The Preferred Practice Pattern^® (PPP) guidelines have been written on the basis of three principles.

• Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
• Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
• Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

In the process of revising this document, a detailed literature search of articles in the English language was conducted on the subject of macular hole for the years 2002 to 2007. The results were reviewed by the Retina Panel and used to prepare the recommendations, which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The ratings of importance are divided into three levels.

• Level A, defined as most important
• Level B, defined as moderately important
• Level C, defined as relevant but not critical

The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The "ratings of strength of evidence" also are divided into three levels.

• Level I includes evidence obtained from at least one properly conducted, well-designed, randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
• Level II includes evidence obtained from the following:
  • Well-designed controlled trials without randomization
  • Well-designed cohort or case-control analytic studies, preferably from more than one center
  • Multiple-time series with or without the intervention
• Level III includes evidence obtained from one of the following:
  • Descriptive studies
  • Case reports
  • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review)

The evidence cited is that which supports the value of the recommendation as something that should be performed to improve the quality of care. The panel believes that it is important to make available the strength of the evidence underlying the recommendation. In this way, readers can appreciate the degree of importance the committee attached to each recommendation and they can understand what type of evidence supports the recommendation.

The ratings of importance and the ratings of strength of evidence are given in bracketed superscripts after each recommendation. For instance, "[A:II]" indicates a recommendation with high importance to clinical care [A], supported by sufficiently rigorous published evidence, though not by a randomized controlled trial [II].

The sections entitled Orientation and Background do not include recommendations; rather they are designed to educate and provide summary background information and rationale for the recommendations that are presented in the Care Process section. A summary of the major recommendations for care is included in Appendix 2.

ENTITY
Macular hole (ICD-9 #362.54)

DISEASE DEFINITION
A macular hole is a full-thickness opening of the neurosensory retina in the center of the fovea.

PATIENT POPULATION
The patient population consists of individuals with idiopathic macular holes.

ACTIVITY
Evaluation and treatment of patients with idiopathic macular holes.

PURPOSE
The purpose of evaluating, diagnosing, and managing patients with macular hole is to identify those who might benefit from macular hole surgery, to inform these patients of the risks and benefits of such surgery, and to perform surgery and follow-up care in appropriate patients to maintain optimal central vision and vision-related quality of life.

GOALS

• Identify patients at risk for macular hole
• Educate high-risk patients about symptoms of macular hole and about the need for periodic follow-up
• Inform patients of the risks and benefits of macular hole surgery
• Manage patients who are at risk for visual loss from macular hole
• Maximize central vision recovery

A macular hole is an anatomic opening in the retina that develops at the fovea. The patient experiences metamorphopsia and decreased visual acuity. Clinical details are available in review articles.^1,2

EPIDEMIOLOGY AND RISK FACTORS
Most investigators believe that macular holes are caused by idiopathic vitreoretinal traction; case series have reported that trauma is responsible for a minority of cases.^3,4

In a case-control study, 72% of the idiopathic macular holes occurred in women and more than 50% of the macular holes occurred in patients 65 to 74 years old.⁵ Only 3% were found to occur in patients under age 55 years.⁵ The 5-year risk for developing a full-thickness macular hole (FTMH), defined as a stage 2, stage 3, or stage 4 macular hole, in the fellow eye of a patient with an FTMH in one eye is about 10% to 15%.^6-11 Fellow eyes with a complete posterior vitreous detachment have been reported to be at lower risk of developing an FTMH. Over a median follow-up period of 33 months (range, 9 to 99 months), Fisher et al reported that no fellow eye with a complete posterior vitreous detachment developed an FTMH.⁹

NATURAL HISTORY
Macular hole formation typically evolves over a period of weeks to months through a series of stages first described by Gass. Macular holes also may develop more rapidly. In both cases, macular holes frequently are detected when the patient's symptoms change abruptly.^12,13 Stages and characteristics of macular holes at each stage are described in Table 1.

Table 1. Stages and Characteristics of Macular Holes.

Recent evidence provided by optical coherence tomography,^14,15,19-22 retinal thickness analyzer,²³ scanning laser ophthalmoscopy,²⁴ and observations made during vitrectomy^25,26 very strongly suggest that anteroposterior vitreomacular traction is responsible for stage 1-A holes. Some of these "pseudocysts" resolve completely.^27,28 A few evolve into a lamellar (partial-thickness) hole. Those pseudocysts that progress to an FTMH do so over a period of weeks to months, often passing through stage 1-B. About 75% of stage 2 macular holes progress to a full-thickness stage 3 or stage 4 macular hole.^10,29-32

The prognosis of untreated FTMHs is poor. Only approximately 5% will have 20/50 visual acuity or better, 55% to 58% will have visual acuity of 20/100 or better, and approximately 40% will have visual acuity of 20/200 or worse.^{8,11,17,33,34} In about 3% to 11% of cases, an FTMH closes spontaneously.^10,11,35-37 If the hole does close, the visual acuity can recover dramatically. The vast majority of patients with untreated macular holes ultimately retain vision in the 20/100 to 20/400 range, with no further loss of central or peripheral vision. The fellow eyes of patients with macular holes have approximately a 10% to 20% risk of developing a macular hole, especially if the hyaloid remains attached.⁸

There are no useful measures to prevent the development of an idiopathic macular hole that are known at this time. Early detection may be important for the fellow eye of affected individuals. They should be educated to assess their central vision for the early changes of metamorphopsia and mild visual decrease, because the prognosis is better with surgical repair at an earlier stage, with a smaller hole, and with better preoperative vision. Optical coherence tomography may be helpful to identify fellow eyes at risk.³⁸

PATIENT OUTCOME CRITERIA
Patient outcome criteria include the following:

• Prevention of visual loss and functional impairment
• Improvement of visual function
• Maintenance of quality of life

DIAGNOSIS
The initial evaluation of a patient with symptoms and signs suggestive of macular hole includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to macular hole.³⁹ Conditions often mistaken for the various stages of macular hole include cystoid macular edema, central serous retinopathy, a subfoveolar druse, lamellar macular hole, epiretinal membrane with pseudohole, and solar maculopathy.^40-42

History
In general, a complete history includes the following elements, although the exact composition varies with the patient's particular problems and needs.

