management of vitreoretinal interface disorders · management of vitreoretinal interface disorders...
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Management of Vitreoretinal
Interface Disorders
Justis P. Ehlers, MDAssistant ProfessorCole Eye InstituteCleveland Clinic
Justis P. Ehlers, MDAssistant ProfessorCole Eye InstituteCleveland Clinic
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Financial Disclosures
● Bioptigen (P)
● Synergetics (P)
● Thrombogenics (C,R,S)
● Genentech (R)
● Regeneron (S)
● Bioptigen (P)
● Synergetics (P)
● Thrombogenics (C,R,S)
● Genentech (R)
● Regeneron (S)
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Off-label Discussion
● Ocriplasmin (Jetrea)
● Indocyanine green
● Brilliant blue
● Zeiss RESCAN 700
● Ocriplasmin (Jetrea)
● Indocyanine green
● Brilliant blue
● Zeiss RESCAN 700
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Case Presentation
● 60 year old female:
● Decreased vision OS
● Moderate distortion OS
● Mild floaters OS
● No flashes
● All for several months
● VA: 20/50
● 60 year old female:
● Decreased vision OS
● Moderate distortion OS
● Mild floaters OS
● No flashes
● All for several months
● VA: 20/50
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Diagnosis
Epiretinal MembraneEpiretinal Membrane
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Epiretinal Membrane
• Etiology
• Idiopathic
• Secondary– Uveitis
– Trauma
– Retinal breaks
– Intraocular surgery, part of the PVR spectrum
– Retinal vascular occlusions
– Others
• Etiology
• Idiopathic
• Secondary– Uveitis
– Trauma
– Retinal breaks
– Intraocular surgery, part of the PVR spectrum
– Retinal vascular occlusions
– Others
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Epiretinal Membrane
• Symptoms:– Asymptomatic
– Metamorphopsia
– Micropsia
– Monocular Diplopia
– Photopsia
– Reduced visual acuity (20/20 to 20/200)
• Symptoms:– Asymptomatic
– Metamorphopsia
– Micropsia
– Monocular Diplopia
– Photopsia
– Reduced visual acuity (20/20 to 20/200)
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Epiretinal Membrane
• Symptoms:– Appearance and visual acuity remain stable in
majority of patients
– 75% of patients maintain VA 20/50 or better
– Over 2 years 10-25% lose one or two lines of VA
• Symptoms:– Appearance and visual acuity remain stable in
majority of patients
– 75% of patients maintain VA 20/50 or better
– Over 2 years 10-25% lose one or two lines of VA
Epiretinal Membrane
• Diagnostic Testing– FA:
• Vascular tortuosity/straightening
• Leakage usually irregular and corresponds to area covered by the membrane
• Facilitates evaluation for concurrent disease
• Diagnostic Testing– FA:
• Vascular tortuosity/straightening
• Leakage usually irregular and corresponds to area covered by the membrane
• Facilitates evaluation for concurrent disease
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Epiretinal Membrane
• Diagnostic Testing– OCT:
• Hyperreflective preretinal band
• Cystic and/or noncystic thickening
• Irregular inner retinal surface consistent with retinal striae/folds
• Evaluate subretinal pathology and integrity of the ellipsoid zone
• Diagnostic Testing– OCT:
• Hyperreflective preretinal band
• Cystic and/or noncystic thickening
• Irregular inner retinal surface consistent with retinal striae/folds
• Evaluate subretinal pathology and integrity of the ellipsoid zone
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Epiretinal Membrane
Example of Noncystic Thickening
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Epiretinal Membrane
Example of Cystic Thickening
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Epiretinal Membrane
• Prognostic Factors– RPE disruption poor prognostic factor
– Long-standing leakage or cystoid edema may be poor prognostic factor
– Membranes following RD may have poorer prognosis
• Prognostic Factors– RPE disruption poor prognostic factor
– Long-standing leakage or cystoid edema may be poor prognostic factor
– Membranes following RD may have poorer prognosis
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Epiretinal Membrane
● Treatment
● Observation
● Pars plana vitrectomy with membrane peeling
● Consider for patients with VA < 20/40 or with other severe symptoms and VA > 20/40
● Treatment
● Observation
● Pars plana vitrectomy with membrane peeling
● Consider for patients with VA < 20/40 or with other severe symptoms and VA > 20/40
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Epiretinal Membrane
● Procedure:
