Reappraisal of Biomicroscopic Classification of Stages of Development of a Macular Hole

TLDR

Age‑related macular holes progress through distinct biomicroscopic stages, with early yellow‑spot to yellow‑ring changes and prehole opacities that often lack retinal receptors, indicating pseudo‑opercula. The study aims to refine the biomicroscopic classification of age‑related macular hole stages and explain why some patients regain visual acuity after vitreous surgery. The authors describe how a semi‑opaque contracted prefoveolar vitreous cortex can conceal early holes, how its separation or tearing reveals stage 2 holes, and how surgical reattachment and gliosis‑driven centripetal foveolar movement can restore anatomy. Surgery that reattaches the retina and promotes centripetal foveolar movement via gliosis can restore near‑normal foveal anatomy and function.

Abstract

To update the biomicroscopic classification and anatomic interpretations of the stages of development of age-related macular hole and provide explanations for the remarkable recovery of visual acuity that occurs in some patients after vitreous surgery.Recent biomicroscopic observations of various stages of macular holes are used to postulate new anatomic explanations for these stages.Biomicroscopic observations include the following: (1) the change from a yellow spot (stage 1-A) to a yellow ring (stage 1-B) during the early stages of foveal detachment is unique to patients at risk of macular hole; (2) the prehole opacity with a small stage 2 hole may be larger than the hole diameter; and (3) the opacity resembling an operculum that accompanies macular holes is indistinguishable from a pseudo-operculum found in otherwise normal fellow eyes.The change from a yellow spot (stage 1-A) to a yellow ring (stage 1-B) is caused primarily by centrifugal displacement of retinal receptors after a dehiscence at the umbo. The hole may be hidden by semiopaque contracted prefoveolar vitreous cortex bridging the yellow ring (stage 1-B occult hole). Stage 1-B occult holes become manifest (stage 2 holes) either after early separation of the contracted prefoveolar vitreous cortex from the retina surrounding a small hole or as an eccentric can-opener-like tear in the contracted prefoveolar vitreous cortex, at the edge of larger stage 2 holes. Most prehole opacities probably contain no retinal receptors (pseudo-opercula). Surgical reattachment of the retina surrounding the hole and centripetal movement of the foveolar retina induced by gliosis may restore foveal anatomy and function to near normal.