• Duration of symptoms^[A:III]
• Ocular history: glaucoma or other prior eye diseases, injuries, surgery, or other treatments; prolonged gazing at the sun^[A:III]
• Medications that may be related to macular cysts (e.g., systemic niacin, topical prostaglandin analogues)^[A:III]

Examination

• Slit-lamp biomicroscopy of the macula and the vitreoretinal interface^[A:III]

Ancillary Tests
In most cases the diagnosis is made by clinical evaluation. Optical coherence tomography provides useful information on the anatomy of the macular hole and aids in diagnosis and staging.⁴³

MANAGEMENT
In 1991, Kelly and Wendel introduced the use of pars plana vitrectomy to treat macular holes.^44,45 Subsequent studies have verified the benefit of surgery.^2,32,36 The surgical objective is to relieve anteroposterior or tangential vitreomacular traction and to induce glial tissue to bridge and close the hole.^46,47 Management includes informing patients with macular holes of the natural history of the condition, the risk of developing a macular hole in the fellow unaffected eye, the alternatives to surgery, the predictors of good surgical outcome, the associated adverse effects of macular hole surgery, and the benefits of such surgery. The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery,^48,49 and, in particular, of the need for use of intraocular gas or special patient positioning postoperatively.^[A:III] Patients with glaucoma should be informed of the possibility of a perioperative increase in intraocular pressure.^[A:III] The surgeon is responsible for formulating a postoperative care plan and should inform the patient of these arrangements.^{48,49 [A:III]}

Table 2 delineates management recommendations for each of the stages of macular hole.

Table 2. Management Recommendations for Macular Hole.

Surgical Techniques
Pars plana vitrectomy can be performed under local or general anesthesia. Nitrous oxide should not be used near the end of the procedure if general anesthesia is used, because the diffusion of nitrous oxide into the vitreous causes an early decrease in the size of the intraocular gas bubble and, consequently, insufficient retinal tamponade. It is preferable that if general anesthesia is used, nitrous oxide be avoided or turned off before the last hour of the operation. An important early element of the pars plana vitrectomy is to achieve separation of the posterior cortical hyaloid from the retinal surface.

Retinal tamponade is created by different methods at the end of macular hole surgery to help flatten the macular hole and achieve closure. Two early studies found that better results were achieved by creating retinal tamponade with C₃F₈ gas rather than with SF₆ gas.^50,51 A later study found no difference in results.⁵² Closure rates as high as 100% with air tamponade alone after internal limiting membrane (ILM) peeling have been reported.^53,54 Silicone oil has been recommended for patients who cannot be positioned postoperatively or who need to travel in airplanes soon after surgery.^55,56 In one study, 86% of 40 holes were closed using this approach,⁵⁵ but these investigators have recently concluded that the anatomic and visual results are better with gas tamponade.⁵⁷ Using silicone oil requires that the patient undergo a second operation to remove the oil. There is no consensus about the effect on outcome of the choice of gas tamponade.

Some surgeons instruct their patients to maintain a facedown position postoperatively to tamponade the macular hole, but there is no consensus how long they should do so or even whether positioning is necessary at all. Initially 10 to 14 days was recommended, but shorter periods are often used because of the difficulties patients have in maintaining the facedown position. In addition, some series have reported similar closure rates with no positioning^58,59 or with 1-day positioning.^60,61

Another unsettled controversy is peeling of the ILM during surgery. This has been advocated, because the ILM may act as a scaffold for cellular proliferation that can cause persistent vitreomacular traction, failure of the original surgery, or late reopening of initially successfully closed holes.⁶² Closure rates between 88% and 100% and median postoperative visual acuity as good as 20/40 have been reported with ILM peeling.^53,54,63-68 However, there are no randomized controlled studies to prove the benefit of ILM peeling, and there are many reports of similar results without peeling. Current evidence is inconclusive. In a retrospective comparative study, there was no statistical difference in successful hole closure or postoperative visual improvement between patients who underwent preretinal/ILM peeling and those who did not.⁶⁹

Indocyanine green (ICG), trypan blue, other dyes, or triamcinolone allow visualization of the ILM during surgery, facilitating its removal.^70-74 There have been reports of toxicity to the retinal pigment epithelium with the use of ICG dye.^73,75-79 The current evidence is inconclusive to recommend for or against the use of ICG, trypan blue, other dyes, or triamcinolone during surgery.

Intraoperative adjutants such as transforming growth factor-b2,^80-83 serum,^84-87 an absorbable partially cross-linked gelatin (collagen) plug,⁸⁸ thrombin-activated fibrinogen,⁶⁵ plasmin,^89,90 thrombin,^65,91 and a plasma-thrombin mixture⁹² have been studied. While initial reports suggested possible value, at this time there is no convincing evidence that any intraoperative adjuvant improves the closure of the macular holes.

Outcomes of Surgery
Two reports from multicenter randomized controlled trials provide evidence about the efficacy of surgery compared with observation for FTMH.^32,36 Freeman and colleagues studied patients with stage 3 and stage 4 macular holes and reported a benefit in closure rate and final visual acuity with surgery.³⁶ However, the same study group's results with stage 2 macular holes did not find a benefit.³² Nevertheless, the consensus of the vitreoretinal community is to recommend surgery for a stage 2 macular hole, not only because the visual results are probably better, but also to prevent the further visual loss associated with progression to a stage 3 or stage 4 macular hole.

One randomized controlled trial studied patients with stage 1 macular holes; all participants had an FTMH in their fellow eye.²⁷ In the observation group, 14 of 35 eyes (40%) progressed to FTMH, while 10 of 27 eyes (37%) in the group randomized to vitrectomy progressed (P=0.81). Postoperatively, 33% of the surgery group had a visual acuity of 20/80 or worse compared with 20% of the observation group. The small number of participants limited the power of the study to detecting only large treatment effects (30%). Currently, with the increased imaging capabilities offered by optical coherence tomography, the value of preventative vitrectomy has resurfaced; no trial or comprehensive series has established the indications for such surgery, however.⁹³

The current anatomic success rate of vitreous surgery for FTMH as reported in nonrandomized studies is approximately 80% to 100%.^{53,54,63,66,71,94-100} If the initial surgery fails, 80% to 100% of holes can be closed with good visual results with additional surgery.^101-104 The likelihood of recovering visual acuity of 20/40 or better ranges from approximately 25% to 40%.^{68,94,98,105-108}

Measures of patient satisfaction after surgery conform to the visual and anatomic results.^98,106,109 Visual quality of life, assessed by the National Eye Institute Visual Function Questionnaire 25, has been reported to improve following surgery for idiopathic macular hole; the improvement was not correlated with improved postoperative visual acuity.¹¹⁰

