Improvements in the understanding and treatment of macular hole.

Recent innovations in macular imaging and surgery have provided important new information concerning the pathogenesis and treatment of idiopathic macular hole. New imaging data suggest that localized perifoveal vitreous detachment (an early stage of age-related posterior vitreous detachment) is the primary pathogenic event in idiopathic macular hole formation. Detachment of the posterior hyaloid from the pericentral retina exerts anterior traction on the foveola and localizes into the foveola the dynamic vitreous traction associated with ocular rotations. Optical coherence tomography has clarified the pathoanatomy of early macular hole stages, beginning with a foveal pseudocyst (stage 1A) and typically followed by disruption of the outer retina (stage 1B) before progressing to a full-thickness dehiscence (stage 2). The treatment of macular hole continues to evolve as modifications to the standard surgical procedure are proposed and evaluated. These innovations include the use of cytokine adjuvants, peeling of the internal limiting membrane, vital staining of the internal limiting membrane with indocyanine green dye, and variations in the length of postoperative face-down positioning.