● Pars plana vitrectomy
● Core vitrectomy performed, PVD induced if not present
● Chromovitrectomy may be used to highlight surgical anatomy:
● Indocyanine green (ICG), membrane blue, brilliant blue, triamcinolone, and others
● Differential staining (ERM vs ILM)
• Example: Negative staining ERM with ICG
● Procedure:
● Pars plana vitrectomy
● Core vitrectomy performed, PVD induced if not present
● Chromovitrectomy may be used to highlight surgical anatomy:
● Indocyanine green (ICG), membrane blue, brilliant blue, triamcinolone, and others
● Differential staining (ERM vs ILM)
• Example: Negative staining ERM with ICG
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Epiretinal Membrane
● Procedure● Forceps, membrane scraper, pick, or barbed MVR
blade can be used to elevate an edge from the retinal surface
● ERM peeled gently off the retinal surface, with close attention to removal over the fovea
● Consider ILM Peel:
● Simultaneous
● Sequential
● Reduces ERM recurrence, does not appear to change final visual outcome
● Consider image-assisted/guided surgery with intraoperative OCT (iOCT)
● Procedure● Forceps, membrane scraper, pick, or barbed MVR
blade can be used to elevate an edge from the retinal surface
● ERM peeled gently off the retinal surface, with close attention to removal over the fovea
● Consider ILM Peel:
● Simultaneous
● Sequential
● Reduces ERM recurrence, does not appear to change final visual outcome
● Consider image-assisted/guided surgery with intraoperative OCT (iOCT)
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iOCT and ERM: Exploring a new view
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iOCT and ERM: Exploring a new view
Zeiss RESCAN 700
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Epiretinal Membrane
● Surgical Complications:– Increased nuclear sclerosis
– Retinal tears occur in 1-6% of cases
– Retinal detachment is seen in 1-7%
– Visually significant recurrent ERMs occur in 5%
● Recent study suggested iOCT may change surgical decision-making in > 10% of cases (e.g., more peeling, completed surgical objectives).
● Surgical Complications:– Increased nuclear sclerosis
– Retinal tears occur in 1-6% of cases
– Retinal detachment is seen in 1-7%
– Visually significant recurrent ERMs occur in 5%
● Recent study suggested iOCT may change surgical decision-making in > 10% of cases (e.g., more peeling, completed surgical objectives).
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Epiretinal Membrane
● Recovery/Prognosis:
● Visual recovery takes months
● > 60% of patients improve 2 or more lines
● Many eyes have residual symptoms
● Metamorphopsia improved but typically not resolved
● Recovery/Prognosis:
● Visual recovery takes months
● > 60% of patients improve 2 or more lines
● Many eyes have residual symptoms
● Metamorphopsia improved but typically not resolved
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Case Presentation
● 55 year old male blurred VA OS for 6 months
● Main complaint is distortion
● VA 20/50
● Anterior exam is WNL
● Posterior exam as shown
● 55 year old male blurred VA OS for 6 months
● Main complaint is distortion
● VA 20/50
● Anterior exam is WNL
● Posterior exam as shown
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Case Presentation
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Diagnosis
Vitreomacular TractionVitreomacular Traction
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VMT Syndrome
• Diagnostic Tests
– FA: May show leakage of fluorescein from vessels as well as optic nerve
– OCT: Demonstrates vitreoretinal interface abnormalities. Vitreous traction. Cystic changes in the retina
• Clinical Course:
– Variable
– May be progresssive
– May spontaneously resolve
• Diagnostic Tests
– FA: May show leakage of fluorescein from vessels as well as optic nerve
– OCT: Demonstrates vitreoretinal interface abnormalities. Vitreous traction. Cystic changes in the retina
• Clinical Course:
– Variable
– May be progresssive
– May spontaneously resolve
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Progression ExamplesProgression Examples
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Progression Examples
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VMT
• Treatment:
– Observation
– Intravitreal ocriplasmin
– Pars plana vitrectomy with membrane peeling
– Elevate the posterior hyaloid
– Care to avoid unroofing foveal cyst
• Treatment:
– Observation
– Intravitreal ocriplasmin
– Pars plana vitrectomy with membrane peeling