Predictors of Visual Results
In case series, many authors have reported better closure rates and better final visual acuities if the duration of symptoms is less than 6 months.^{45,53,96,111-113} Findings from case series indicate that a macular hole that has been present for more than 2 or 3 years can be closed, but the success rate is lower (63%) than it is for a macular hole of shorter duration, and the patient is unlikely to derive as much visual benefit from surgery.^111,114

Some studies have found that if a macular hole is larger than 300 to 400 microns in diameter, the closure rate is reduced, and even if the hole can be closed, the final visual acuity is often not good.^{54,97,115-118}

Patients who have had two failed surgeries for a macular hole generally derive little or no visual benefit, even if a third surgery closes the hole. However, in a series of 16 patients, the mean visual acuity improved from 20/80 to 20/40 (P=0.003) if one of the previous surgeries was at least temporarily successful.¹¹⁹

Complications of Surgery

• Cataract:
  The 3-year incidence of clinically significant cataract after surgery is at least 75%.^120-123 Because of this high incidence, some surgeons have advocated combining macular hole surgery with phacoemulsification and placement of an intraocular lens.^58,124-126 Such a procedure not only eliminates the need for two operations; it may also allow a more complete gas fill.^58,124 The potential complications of combining cataract surgery with vitrectomy include hypotony and intraocular lens iris capture, and it may increase the risk of macular edema in selected patients. Up to 10% of successfully closed macular holes later reopen.^127-132 Reopening after cataract surgery has been reported, but most believe that uncomplicated cataract surgery does not increase the risk of reopening.^125,126
• Retinal tears:
  Intraoperative retinal tears, most commonly located inferiorly, have been reported in 3% to 17% of macular hole operations.^{53,95,130,133-135}
• Retinal detachment:
  Postoperative retinal detachment has been reported in up to 14% of cases, but most series report an incidence of 1% to 5%.^{53,58,65,69,71,95,121,130,133} The detachment is typically located inferiorly and caused by small flap tears at the posterior vitreous base. Fortunately, most detachments can be repaired without reopening of the hole.¹³⁵
• Visual field loss:
  Up to 20% of patients note permanent temporal visual field loss after macular hole surgery,^136-140 which may be caused by mechanical or dehydration injury to the retina from air streaming from the infusion cannula toward the retina during the air-fluid exchange.¹⁴¹ Visual field loss potentially can be reduced by secure closure of the sclerotomies to minimize air flow through the sclerotomies during the air-fluid exchange, by leaving a large puddle of fluid posteriorly until the final aspiration,¹⁴² by humidifying the air,¹⁴³ or by using a low air pressure during air-fluid exchange.^144,145
• Endophthalmitis:
  Endophthalmitis has been reported in less than 0.05% of vitrectomies including after macular hole surgery.^130,131
• Retinal tamponade:
  Patients who have retinal tamponade achieved by an intravitreal gas bubble should avoid air travel, because bubble expansion at altitude causes increased intraocular pressure that could risk arterial occlusion.

FOLLOW-UP
Patients who have surgery are usually examined postoperatively within 1 or 2 days and again approximately 1 to 2 weeks after surgery.^[A:III] The frequency and timing of subsequent postoperative visits varies, depending on the outcome of surgery and the patient's symptoms. Components of the follow-up examination should include the following:

• Interval history, including new symptoms^[A:III]
• Measurement of intraocular pressure^[A:III]
• Slit-lamp biomicroscopy of the retina and indirect binocular ophthalmoscopy to evaluate the peripheral retina^[A:III]

Optical coherence tomography is helpful to document the macular anatomy.

In the absence of symptoms, patients with stage 1 macular holes should be seen every 4 to 6 months for follow-up. Patients with stage 2 holes, who have not had surgery, should be seen every 4 to 8 months. Patients who have had a macular hole in one eye should be informed that there is a 10% to 15% chance over a period of 5 years of macular hole formation in the fellow eye if no posterior vitreous detachment is present and a 2% chance if posterior vitreous detachment is present.^{6,8-11,146 [A:III]}

PROVIDER
Diagnosis and management of macular hole requires special expertise and skills and specialized equipment to detect alterations in the retina and to select, perform, and monitor the appropriate treatment regimen. Consultation with or referral to an ophthalmologist who has expertise or experience in managing this condition may be desirable.

The performance of certain diagnostic procedures may be delegated to appropriately trained and supervised personnel. However, the interpretation of results and the medical and surgical management of macular hole require the medical training, clinical judgment, and experience of an ophthalmologist.

COUNSELING/REFERRAL
Patients should be informed to notify their ophthalmologist promptly if they have symptoms such as an increase in floaters, a loss of visual field, or a decrease in visual acuity.^{147-149 [A:II]} Patients should be informed that air travel, high altitudes, or general anesthesia with nitrous oxide should be avoided until the gas tamponade is nearly completely gone.^[A:III] Vision rehabilitation restores functional ability^{150 [A:I]} and patients with functionally limiting postoperative visual impairment should be referred for vision rehabilitation and social services.^{151 [A:III]} More information on vision rehabilitation, including materials for patients, is available at http://www.aao.org/smartsight.

APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA

Providing quality care
is the physician's foremost ethical obligation, and is
the basis of public trust in physicians.
AMA Board of Trustees, 1986

Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of the patient. The discussion that follows characterizes the core elements of such care.

The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest feasible level, consistent with the needs of patients, through training and continuing education. The ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or through referral to appropriate persons and facilities that will provide such care, and he or she supports activities that promote health and prevent disease and disability.

The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The ophthalmologist respects the dignity and integrity of his or her patients, and does not exploit their vulnerability.

Quality ophthalmic care has the following optimal attributes, among others.

