Prethy Rao, MD, MPH Vitreoretinal Surgery Fellow Associated Retinal Consultants/William Beaumont Hospital

Macular hole Classification: What’s in a Name?

This year’s lifetime mentorship lecture was awarded to Jay Duker, MD who gave a fabulous presentation describing the updates in macular hole classification.

Dr. Duker described the elements important in creating a classification system: descriptive (observed patterns), a mature system (predictive of outcomes with natural history and intervention), and other desirable features (simple, objective, quantitative, widely applicable). The initial classification system, described by Donald Gass, MD, was based on tangential traction. However, optical coherence tomography (OCT) has changed our understanding by demonstrating that oblique vitreoretinal traction - a drawbridge theory (partial perifoveal posterior vitreous detachment [PVD] with vitreomacular adhesion [VMA]) - may now be more appropriate.


OCT has allowed us to determine improvements to the original classification. We now know that a PVD lacks prognostic information, smaller macular holes can have PVDs, and not all holes go through all stages. In fact, the term “idiopathic” may no longer apply, since we can now visualize the role of vitreomacular traction (VMT).

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The updated international classification has 3 features: size of defect (<250, 250-400, >400), presence of VMT, and primary/secondary hole. Four hundred microns appears to be a pivot point: holes < 400 microns may not necessarily benefit from ILM peeling. The correlations between the old and new classification may be summarized with the following: Gass Stage 0 (VMA), Gass Stage 1 (VMT), Gass Stage 2 (small or medium hole +/- VMT), Gass Stage 3 (medium or large hole +/- VMT), and Gass Stage 4 (small, medium or large macular hole with PVD).

Lastly, while OCT is a great way to identify VMT, it is still difficult to predict which eyes with VMT eyes will progress to a macular hole. In general, one third of eyes with VMT develop a PVD. However, Dr. Duker also showed several examples of VMT progressing to lamellar holes and macular schisis.

RETINA Roundup VBS VI Coverage: 3/27/2018  VBS VI: Historic Delivery of Gene Therapy for LCA 3/27/2018  VBS VI: Surgical Adventures - Curing One Eye at a Time 3/26/2018  VBS VI: Retinaws 3/26/2018  VBS VI: Complications Session 3/26/2018  VBS VI: Women of VBS Breakfast 3/26/2018  VBS VI: Endophthalmitis Session 3/25/2018  VBS VI: Retina Caliente 3/25/2018  VBS VI: Lifetime Mentorship Award: Jay Duker 3/24/2018  VBS VI: Surgical Adventures - Bridging the Gap 3/24/2018  VBS VI: Real World Retina - Practice Management, Private Equity, Advice for Young Retina Specialists 3/24/2018  VBS VI: Medical Retina 3/24/2018  VBS VI: Live Surgery Session 3/23/2018  VBS VI: Fellows' Forray 3/24/2018  VBS VI: Welcome to Miami