– Elevate the posterior hyaloid
– Care to avoid unroofing foveal cyst
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Clinical Example 1
20/50 20/40
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Clinical Example 16 weeks later
20/5020/25
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Clinical Example 14 months later
20/2020/20
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Clinical Example 2
20/50
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Clinical Example 21 week later
20/50
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Clinical Example 24 months later
20/50
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Pharmacologic Vitreolysis
● Ocriplasmin (Jetrea, Thrombogenics)
● Approved in 2012 for the treatment of symptomatic vitremacular adhesion (e.g., VMT)
● Proteolytic enzyme with activity against proteins related to the vitreous and vitreoretinal interface (e.g., fibronectin, collagen, and laminin)
● Phase III studies included 464 eyes treated with ocriplasmin and 188 treated with vehicle
● Primary endpoint—resolution of VMA at 28 days
● 26.5% ocriplasmin vs 10.1% vehicle
● First pharmacologic alternative to surgical intervention for VMI condition
● Ocriplasmin (Jetrea, Thrombogenics)
● Approved in 2012 for the treatment of symptomatic vitremacular adhesion (e.g., VMT)
● Proteolytic enzyme with activity against proteins related to the vitreous and vitreoretinal interface (e.g., fibronectin, collagen, and laminin)
● Phase III studies included 464 eyes treated with ocriplasmin and 188 treated with vehicle
● Primary endpoint—resolution of VMA at 28 days
● 26.5% ocriplasmin vs 10.1% vehicle
● First pharmacologic alternative to surgical intervention for VMI condition
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Pharmacologic Vitreolysis
● Ocriplasmin (Jetrea, Thrombogenics)
● Patient selection and counseling critical.
● Advise of potential peri-injection symptoms:
• Blurred vision
• Photopsia
• Alterations in color vision
● Ocriplasmin (Jetrea, Thrombogenics)
● Patient selection and counseling critical.
● Advise of potential peri-injection symptoms:
• Blurred vision
• Photopsia
• Alterations in color vision
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Pharmacologic Vitreolysis
● Ocriplasmin (Jetrea, Thrombogenics)
● Advantages:
● Avoids concerns related to vitrectomy (e.g., anesthesia, increased nuclear sclerosis)
● Office-based procedure
● Potential predictors of response
● Lack of ERM
● Small adhesion width (<1500 microns)
● Phakic
● Age < 65
● Macular hole
● Ocriplasmin (Jetrea, Thrombogenics)
● Advantages:
● Avoids concerns related to vitrectomy (e.g., anesthesia, increased nuclear sclerosis)
● Office-based procedure
● Potential predictors of response
● Lack of ERM
● Small adhesion width (<1500 microns)
● Phakic
● Age < 65
● Macular hole
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Pharmacologic Vitreolysis
● Ocriplasmin (Jetrea, Thrombogenics)
● Possible safety concerns
● Dyschromatopsia
● ERG changes
● Vision changes
● Lens subluxation (animal studies)
● Retinal tear/retinal detachment (higher in vehicle group)
● Ocriplasmin (Jetrea, Thrombogenics)
● Possible safety concerns
● Dyschromatopsia
● ERG changes
● Vision changes
● Lens subluxation (animal studies)
● Retinal tear/retinal detachment (higher in vehicle group)
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Clinical Example 3
20/30
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Clinical Example 32 days later
20/200
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Clinical Example 32 days later
20/200
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Clinical Example 37 days later
20/80
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Clinical Example 31 month later
20/20
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Ocriplasmin: Cole Eye Initial Experience
• Nineteen eyes treated with ocriplasmin for symptomatic VMA
• 9/19 (47%) showed release
• Mean stability in vision
• No eyes lost > 2 lines at final follow-up
• Nineteen eyes treated with ocriplasmin for symptomatic VMA
• 9/19 (47%) showed release
• Mean stability in vision
• No eyes lost > 2 lines at final follow-up
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Ocriplasmin: Cole Eye Initial Experience
• Nineteen eyes treated with ocriplasmin for symptomatic VMA
• 10/19 (52%) showed ellipsoid zone attenuation
• Outer retinal thickness reduced significantly at 1 week but returned to baseline at 3 months.