• The essence of quality care is a meaningful partnership relationship between patient and physician. The ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure their meaningful participation (appropriate to their unique physical, intellectual and emotional state) in decisions affecting their management and care, to improve their motivation and compliance with the agreed plan of treatment, and to help alleviate their fears and concerns.
• The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the urgency and nature of the patient's condition and unique needs and desires.
• The ophthalmologist carries out only those procedures for which he or she is adequately trained, experienced and competent, or, when necessary, is assisted by someone who is, depending on the urgency of the problem and availability and accessibility of alternative providers.
• Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be described as follows.
  • The ophthalmologist treats patients with due regard to timeliness, appropriateness and his or her own ability to provide such care.
  • The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative patient care.
  • When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and procedures for obtaining it.
  • The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications of the person to whom the referral is made, and access and availability.
  • The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other medical or surgical problem. Consultants are suggested for their skill, competence and accessibility. They receive as complete and accurate an accounting of the problem as necessary to provide efficient and effective advice or intervention, and in turn respond in an adequate and timely manner.
  • The ophthalmologist maintains complete and accurate medical records.
  • On appropriate request, the ophthalmologist provides and full and accurate rendering of the patient's records in his or her possession.
  • The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective manner and takes appropriate actions.
  • The ophthalmologist and those who assist in providing care identify themselves and their profession.
  • For patients whose conditions fail to respond to treatment and for whom further treatment is unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and social services, and referral as appropriate and accessible.
• Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately conversant with the patient's condition by collecting pertinent historical information and performing relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks, benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks and benefits of no treatment.
• The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its demonstrated safety and efficacy.
• The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and assessing his or her personal performance in relation to established standards, and by revising or altering his or her practices and techniques appropriately.
• The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate professional channels, knowledge gained through clinical research and practice. This includes alerting colleagues of instances of unusual or unexpected rates of complications and problems related to new drugs, devices or procedures.
• The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with potential ocular and systemic complications requiring immediate attention.
• The ophthalmologist also provides ophthalmic care in a manner that is cost effective without unacceptably compromising accepted standards of quality.

Reviewed by: Council
Approved by: Board of Trustees
October 12, 1988

2^nd Printing: January 1991
3^rd Printing: August 2001
4^th Printing: July 2005

APPENDIX 2. SUMMARY OF MAJOR RECOMMENDATIONS FOR CARE

DIAGNOSIS
The initial evaluation of a patient with symptoms and signs suggestive of macular hole includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to macular hole.¹ Conditions often mistaken for the various stages of macular hole include cystoid macular edema, central serous retinopathy, a subfoveolar druse, lamellar macular hole, epiretinal membrane with pseudohole, and solar maculopathy.^2-4

History
In general, a complete history includes the following elements, although the exact composition varies with the patient's particular problems and needs.

• Duration of symptoms^[A:III]
• Ocular history: glaucoma or other prior eye diseases, injuries, surgery, or other treatments; prolonged gazing at the sun^[A:III]
• Medications that may be related to macular cysts (e.g., systemic niacin, topical prostaglandin analogues)^[A:III]

Examination

• Slit-lamp biomicroscopy of the macula and the vitreoretinal interface^[A:III]

MANAGEMENT
Table 2 delineates management recommendations for each of the stages of macular hole.

Table 2. Management Recommendations for Macular Hole.

The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery,^8,9 and, in particular, of the need for use of intraocular gas or special patient positioning postoperatively.^[A:III] Patients with glaucoma should be informed of the possibility of a perioperative increase in intraocular pressure.^[A:III] The surgeon is responsible for formulating a postoperative care plan and should inform the patient of these arrangements.^{8,9 [A:III]}

FOLLOW-UP
Components of the follow-up examination should include the following:

• Interval history, including new symptoms^[A:III]
• Measurement of intraocular pressure^[A:III]
• Slit-lamp biomicroscopy of the retina and indirect binocular ophthalmoscopy to evaluate the peripheral retina^[A:III]

Optical coherence tomography is helpful to document the macular anatomy.

Patients who have had a macular hole in one eye should be informed that there is a 10% to 15% chance over a period of 5 years of macular hole formation in the fellow eye if no posterior vitreous detachment is present and a 2% chance if posterior vitreous detachment is present.^{10-15 [A:III]}

COUNSELING/REFERRAL
Patients should be informed to notify their ophthalmologist promptly if they have symptoms such as an increase in floaters, a loss of visual field, or a decrease in visual acuity.^{16-18 [A:II]} Patients should be informed that air travel, high altitudes, or general anesthesia with nitrous oxide should be avoided until the gas tamponade is nearly completely gone.^[A:III] Vision rehabilitation restores functional ability^{19 [A:I]} and patients with functionally limiting postoperative visual impairment should be referred for vision rehabilitation and social services.^{20 [A:III]} More information on vision rehabilitation, including materials for patients, is available at http://www.aao.org/smartsight.

1. American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern^® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; 2005. Available at: http://www.aao.org/ppp.
2. Ho AC, Guyer DR, Fine SL. Macular hole. Surv Ophthalmol 1998;42:393-416.
3. Gass JD, Joondeph BC. Observations concerning patients with suspected impending macular holes. Am J Ophthalmol 1990;109:638-46.
4. Smiddy WE, Gass JD. Masquerades of macular holes. Ophthalmic Surg 1995;26:16-24.
5. de Bustros S. Vitrectomy for Prevention of Macular Hole Study Group. Vitrectomy for prevention of macular holes. Results of a randomized multicenter clinical trial. Ophthalmology 1994;101:1055-9; discussion 1060.
6. Kim JW, Freeman WR, Azen SP, et al. Vitrectomy for Macular Hole Study Group. Prospective randomized trial of vitrectomy or observation for stage 2 macular holes. Am J Ophthalmol 1996;121:605-14.
7. Freeman WR, Azen SP, Kim JW, et al. The Vitrectomy for Treatment of Macular Hole Study Group. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. Arch Ophthalmol 1997;115:11-21.
8. American Academy of Ophthalmology. Policy Statement. Pretreatment Assessment: Responsibilities of the Ophthalmologist. San Francisco, CA: American Academy of Ophthalmology; 2006. Available at: http://one.aao.org/CE/PracticeGuidelines/ClinicalStatements.aspx.
9. American Academy of Ophthalmology. Policy Statement. An Ophthalmologist's Duties Concerning Postoperative Care. San Francisco, CA: American Academy of Ophthalmology; 2006. Available at: http://one.aao.org/CE/PracticeGuidelines/ClinicalStatements.aspx.
10. Ezra E, Wells JA, Gray RH, et al. Incidence of idiopathic full-thickness macular holes in fellow eyes. A 5-year prospective natural history study. Ophthalmology 1998;105:353-9.
11. Akiba J, Quiroz MA, Trempe CL. Role of posterior vitreous detachment in idiopathic macular holes. Ophthalmology 1990;97:1610-3.
12. Lewis ML, Cohen SM, Smiddy WE, Gass JD. Bilaterality of idiopathic macular holes. Graefes Arch Clin Exp Ophthalmol 1996;234:241-5.
13. Fisher YL, Slakter JS, Yannuzzi LA, Guyer DR. A prospective natural history study and kinetic ultrasound evaluation of idiopathic macular holes. Ophthalmology 1994;101:5-11.
14. Guyer DR, de Bustros S, Diener-West M, Fine SL. Observations on patients with idiopathic macular holes and cysts. Arch Ophthalmol 1992;110:1264-8.
15. Chew EY, Sperduto RD, Hiller R, et al. Clinical course of macular holes: the Eye Disease Case-Control Study. Arch Ophthalmol 1999;117:242-6.
16. Dayan MR, Jayamanne DG, Andrews RM, Griffiths PG. Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment? Eye 1996;10:456-8.
17. Byer NE. Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology 1994;101:1503-14.
18. Smiddy WE, Michels RG, de Bustros S, et al. Histopathology of tissue removed during vitrectomy for impending idiopathic macular holes. Am J Ophthalmol 1989;108:360-4.
19. Stelmack JA, Tang XC, Reda DJ, et al, LOVIT Study Group. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126:608-17.
20. American Academy of Ophthalmology Vision Rehabilitation Committee. Preferred Practice Pattern^® Guidelines. Vision Rehabilitation for Adults. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.

