 (24-month visit) letters on
ETDRS charts. The central fo-
veal thickness remained stable
at 180 μm for 12 months of
follow-up (d, e). It decreased to
172 and 159 μm after 18 (f) and
24 (g) months respectively
Fig. 9 Baseline and follow-up
FAF and SD-OCT images of a
59-year-old male patient. (a–c)
Baseline FAF (a) and SD-OCT
(b, c) images showed a LMH of
1010 μm. (d–g) SD-OCT after
6 (d), 12 (e), 18 (f) and 24 (g)
months of follow-up. A thicker
epiretinal membrane was
detected. The BCVA changed
from 56 (baseline) to 58
(24 month visit) letters on
ETDRS charts. Central foveal
thickness remained stable
throughout follow-up: 134 μm
at baseline (c), 133 μm after
24 months (g). IS/OS junction
line and ELM were still present
at the end of follow-up (g)
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up scans compared to the baseline examination. Therefore
apparent structural changes might also be due to differences
in the scanning position. However, due to the active real-time
eye tracker of the system we used, this uncertainty is much
smaller than the spacing between the B-scans. B-scan spacing
in our series varied from 119 to 271 μm. Since the smallest
LMH diameter was 230 μm, we were reasonably confident of
being within the area of the LMH with follow-up scans.
InadditiontoOCT,weusedFAFimagingfor the diagnosis
of LMHs. Fundus autofluorescence was crucial for the initial
Fig. 10 Baseline and follow-up
FAF and SD-OCT images of a
72-year-old female patient. (a,
b) Fundus autofluorescence (a)
and SD-OCT (b) baseline
images showing a LMH of
340 μm. (c–f) SD-OCT after 6
(c), 12 (d), 18 (e) and 24 (f)
months of follow-up. A normal
epiretinal membrane was evi-
dent. The BCVA remained at 65
letters on ETDRS charts
throughout follow up. Central
foveal thickness decreased from
212 μm at baseline (b), to
199 μm after 24 months (f). IS/
OS junction line and ELM were
always present during follow-up
Fig. 11 Baseline and follow-up
FAF and SD-OCT images of a
73-year-old female patient. (a,
b) Fundus autofluorescence (a)
and SD-OCT (b) baseline
images showing a LMH of
900 μm. A thicker epiretinal
membrane was evident. The
ELM was continuous whereas
the IS/OS junction was disrup-
ted. No outer nuclear layer is
visible centrally. The BCVA
and central foveal thickness
were 47 letters and 108 μm re-
spectively. A full-thickness
macular hole developed after
6 months (c). (d, e) Six months
after surgery, FAF (d) showed a
decreased hyperautofluores-
cence in the macula. SD-OCT
(e) revealed a closed macular
hole with persistent defect of
the IS/OS junction. Best cor-
rected visual acuity regained 60
letters on ETDRS charts
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diagnosis of 4 cases (12 %) that lacked a clear break in the
inner fovea and a dehiscence of the inner foveal retina from
the outer retina, which are important criteria for diagnosis of
LMHs by OCT. Each of these four cases exhibited foveal
hyperautofluorescence suggesting a loss of macular pigment.
In our study, neither mean BCVA and nor the mean foveal
thickness changedsignificantlyduringfollow-up.Thisispart-
ly consistent with the findings of Theodossiadis et al [17]. Of
interest is the marked difference between our two studies with
respect to BCVA and foveal retinal thickness at baseline: 63±
6 letters and 180±29 μm in our series compared with 39.41±
10.09 letters and 93.73±20.2 μm in theirs. It is not possible to
compare TD- and SD-OCT measurements of foveal retinal
thickness. However, Theodossiadis et al. reported that the
baseline thickness as determined by TD-OCTwas 36 % thin-
ner than the 146 μm in normals [17]. By contrast, we found
baseline foveal thickness measured by SD-OCT in LMH
patients was 21 % thinner than the 227 μm in normal subjects
[19]. This finding might simply reflect an earlier diagnosis in
our series; consequently, at earlier diagnosis the foveal outer
retina might be better preserved. This in turn would be con-
sistent with the better presenting VA. A thicker foveal center
with preserved VA might also explain the lack of correlation
we found between BCVA and thickness of residual foveal
tissue throughout follow-up.