• This reduction was related to changes in the ellipsoid changes
• Subretinal fluid accumulation was strongly associated with ellipsoid zone loss and symptomatic dyschromatopsia.
• Nineteen eyes treated with ocriplasmin for symptomatic VMA
• 10/19 (52%) showed ellipsoid zone attenuation
• Outer retinal thickness reduced significantly at 1 week but returned to baseline at 3 months.
• This reduction was related to changes in the ellipsoid changes
• Subretinal fluid accumulation was strongly associated with ellipsoid zone loss and symptomatic dyschromatopsia.
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Ocriplasmin: Cole Eye Initial Experience
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Ocriplasmin: Cole Eye Initial Experience
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VMT: Vitrectomy
● Procedure goal
● Release hyaloid traction
● Preserve inner retinal continuity
● Identify residual membranes
● Consider gas tamponade and ILM peeling
● Procedure goal
● Release hyaloid traction
● Preserve inner retinal continuity
● Identify residual membranes
● Consider gas tamponade and ILM peeling
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iOCT and VMT
● Immediate surgical feedback
● Release of traction
● Preservation of inner retinal wall
● Residual membrane
● New discoveries
● Increased subretinal hyporeflectivity
● Immediate surgical feedback
● Release of traction
● Preservation of inner retinal wall
● Residual membrane
● New discoveries
● Increased subretinal hyporeflectivity
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iOCT: Intraoperative Development of FTMHJPE20
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Case Presentation
● 60 y/o male with blindspot OS for 2 months
● VA 20/100 OS
● Anterior exam WNL
● Posterior exam as shown
● 60 y/o male with blindspot OS for 2 months
● VA 20/100 OS
● Anterior exam WNL
● Posterior exam as shown
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Case Presentation
Slide 54
JPE20 Garbo for vitreous schisisVMT for butlerParsley for macula involving RDJustis P. EHlers, 10/16/2011
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Diagnosis
Primary Full-thickness Macular HolePrimary Full-thickness Macular Hole
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Primary Macular Hole
● Treatment options:
● Observation
● Ocriplasmin:
● Small holes with associated VMT
● Vitrectomy with gas tamponade
● Small holes: +/- ILM peeling
● Medium to large holes: ILM peeling
● Treatment options:
● Observation
● Ocriplasmin:
● Small holes with associated VMT
● Vitrectomy with gas tamponade
● Small holes: +/- ILM peeling
● Medium to large holes: ILM peeling
Primary Macular Hole
● Stage Zero: Configuration proposed in eyes at risk for macular hole development
● Fellow eyes with FTMH history
● At least one definitive perifoveal insertion of the posterior hyaloid
● Impending hole: Stage zero hole with associated VMT
● Stage Zero: Configuration proposed in eyes at risk for macular hole development
● Fellow eyes with FTMH history
● At least one definitive perifoveal insertion of the posterior hyaloid
● Impending hole: Stage zero hole with associated VMT
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Primary Macular Hole
• Vitreoretinal surgery:
• Core vitrectomy
• Elevate posterior hyaloid if not separated (may be sufficient with gas bubble for smaller holes)
• Consider internal limiting membrane peel
• May augment visualization with dyes or highlighting agents (e.g., ICG, triamcinolone) Circumferential peel around the hole, “maculorrhexis”
• Vitreoretinal surgery:
• Core vitrectomy
• Elevate posterior hyaloid if not separated (may be sufficient with gas bubble for smaller holes)
• Consider internal limiting membrane peel
• May augment visualization with dyes or highlighting agents (e.g., ICG, triamcinolone) Circumferential peel around the hole, “maculorrhexis”