Basic and Clinical Science Course
Retina and Vitreous (Section 12, 2008-2009)

Eye Fact Sheets
Macular Hole (2005)

Focal Points
Practical Management of Diabetic Retinopathy (2003)
Optical Coherence Tomography in the Management of Retinal Disorders (2006)

LEO: Clinical Update Course DVD-ROM
Retina (2006)

Ophthalmic Technology Assessment
Surgical Management of Macular Holes (2001; reviewed for currency 2006)

Preferred Practice Pattern
Comprehensive Adult Medical Eye Evaluation (2005)

Recommendations of Care Ratings
Care Process Ratings:

• Level A: Most important to the care process
• Level B: Moderately important to the care process
• Level C: Relevant but not critical to the care process

Strength of Evidence Ratings:

• Level I: Randomized controlled trial or meta-analyses
• Level II: Controlled trials, cohort, or case-control studies
• Level III: Descriptive studies or case reports

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31. Kim JW, Freeman WR, Azen SP, et al. Vitrectomy for Macular Hole Study Group. Prospective randomized trial of vitrectomy or observation for stage 2 macular holes. Am J Ophthalmol 1996;121:605-14.
32. Hikichi T, Trempe CL. Risk of decreased visual acuity in full-thickness idiopathic macular holes. Am J Ophthalmol 1993;116:708-12.
33. Morgan CM, Schatz H. Idiopathic macular holes. Am J Ophthalmol 1985;99:437-44.
34. Hikichi T, Akiba J, Trempe CL. Effect of the vitreous on the prognosis of full-thickness idiopathic macular hole. Am J Ophthalmol 1993;116:273-8.
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37. Chan A, Duker JS, Schuman JS, Fujimoto JG. Stage 0 macular holes: observations by optical coherence tomography. Ophthalmology 2004;111:2027-32.
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40. Gass JD, Joondeph BC. Observations concerning patients with suspected impending macular holes. Am J Ophthalmol 1990;109:638-46.
41. Smiddy WE, Gass JD. Masquerades of macular holes. Ophthalmic Surg 1995;26:16-24.
42. McDonald HR, Williams GA, Scott IU, et al. Laser scanning imaging for macular disease: a report by the American Academy of Ophthalmology. Ophthalmology 2007;114:1221-8.
43. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-9.
44. Wendel RT, Patel AC, Kelly NE, et al. Vitreous surgery for macular holes. Ophthalmology 1993;100:1671-6.
45. Rosa RH Jr, Glaser BM, de la Cruz Z, Green WR. Clinicopathologic correlation of an untreated macular hole and a macular hole treated by vitrectomy, transforming growth factor-beta 2, and gas tamponade. Am J Ophthalmol 1996;122:853-63.
46. Madreperla SA, Geiger GL, Funata M, et al. Clinicopathologic correlation of a macular hole treated by cortical vitreous peeling and gas tamponade. Ophthalmology 1994;101:682-6.
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50. Thompson JT, Glaser BM, Sjaarda RN, et al. Effects of intraocular bubble duration in the treatment of macular holes by vitrectomy and transforming growth factor-beta 2. Ophthalmology 1994;101:1195-200.
51. Mulhern MG, Cullinane A, Cleary PE. Visual and anatomical success with short-term macular tamponade and autologous platelet concentrate. Graefes Arch Clin Exp Ophthalmol 2000;238:577-83.
52. Park DW, Sipperley JO, Sneed SR, et al. Macular hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology 1999;106:1392-7; discussion 1397-8.
53. Brooks HL Jr. Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology 2000;107:1939-48; discussion 1948-9.
54. Goldbaum MH, McCuen BW, Hanneken AM, et al. Silicone oil tamponade to seal macular holes without position restrictions. Ophthalmology 1998;105:2140-8.
55. Pertile G, Claes C. Silicone oil vs. gas for the treatment of full-thickness macular hole. Bull Soc Belge Ophtalmol 1999;274:31-6.
56. Lai JC, Stinnett SS, McCuen BW. Comparison of silicone oil versus gas tamponade in the treatment of idiopathic full-thickness macular hole. Ophthalmology 2003;110:1170-4.
57. Tornambe PE, Poliner LS, Grote K. Macular hole surgery without face-down positioning. A pilot study. Retina 1997;17:179-85.
58. Tranos PG, Peter NM, Nath R, et al. Macular hole surgery without prone positioning. Eye 2007;21:802-6.
59. Isomae T, Sato Y, Shimada H. Shortening the duration of prone positioning after macular hole surgery- comparison between 1-week and 1-day prone positioning. Jpn J Ophthalmol 2002;46:84-8.
60. Simcock PR, Scalia S. Phacovitrectomy without prone posture for full thickness macular holes. Br J Ophthalmol 2001;85:1316-9.
61. Eckardt C, Eckardt U, Groos S, et al. Removal of the internal limiting membrane in macular holes. Clinical and morphological findings. Ophthalmologe 1997;94:545-51.
62. Tognetto D, Grandin R, Sanguinetti G, et al. Internal limiting membrane removal during macular hole surgery: results of a multicenter retrospective study. Ophthalmology 2006;113:1401-10.
63. Lewis JM, Park I, Ohji M, et al. Diamond-dusted silicone cannula for epiretinal membrane separation during vitreous surgery. Am J Ophthalmol 1997;124:552-4.
64. Olsen TW, Sternberg P Jr, Capone A Jr, et al. Macular hole surgery using thrombin-activated fibrinogen and selective removal of the internal limiting membrane. Retina 1998;18:322-9.
65. Mester V, Kuhn F. Internal limiting membrane removal in the management of full-thickness macular holes. Am J Ophthalmol 2000;129:769-77.
66. Haritoglou C, Gass CA, Schaumberger M, et al. Long-term follow-up after macular hole surgery with internal limiting membrane peeling. Am J Ophthalmol 2002;134:661-666f.
67. Smiddy WE, Feuer W, Cordahi G. Internal limiting membrane peeling in macular hole surgery. Ophthalmology 2001;108:1471-8.
68. Margherio RR, Margherio AR, Williams GA, et al. Effect of perifoveal tissue dissection in the management of acute idiopathic full-thickness macular holes. Arch Ophthalmol 2000;118:495-8.
69. Tognetto D, Zenoni S, Sanguinetti G, et al. Staining of the internal limiting membrane with intravitreal triamcinolone acetonide. Retina 2005;25:462-7.
70. Da Mata AP, Burk SE, Foster RE, et al. Long-term follow-up of indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for idiopathic macular hole repair. Ophthalmology 2004;111:2246-53.
71. Beutel J, Dahmen G, Ziegler A, Hoerauf H. Internal limiting membrane peeling with indocyanine green or trypan blue in macular hole surgery: a randomized trial. Arch Ophthalmol 2007;125:326-32.
