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. 2006 Mar;113(3):388-97.
doi: 10.1016/j.ophtha.2005.10.047.

Redefining Lamellar Holes and the Vitreomacular Interface: An Ultrahigh-Resolution Optical Coherence Tomography Study

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Free PMC article

Redefining Lamellar Holes and the Vitreomacular Interface: An Ultrahigh-Resolution Optical Coherence Tomography Study

Andre J Witkin et al. Ophthalmology. .
Free PMC article

Abstract

Objectives: To define optical coherence tomographic (OCT) criteria for the diagnosis of a lamellar macular hole, and to increase understanding of lamellar hole pathogenesis by examining fine anatomic features using ultrahigh-resolution optical coherence tomography (UHR OCT).

Design: Retrospective observational case series.

Participants: Nineteen eyes of 18 patients with lamellar holes were imaged with UHR OCT between 2002 and 2004.

Methods: A UHR OCT system was developed for use in the ophthalmology clinic. All 6 UHR OCT images for each eye imaged were examined. Lamellar holes were diagnosed based on a characteristic OCT appearance. Criteria for the OCT diagnosis of a lamellar hole were as follows: (1) irregular foveal contour; (2) break in the inner fovea; (3) intraretinal split; and (4) intact foveal photoreceptors. From 1205 eyes of 664 patients imaged with UHR OCT, and retrospectively reviewed, 19 eyes of 18 patients were diagnosed with a lamellar hole based on these criteria. All 19 eyes were also imaged with standard resolution OCT. Their charts were retrospectively reviewed.

Main outcome measures: Standard and ultrahigh-resolution OCT images.

Results: On chart review, clinical diagnosis of a lamellar hole was made in only 7 of 19 eyes (37%). Twelve of 19 eyes (63%) had an epiretinal membrane (ERM) on clinical examination. Ten of 19 eyes (53%) had a posterior vitreous detachment. On UHR OCT, 17 of 19 eyes (89%) had ERMs. Eleven ERMs had an unusual thick appearance on UHR OCT. Due to poor visual acuity, 4 eyes underwent vitrectomy. Only 1 of 4 surgeries (25%) was visually and anatomically successful. Another eye improved visually, but a lamellar hole persisted. One eye progressed to a full-thickness macular hole preoperatively, which reopened after surgery. One eye developed a full-thickness hole postoperatively.

Conclusions: The diagnosis of a lamellar hole can be made based on OCT criteria, which could be applied to both standard and ultrahigh-resolution OCT. The increased resolution of UHR OCT sheds light on the pathogenesis of the lamellar hole. Epiretinal membranes were visualized on UHR OCT in the majority of eyes. Many ERMs had an unusual thick appearance on UHR OCT, which may represent either trapped vitreous or posterior hyaloid, and may help stabilize retinal anatomy. Conversely, ERM contraction may play a role in lamellar hole formation. Vitrectomy surgery was anatomically and visually successful in only 1 of 4 patients, suggesting caution when performing vitrectomy on lamellar holes.