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Primary Macular Hole
• Vitreoretinal surgery:
• Adjuncts used:
• ILM peeling
• Improves closure rates
• Dye‐assisted visualization
• Autologous serum
• Fibrinogen
• TGF‐beta
• Tamponade: Air, SF6, C3F8, Silicone Oil
• Positioning: Requirement and duration controversial
• Vitreoretinal surgery:
• Adjuncts used:
• ILM peeling
• Improves closure rates
• Dye‐assisted visualization
• Autologous serum
• Fibrinogen
• TGF‐beta
• Tamponade: Air, SF6, C3F8, Silicone Oil
• Positioning: Requirement and duration controversial
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Trans-tamponade OCT: Clinical Management
Postop Day 1
Postop Day 1
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Trans-Tamponade OCT Post-op Day 1
● Scan Classification Trans-Tamponade OCT
● Class 0: No image obtained
● Class 1: Tamponade/Retina Interface
● Class 2: TR Interface + RPE
● Class 3: Retinal architecture
● Class 4: Near-fluid filled quality
● Scan Classification Trans-Tamponade OCT
● Class 0: No image obtained
● Class 1: Tamponade/Retina Interface
● Class 2: TR Interface + RPE
● Class 3: Retinal architecture
● Class 4: Near-fluid filled quality
Class 1 Class 2
Class 4Class 3
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Trans-Tamponade OCT Case 1: Macular hole
Preop
Postop Day 1
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Trans-Tamponade OCT Case 2: Macular hole
Postop Day 1
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Trans-Tamponade OCT Case 3: Macular hole
Postop Hour 1
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Trans-Tamponade OCT Case 4: Macular hole
Postop Day 1
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Primary Macular Hole
• Surgical Complications
• Peripheral retinal breaks and rhegmatogenousretinal detachments
• RD occurs in approximately 2‐10% of cases
• Progression of nuclear sclerosis
• Others include endophthalmitis, increased IOP, progressive cataract
• Surgical Complications
• Peripheral retinal breaks and rhegmatogenousretinal detachments
• RD occurs in approximately 2‐10% of cases
• Progression of nuclear sclerosis
• Others include endophthalmitis, increased IOP, progressive cataract
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Other Macular Holes
● Lamellar Macular Hole
● Unique OCT features
● Partial thickness
● Surgical repair controversial
● Visual outcomes highly variable
● Management options
● Observation
● Vitrectomy with membrane peeling
• +/- ILM peeling and gas tamponade
● Lamellar Macular Hole
● Unique OCT features
● Partial thickness
● Surgical repair controversial
● Visual outcomes highly variable
● Management options
● Observation
● Vitrectomy with membrane peeling
• +/- ILM peeling and gas tamponade
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Clinical Example
20/200
30-50%“Thick”, “Dense” “LHEP”
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Clinical Example
20/200
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Clinical ExamplePost-op Week 1
20/60
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Clinical ExamplePost-op Month 3
20/30
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Other Macular Holes
● Traumatic Macular Hole
● May be associated with choroidal ruptures, subretinal hemorrhage
● Mechanism may be different:
● Direct foveal rupture
● Blunt trauma may result in retinal stretching, thinning and subsequent hole formation
● Direct vitreous traction during injury
● High rate of spontaneous hole closure.
● Traumatic Macular Hole
● May be associated with choroidal ruptures, subretinal hemorrhage
● Mechanism may be different:
● Direct foveal rupture
● Blunt trauma may result in retinal stretching, thinning and subsequent hole formation
● Direct vitreous traction during injury
● High rate of spontaneous hole closure.
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