72. Kwok AK, Li WW, Pang CP, et al. Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome. Am J Ophthalmol 2001;132:178-83.
73. Shah GK, Rosenblatt BJ, Blinder KJ, et al. Triamcinolone-assisted internal limiting membrane peeling. Retina 2005;25:972-5.
74. Haritoglou C, Gandorfer A, Gass CA, et al. Indocyanine green-assisted peeling of the internal limiting membrane in macular hole surgery affects visual outcome: a clinicopathologic correlation. Am J Ophthalmol 2002;134:836-41.
75. Engelbrecht NE, Freeman J, Sternberg P Jr, et al. Retinal pigment epithelial changes after macular hole surgery with indocyanine green-assisted internal limiting membrane peeling. Am J Ophthalmol 2002;133:89-94.
76. Gandorfer A, Haritoglou C, Gass CA, et al. Indocyanine green-assisted peeling of the internal limiting membrane may cause retinal damage. Am J Ophthalmol 2001;132:431-3.
77. Sippy BD, Engelbrecht NE, Hubbard GB, et al. Indocyanine green effect on cultured human retinal pigment epithelial cells: implication for macular hole surgery. Am J Ophthalmol 2001;132:433-5.
78. Horio N, Horiguchi M. Effect on visual outcome after macular hole surgery when staining the internal limiting membrane with indocyanine green dye. Arch Ophthalmol 2004;122:992-6.
79. Smiddy WE, Glaser BM, Thompson JT, et al. Transforming growth factor-beta 2 significantly enhances the ability to flatten the rim of subretinal fluid surrounding macular holes. Preliminary anatomic results of a multicenter prospective randomized study. Retina 1993;13:296-301.
80. Thompson JT, Smiddy WE, Williams GA, et al. Comparison of recombinant transforming growth factor-beta-2 and placebo as an adjunctive agent for macular hole surgery. Ophthalmology 1998;105:700-6.
81. Glaser BM, Michels RG, Kuppermann BD, et al. Transforming growth factor-beta 2 for the treatment of full-thickness macular holes. A prospective randomized study. Ophthalmology 1992;99:1162-73.
82. Kozy DW, Maberley AL. Closure of persistent macular holes with human recombinant transforming growth factor-beta 2. Can J Ophthalmol 1996;31:179-82.
83. Banker AS, Freeman WR, Azen SP, Lai MY. Vitrectomy for Macular Hole Study Group. A multicentered clinical study of serum as adjuvant therapy for surgical treatment of macular holes. Arch Ophthalmol 1999;117:1499-502.
84. Kusaka S, Sakagami K, Kutsuna M, Ohashi Y. Treatment of full-thickness macular holes with autologous serum. Jpn J Ophthalmol 1997;41:332-8.
85. Liggett PE, Skolik DS, Horio B, et al. Human autologous serum for the treatment of full-thickness macular holes. A preliminary study. Ophthalmology 1995;102:1071-6.
86. Melberg NS, Meredith TA. Success with macular hole surgery. Ophthalmology 1996;103:200-1.
87. Peyman GA, Daun M, Greve MD, et al. Surgical closure of macular hole using an absorbable macular plug. Int Ophthalmol 1997;21:87-91.
88. Margherio AR, Margherio RR, Hartzer M, et al. Plasmin enzyme-assisted vitrectomy in traumatic pediatric macular holes. Ophthalmology 1998;105:1617-20.
89. Trese MT, Williams GA, Hartzer MK. A new approach to stage 3 macular holes. Ophthalmology 2000;107:1607-11.
90. Vine AK, Johnson MW. Thrombin in the management of full thickness macular holes. Retina 1996;16:474-8.
91. Blumenkranz MS, Ohana E, Shaikh S, et al. Adjuvant methods in macular hole surgery: intraoperative plasma-thrombin mixture and postoperative fluid-gas exchange. Ophthalmic Surg Lasers 2001;32:198-207.
92. Bainbridge J, Herbert E, Gregor Z. Macular holes: vitreoretinal relationships and surgical approaches. Eye 2008;22:1301-9.
93. Haritoglou C, Reiniger IW, Schaumberger M, et al. Five-year follow-up of macular hole surgery with peeling of the internal limiting membrane: update of a prospective study. Retina 2006;26:618-22.
94. Paques M, Chastang C, Mathis A, et al. Platelets in Macular Hole Surgery Group. Effect of autologous platelet concentrate in surgery for idiopathic macular hole: results of a multicenter, double-masked, randomized trial. Ophthalmology 1999;106:932-8.
95. Kang HK, Chang AA, Beaumont PE. The macular hole: report of an Australian surgical series and meta-analysis of the literature. Clin Experiment Ophthalmol 2000;28:298-308.
96. Kobayashi H, Kobayashi K. Correlation of quantitative three-dimensional measurements of macular hole size with visual acuity after vitrectomy. Graefes Arch Clin Exp Ophthalmol 1999;237:283-8.
97. Pearce IA, Branley M, Groenewald C, et al. Visual function and patient satisfaction after macular hole surgery. Eye 1998;12 ( Pt 4):651-8.
98. Smiddy WE, Pimentel S, Williams GA. Macular hole surgery without using adjunctive additives. Ophthalmic Surg Lasers 1997;28:713-7.
99. Gaudric A, Paques M, Massin P, et al. Use of autologous platelet concentrate in macular hole surgery: report of 77 cases. Dev Ophthalmol 1997;29:30-5.
100. Ezra E, Aylward WG, Gregor ZJ. Membranectomy and autologous serum for the retreatment of full-thickness macular holes. Arch Ophthalmol 1997;115:1276-80.
101. Johnson RN, McDonald HR, Schatz H, Ai E. Outpatient postoperative fluid-gas exchange after early failed vitrectomy surgery for macular hole. Ophthalmology 1997;104:2009-13.
102. Ie D, Glaser BM, Thompson JT, et al. Retreatment of full-thickness macular holes persisting after prior vitrectomy. A pilot study. Ophthalmology 1993;100:1787-93.
103. Smiddy WE, Sjaarda RN, Glaser BM, et al. Reoperation after failed macular hole surgery. Retina 1996;16:13-8.
104. Jaycock PD, Bunce C, Xing W, et al. Outcomes of macular hole surgery: implications for surgical management and clinical governance. Eye 2005;19:879-84.
105. Polk TD, Smiddy WE, Flynn HW Jr. Bilateral visual function after macular hole surgery. Ophthalmology 1996;103:422-6.
106. Valldeperas X, Wong D. Is it worth reoperating on macular holes? Ophthalmology 2008;115:158-63.
107. Hillenkamp J, Kraus J, Framme C, et al. Retreatment of full-thickness macular hole: predictive value of optical coherence tomography. Br J Ophthalmol 2007;91:1445-9.
108. Hikichi T, Onodera A, Ishiko S, et al. Stereo acuity in patients with unilateral macular hole and after unilateral macular hole surgery. Graefes Arch Clin Exp Ophthalmol 2001;239:128-32.
109. Hirneiss C, Neubauer AS, Gass CA, et al. Visual quality of life after macular hole surgery: outcome and predictive factors. Br J Ophthalmol 2007;91:481-4.
110. Thompson JT, Sjaarda RN, Lansing MB. The results of vitreous surgery for chronic macular holes. Retina 1997;17:493-501.
