The Casebook
Welcome to the first edition of The Casebook, an occasional newsletter for eyecare professionals in the Lowveld. Each edition looks at one instructive case, with a short teaching point you can carry into your own consulting room. Cases will range across the whole of eye care, from oculoplastics and cornea to cataract and retina. We open with a macular hole that had already failed to close twice before it reached us.
A refractory macular hole, closed at the third attempt
A 61-year-old woman was referred with a persistent full-thickness macular hole (FTMH) in the right eye. She had already undergone two vitrectomy repairs in the United States, in 2022 and again in 2024, and the hole had not closed on either occasion. By the time she reached us the hole was both long-standing and refractory, the two features that make closure hardest to achieve.
A macular hole is a small, full-thickness gap in the fovea, the very centre of the macula and the part of the retina responsible for sharp, straight-ahead vision. Most holes are idiopathic and develop when the vitreous gel pulls on the fovea and separates the layers of the retina. Patients typically notice central blur, distortion of straight lines (metamorphopsia), or a grey spot in the middle of their vision, usually in one eye.
OCT is the single most useful test. It confirms the hole, shows whether it is full-thickness, and measures its size, which is the number that drives the prognosis.
The likelihood of closing a macular hole, and how much vision returns afterwards, is largely set before surgery by two factors: how big the hole is and how long it has been open.
Holes are graded by their minimum width on OCT. A smaller hole is easier to close and carries the best visual prognosis. The longer a hole stays open, the more the surrounding photoreceptors are lost, so early referral matters: the sooner we operate, and the smaller the hole, the higher the chance of closure and a good visual result.
Understanding the steps below helps explain why a hole that failed older techniques can still close with a modern approach.
When a hole is large or has already failed surgery, several additional techniques can be layered onto a flap repair to encourage closure:
- Platelet-rich plasma (Optistim), an autologous platelet concentrate placed over the hole to promote healing and help hold the flap in place.
- Silicone oil as a longer tamponade, advocated by some but not widely popularised.
- Amniotic membrane graft, used in selected difficult cases.
- Autologous retinal transplant, moving a small patch of retina from elsewhere to plug the hole. It can achieve anatomical closure, though how much it improves function remains debated.
The hole closed at the third attempt
After two unsuccessful repairs, the hole closed in 2026 and has remained closed, with stable tamponade and no complications.
- 23-gauge pars plana vitrectomy, right eye
- Temporal inverted ILM flap raised from the residual membrane
- Heavy liquid (perfluorocarbon) to stabilise the flap during positioning
- Platelet-rich plasma (Optistim) applied to promote closure
- Fibrin glue to secure the flap
- Long-acting C3F8 gas tamponade with face-down positioning
A failed macular hole repair is not the end of the road. Refractory and reopened holes remain surgically closable. Where the ILM has already been peeled, an inverted flap from residual temporal membrane, adjuncts such as platelet-rich plasma and fibrin glue, and a longer-acting C3F8 tamponade can still achieve closure. It is worth referring persistent or recurrent holes for a surgical opinion rather than telling a patient that nothing more can be done.
When a patient describes distortion of their central vision, often followed by a blur or a missing patch right in the middle, keep a macular hole in mind. Fundus photographs or a dilated fundus examination will often reveal it. Where the symptoms fit, it is worth the patient having an OCT to confirm the diagnosis. Surgery is the only treatment, and because timing and hole size drive the outcome, early referral gives the best chance of closing the hole and preserving central vision.
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The Casebook goes out to a small WhatsApp group of optometrists and eyecare professionals in the Lowveld. One case at a time, no more than one message a month, and you can leave whenever you like.
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