Figures

Figure 1
Figure 1
Lamellar hole and typical epiretinal membrane (ERM). The patient is a 69-year-old woman who presented with a best-corrected visual acuity of 20/40 in the right eye. Dilated fundus examination revealed an ERM in the macula, with a small sharply-circumscribed red lesion at the fovea, which was believed to be a pseudohole. A, Fundus photograph depicting lamellar hole and the direction of optical coherence tomographic (OCT) scans. B, Stratus OCT image demonstrates all 4 criteria for the diagnosis of a lamellar hole, which are labeled 1, an irregular foveal contour; 2, break in the inner fovea; 3, separation of the inner from the outer foveal retinal layers; and 4, absence of a full thickness foveal defect with intact foveal photoreceptors. The posterior hyaloid is detached from the macula, and an ERM of typical appearance is visible. C, Ultrahigh-resolution optical coherence tomographic (UHR OCT) image, which also shows intraretinal separation occurring between the outer plexiform layer (OPL) and the outer nuclear layer (ONL). The foveal photoreceptor layers are intact below the area of foveal dehiscence (i.e., the ONL, the inner/outer segment junction [IS/OS], and the external limiting membrane [ELM]). Other retinal layers and the retinal pigment epithelium (RPE) are labeled as follows: retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), and inner nuclear layer (INL). D, Magnification (×2) of UHR OCT image shows strands of tissue spanning between the separated ONL and OPL (yellow asterisks), and the intraretinal split.
Figure 2
Figure 2
Lamellar hole and thick epiretinal membrane. The patient is a 65-year-old woman who presented with a best-corrected visual acuity of 20/30 in both eyes. She was diagnosed with bilateral lamellar holes 4 years prior. Dilated fundus examination revealed a mild epiretinal membrane (ERM) with a small sharply-circumscribed red lesion in the macula of the left eye. A, Fundus photograph depicting lamellar hole and the direction of the optical coherence tomographic (OCT) scans. B, Stratus OCT image meeting all 4 criteria for the diagnosis of the lamellar hole which are labeled as follows: 1, an irregular foveal contour; 2, break in the inner fovea; 3, separation of the inner from the outer foveal retinal layers; and 4, absence of a full thickness foveal defect with intact foveal photoreceptors. C, The corresponding ultrahigh-resolution optical coherence tomographic (UHR OCT) image, which also shows a thick ERM of moderate reflectivity. The photoreceptors (outer nuclear layer [ONL], the inner/outer segment junction [IS/OS], and the external limiting membrane [ELM]) are intact across the macula. D, Magnification (×2) of the UHR OCT image shows the thick ERM of moderate reflectivity dipping posteriorly into the area of foveal dehiscence. RPE = retinal pigment epithelium.
Figure 3
Figure 3
Lamellar hole, thick epiretinal membrane, and vitreomacular traction. The patient is a 46-year-old myopic woman (−7.25 diopters) who presented with a best-corrected visual acuity of 20/40 in the left eye. Dilated fundus examination revealed a prominent posterior hyaloid. There was a mild epiretinal membrane (ERM) with a small sharply-circumscribed red lesion in the fovea, which was believed to be a full-thickness macular hole with surrounding macular thickening. A, Red-free fundus photograph depicting the lamellar hole and the direction of the optical coherence tomographic (OCT) scans. B, Stratus OCT image meeting all 4 criteria for the diagnosis of lamellar hole, which are labeled as follows: 1, an irregular foveal contour; 2, break in the inner fovea; 3, separation of the inner from the outer foveal retinal layers; and 4, absence of a full thickness foveal defect with intact foveal photoreceptors. Vitreomacular traction is apparent. C, The corresponding UHR OCT image also shows a thick ERM of moderate reflectivity. This membrane appears continuous with the partially-separated posterior hyaloid. The photoreceptors (i.e., the outer nuclear layer [ONL], the inner/outer segment junction [IS/OS], and the external limiting membrane [ELM]) are intact across the macula. D, Magnification (×2) of UHR OCT image shows the thick ERM as it extends to the edge of the foveal break. In this case, the intraretinal split appears to be within the outer plexiform layer (OPL). RPE = retinal pigment epithelium.
Figure 4
Figure 4
Lamellar hole, typical epiretinal membrane, and vitreomacular traction. The patient is a 61-year-old woman who presented with a best-corrected visual acuity of 20/50 in the right eye. Dilated fundus examination showed an epiretinal membrane (ERM) with diffuse cystoid macular edema. A, Fundus photograph depicting the lamellar hole and direction of the optical coherence tomographic (OCT) scans. B, Stratus OCT image meeting all 4 criteria for the diagnosis of lamellar hole, which are labeled as follows: 1, an irregular foveal contour; 2, break in the inner fovea; 3, separation of the inner from the outer foveal retinal layers; and 4, absence of a full thickness foveal defect with intact foveal photoreceptors. Vitreomacular traction is apparent. A large amount of intraretinal fluid is spitting the inner and outer retina, with multiple strands of tissue spanning between the split layers (yellow asterisks). C, The corresponding ultrahigh-resolution optical coherence tomographic (UHR OCT) image, which also shows a thin ERM anterior to the macula not detected by Stratus OCT. The outer nuclear layer (ONL), the inner/outer segment junction (IS/OS), and the external limiting membrane (ELM) are intact across the macula. D, Magnification (×2) of the UHR OCT image. Two small cysts are seen within the ganglion cell layer (GCL) (red asterisks). E, Postoperative UHR OCT image. The patient underwent a pars plana vitrectomy with peeling of the posterior hyaloid from the fovea, air/fluid exchange, and sulfur hexafluoride 20% injection. The patient subsequently developed a full-thickness macular hole.
Figure 5
Figure 5
Lamellar hole with photoreceptor disruption and subfoveal fluid. The patient is a 57-year-old myopic woman (−4.75 diopters) who presented with a best-corrected visual acuity (BCVA) of 20/100 in the left eye. Dilated fundus examination revealed a sharply-circumscribed red lesion in the left macula, believed to be a pseudohole. A, Fundus photograph depicting lamellar hole and the direction of optical coherence tomographic (OCT) scans. B, Stratus OCT image meeting all 4 criteria for the diagnosis of lamellar hole, which are labeled as follows: 1, an irregular foveal contour; 2, break in the inner fovea; 3, separation of the inner from the outer foveal retinal layers; and 4, absence of a full thickness foveal defect with intact foveal photoreceptors. A large strand of tissue connects the inner to the outer retina at the fovea. C, The corresponding UHR OCT image, which also shows disruption of the inner/outer segment junction (IS/OS) junction and the external limiting membrane (ELM) at the fovea, but the outer nuclear layer (ONL) remains intact underneath the area of foveal dehiscence. A small pocket of subfoveal fluid is present (blue asterisk). Small cystic spaces are present within the inner nuclear layer (INL). D, Magnification (×2) of UHR OCT image, showing a subretinal fluid pocket and photoreceptor disruption. E, Postoperative UHR OCT image. The patient underwent a pars plana vitrectomy with peeling of the internal limiting membrane (ILM), air/fluid exchange, and sulfur hexafluoride 20% injection. Six months later, the hole was flat and closed on fundus examination and OCT, and BCVA had improved to 20/30 in the left eye.

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