111. Willis AW, Garcia-Cosio JF. Macular hole surgery. Comparison of longstanding versus recent macular holes. Ophthalmology 1996;103:1811-4.
112. Tilanus MA, Cuypers MH, Bemelmans NA, et al. Predictive value of pattern VEP, pattern ERG and hole size in macular hole surgery. Graefes Arch Clin Exp Ophthalmol 1999;237:629-35.
113. Scott RA, Ezra E, West JF, Gregor ZJ. Visual and anatomical results of surgery for long standing macular holes. Br J Ophthalmol 2000;84:150-3.
114. Cheng L, Azen SP, El-Bradey MH, et al. Effects of preoperative and postoperative epiretinal membranes on macular hole closure and visual restoration. Ophthalmology 2002;109:1514-20.
115. Ullrich S, Haritoglou C, Gass C, et al. Macular hole size as a prognostic factor in macular hole surgery. Br J Ophthalmol 2002;86:390-3.
116. Byhr E, Lindblom B. Preoperative measurements of macular hole with scanning laser ophthalmoscopy. Correlation with functional outcome. Acta Ophthalmol Scand 1998;76:579-83.
117. Ip MS, Baker BJ, Duker JS, et al. Anatomical outcomes of surgery for idiopathic macular hole as determined by optical coherence tomography. Arch Ophthalmol 2002;120:29-35.
118. Thompson JT, Sjaarda RN. Surgical treatment of macular holes with multiple recurrences. Ophthalmology 2000;107:1073-7.
119. Leonard RE, 2nd, Smiddy WE, Flynn HW Jr, Feuer W. Long-term visual outcomes in patients with successful macular hole surgery. Ophthalmology 1997;104:1648-52.
120. Minihan M, Goggin M, Cleary PE. Surgical management of macular holes: results using gas tamponade alone, or in combination with autologous platelet concentrate, or transforming growth factor beta 2. Br J Ophthalmol 1997;81:1073-9.
121. Thompson JT, Glaser BM, Sjaarda RN, Murphy RP. Progression of nuclear sclerosis and long-term visual results of vitrectomy with transforming growth factor beta-2 for macular holes. Am J Ophthalmol 1995;119:48-54.
122. Cheng L, Azen SP, El-Bradey MH, et al. Duration of vitrectomy and postoperative cataract in the vitrectomy for macular hole study. Am J Ophthalmol 2001;132:881-7.
123. Simcock PR, Scalia S. Phaco-vitrectomy for full-thickness macular holes. Acta Ophthalmol Scand 2000;78:684-6.
124. Lahey JM, Francis RR, Fong DS, et al. Combining phacoemulsification with vitrectomy for treatment of macular holes. Br J Ophthalmol 2002;86:876-8.
125. Bhatnagar P, Kaiser PK, Smith SD, et al. Reopening of previously closed macular holes after cataract extraction. Am J Ophthalmol 2007;144:252-9.
126. Paques M, Massin P, Blain P, et al. Long-term incidence of reopening of macular holes. Ophthalmology 2000;107:760-6.
127. Christmas NJ, Smiddy WE, Flynn HW Jr. Reopening of macular holes after initially successful repair. Ophthalmology 1998;105:1835-8.
128. Duker JS, Wendel R, Patel AC, Puliafito CA. Late re-opening of macular holes after initially successful treatment with vitreous surgery. Ophthalmology 1994;101:1373-8.
129. Banker AS, Freeman WR, Kim JW, et al. Vitrectomy for Macular Hole Study Group. Vision-threatening complications of surgery for full-thickness macular holes. Ophthalmology 1997;104:1442-52; discussion 1452-3.
130. Park SS, Marcus DM, Duker JS, et al. Posterior segment complications after vitrectomy for macular hole. Ophthalmology 1995;102:775-81.
131. Scott IU, Moraczewski AL, Smiddy WE, et al. Long-term anatomic and visual acuity outcomes after initial anatomic success with macular hole surgery. Am J Ophthalmol 2003;135:633-40.
132. Sjaarda RN, Glaser BM, Thompson JT, et al. Distribution of iatrogenic retinal breaks in macular hole surgery. Ophthalmology 1995;102:1387-92.
133. Minihan M, Cleary PE. Autologous platelet concentrate in the surgical management of macular holes. Dev Ophthalmol 1997;29:36-43.
134. Heier JS, Topping TM, Frederick AR Jr, et al. Visual and surgical outcomes of retinal detachment following macular hole repair. Retina 1999;19:110-5.
135. Pendergast SD, McCuen BW, 2nd. Visual field loss after macular hole surgery. Ophthalmology 1996;103:1069-77.
136. Paques M, Massin P, Santiago PY, et al. Visual field loss after vitrectomy for full-thickness macular holes. Am J Ophthalmol 1997;124:88-94.
137. Arima T, Uemura A, Otsuka S, et al. Macular hole surgery-associated peripheral visual field loss. Jpn J Ophthalmol 1998;42:476-83.
138. Boldt HC, Munden PM, Folk JC, Mehaffey MG. Visual field defects after macular hole surgery. Am J Ophthalmol 1996;122:371-81.
139. Bopp S, Lucke K, Hille U. Peripheral visual field loss after vitreous surgery for macular holes. Graefes Arch Clin Exp Ophthalmol 1997;235:362-71.
140. Welch JC. Dehydration injury as a possible cause of visual field defect after pars plana vitrectomy for macular hole. Am J Ophthalmol 1997;124:698-9.
141. Welch JC. Prevention of visual field defect after macular hole surgery by passing air used for fluid-air exchange through water. Am J Ophthalmol 1999;128:396-7.
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143. Gass CA, Haritoglou C, Messmer EM, et al. Peripheral visual field defects after macular hole surgery: a complication with decreasing incidence. Br J Ophthalmol 2001;85:549-51.
144. Hirata A, Yonemura N, Hasumura T, et al. Effect of infusion air pressure on visual field defects after macular hole surgery. Am J Ophthalmol 2000;130:611-6.
145. Akiba J, Quiroz MA, Trempe CL. Role of posterior vitreous detachment in idiopathic macular holes. Ophthalmology 1990;97:1610-3.
146. Dayan MR, Jayamanne DG, Andrews RM, Griffiths PG. Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment? Eye 1996;10:456-8.
147. Byer NE. Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology 1994;101:1503-14.
148. Smiddy WE, Michels RG, de Bustros S, et al. Histopathology of tissue removed during vitrectomy for impending idiopathic macular holes. Am J Ophthalmol 1989;108:360-4.
149. Stelmack JA, Tang XC, Reda DJ, et al, LOVIT Study Group. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126:608-17.
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Retina/Vitreous Panel Members
Emily Y. Chew, MD, Chair, Macula Society and Retina Society Representative
William E. Benson, MD
Barbara A. Blodi, MD
H. Culver Boldt, MD
Timothy G. Murray, MD, Consultant and American Society of Retina Specialists Representative
Timothy W. Olsen, MD
Carl D. Regillo, MD, FACS
Ingrid U. Scott, MD, MPH
Leslie Hyman, PhD, Methodologist