We decided to look at foveal thickness rather than LMH
diameter for morphological changes because measurements
of foveal thickness seem to be more reliable. The shape of
each LMH, and consequently the largest diameter as mea-
sured on FAF imaging, may change over time because of
increasing traction exerted by the ERM/ILM complex.
Noteworthy in our series, 7 eyes had an increase in LMH
size during follow-up, but only two of them had a
corresponding decrease of foveal thickness.
Epiretinal membranes were identified in all of our cases at
baseline. This is in agreement with previous reports where
ERMswere reportedin82%[17],89%[9],and100% of cases
[12].TheterminologyusedfortheOCTclassificationofERMs
in our series refers to the first OCT description reported by
Witkin et al [9] where “unusual” appearance ERMs are com-
parabletoourgroupof“thicker”ERMs.Recently,Parolinietal
[20] redefined the two types of ERM as “tractional” (instead of
“normal”) and “dense”(instead of “thicker”) based upon a
clinicopathologic correlation: an important difference between
“tractional/normal” and “dense/thicker” membranes was
shown by the immunolabeling of αlpha-smooth muscle actin
(α-SMA), the expression of which was more frequently dem-
onstrated in “tractional” ERMs than in “dense” ERMs [20].
Since the content of α-SMA in epiretinal membranes was
demonstrated to be correlated with clinical contractility [21],
Parolini et al postulated that “tractional” membranes possess
more potential to generate tractional forces at the retina than
“dense” membranes, resulting in a worse functional and
morphological prognosis. We could not confirm this assump-
tion. In our study, LMHs with thicker ERMs had slightly
reduced mean BCVAs and thinner foveal thicknesses at base-
line, indicating that a different pathogenesis is likely. They
might indeed represent ERMs with trapped vitreous or posteri-
or hyaloid between them and the retina [9, 20]. However, both
thicker and normal ERMs showed similar functional and mor-
phological evolution during follow-up with no significant
changes.Additionally,inthisstudyonlytwoLMHsprogressed
to full thickness macular holes, one of each ERM type.
Defects of the IS/OS junction were detected at baseline in
6 cases (three for each ERM type). Noteworthy, the ONL
was absent in 5 of these eyes while the ELM was disrupted
in only 2 cases (one for each ERM type). Consistent with
previous reports on the healing process of macular hole after
surgery [18], ONL more than ELM seems to be important
for the preservation of the photoreceptor layer. The higher
prevalence of IS/OS defects in the thicker ERM group might
be related to the thinner foveal thickness detected at baseline
or to a different pathogenesis of these ERMs. Further studies
are necessary to assess these assumptions.
Indications for surgical treatment of LMH remain con-
troversial. Witkin et al. believe that there is no proof that
surgical intervention is helpful [15]. By contrast, vitrectomy
with removal of the ERM-ILM and with or without gas
injection was beneficial both functionally and morphologi-
cally [12–14, 16]. Our findings support previous indications
[17] in planning treatment strategies; thus, vitrectomy could
be indicated in LMHs showing a progressive thinning of
foveal thickness and/or VA deterioration during the follow-
up of the natural course of the disease.
Our study has some limitations, including the rather
restricted number of patients and the lengths of follow-up.
However, countering these limitations is that several follow-
up visits were performed for each patient, and axial motion
artifacts in the SD-OCT images were minimized by an
active eye tracking system that allowed the same scanning
location to be imaged on each of the following visits. In
summary, the present study supports previous findings [17]
that LMH is a stable macular condition. An additional new
finding is that the type of ERM does not seem to influence
the progression of the disease.
Financial disclosure(s)
from Heidelberg Engineering, Heidelberg, Germany
Prof. Staurenghi has received lecture fees
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