Lamellar macular holes: evolving concepts and propensity for progression to full thickness macular hole
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International Journal of Retina and Vitreous Open Access
COMMENTARY
Lamellar macular holes: evolving concepts and propensity for progression to full thickness macular hole Salim Zafar Asaad*
Abstract Currently the term lamellar macular hole (LMH) alludes to a wide spectrum of macular conditions including distinct clinical entities with different pathomorphologies. Classifications into subtypes, tractional and degenerative or based on the associated preretinal tissue had been proposed. Recent insights suggest that only lesions with tissue loss should be considered ‘true’ LMH and not those morphological changes caused by tractional forces. Inclusion of lesions with foveoschisis with contractile epiretinal membrane (ERM) in earlier studies on LMHs has resulted in imprecise information about its clinical course. This review provides an overview of the evolving concepts of LMHs and analyses its natural history from study cases in previously published literature. Keywords: Epiretinal proliferation, Lamellar macular hole, Full thickness macular hole, Epiretinal proliferation Background There is currently no consensus about what constitutes ‘lamellar macular hole’ (LMH) and its definition. The term alludes to a wide spectrum of macular pathomorphologies. Gass in 1975 first used the term to describe complication of cystoid macular edema after cataract extraction [1]. In 2006 Witkin et al. [2] proposed optical coherence tomography (OCT) criteria for diagnosis of LMHs that were adopted by the International Vitreomacular Traction Study Group [3], which included irregular foveal contour, defect in the inner fovea, intraretinal split and intact photoreceptors. But this definition does not address the associated preretinal tissue or status of ellipsoidal layer which influence clinical course & prognosis. Govetto et al. in 2016 described two subtypes of LMHs which are clinically distinct; the first ‘tractional’ characterised by schitic separation of the neurosensory retina and the second ‘degenerative’ characterised by *Correspondence: [email protected] Department of Ophthalmology, Burjeel Speciality Hospital, Al Kuwaiti street, Al Fayha, Sharjah, United Arab Emirates
intraretinal cavitation with ellipsoidal zone defect [4]. They observed that tractional LMHs are associated with tractional epiretinal membrane (ERM) and degenerative LMHs with nontractional epiretinal proliferation. Many other authors have also described two types of preretinal tissue associated with LMHs (Table 1). The first type referred to as tractional ERM [5] /normal ERM [6] /conventional ERM [7] /typical tractional ERM [8] /standard ERM [9] appears tomographically as an irregular hyperreflective layer attached intermittently to the underlying retina and associated with tractional signs such as retinal wrinkling, thickening & intraretinal cysts. The second type referred to as thick ERM [2] /dense ERM [5] /thicker ERM [6] /lamellar hole-associated epiretinal proliferation or LHEP [7] /atypical epiretinal tissue [8] appears tomographically as a thick homo
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