Preferred Practice Patterns Committee Members
Sid Mandelbaum, MD, Chair
Emily Y. Chew, MD
Linda M. Christmann, MD
Douglas E. Gaasterland, MD
Samuel Masket, MD
Stephen D. McLeod, MD
Christopher J. Rapuano, MD
Donald S. Fong, MD, MPH, Methodologist

Academy Staff
Flora C. Lum, MD
Nancy Collins, RN, MPH
Doris Mizuiri
Medical Editor: Susan Garratt
Design: Socorro Soberano
Reviewed by: Council
Approved by:  Board of Trustees
September 27, 2008

These panel and committee members have disclosed the following financial relationships occurring from January 2007 to October 2008:

H. Culver Boldt, MD: Alcon Laboratories, Inc. - Consultant/Advisor
Donald S. Fong, MD, MPH: Merck - Consultant/Advisor
Douglas E. Gaasterland, MD: Inspire Pharmaceuticals - Consultant/Advisor; IRIDEX - Consultant/Advisor, Equity owner, Patents/Royalty
Samuel Masket, MD: Alcon Laboratories, Inc. - Consultant/Advisor, Lecture fees, Grant support; Allergan, Inc. - Lecture fees; Bausch & Lomb, Inc. - Lecture fees; Omeros Pharmaceuticals, Inc. - Consultant/Advisor; Othera Pharmaceuticals, Inc. - Consultant/Advisor; PowerVision - Consultant/Advisor; Visiogen, Inc. - Consultant/Advisor
Stephen D. McLeod, MD: Alcon Laboratories, Inc. - Consultant/Advisor, Grant support; InSite Vision, Inc. - Consultant/Advisor, Visiogen, Inc. - Consultant/Advisor, Equity owner, Grant support
Timothy W. Olsen, MD: iScience - Grant support; Powerscope, Inc. - Grant support
Christopher J. Rapuano, MD: Alcon Laboratories, Inc. - Lecture fees; Allergan, Inc. - Consultant/Advisor, Lecture fees; Inspire Pharmaceuticals - Lecture fees; Ista Pharmaceuticals - Lecture fees; Rapid Pathogen Screening - Equity/owner; Ziemer Ophthalmic Systems AG - Consultant/Advisor
Carl D. Regillo, MD, FACS: Alcon Laboratories, Inc. - Consultant/Advisor; Eyetech, Inc. - Consultant/Advisor, Grant support; Genentech, Inc. - Consultant/Advisor, Grant support; Novartis - Consultant/Advisor, Grant support; QLT Phototherapeutics, Inc. - Consultant/Advisor, Grant support
Ingrid U. Scott, MD, MPH: Eyetech, Inc. - Consultant/Advisor, Lecture fees; Genentech, Inc. - Consultant/Advisor, Lecture fees; Pfizer Ophthalmics - Consultant/Advisor, Lecture fees

Copyright American Academy of Ophthalmology 2008
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AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners.

This document should be cited as:
American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern^® Guidelines. Idiopathic Macular Hole. San Francisco, CA: American Academy of Ophthalmology; 2008. Available at: http://www.aao.org/ppp.

As a service to its members and the public, the American Academy of Ophthalmology has developed a series of guidelines called Preferred Practice Patterns that identify characteristics and components of quality eye care. (See Appendix 1.)

The Preferred Practice Pattern^® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence.

Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

The Preferred Practice Pattern^® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.  

Innovation in medicine is essential to assure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration.

All PPPs are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the "approved by" date unless superseded by a revision. Preferred Practice Pattern guidelines are developed by the Academy's H. Dunbar Hoskins Jr., M.D. Center for Quality Eye Care without any external financial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders before publication.