A study recently published in Graefe’s Archive for Clinical and Experimental Ophthalmology sought to elucidate potential causes of the spontaneous closure of idiopathic full-thickness macular holes (iFTMHs).
Give me some background.
Spontaneous closure of iFTMHs is a known phenomenon, but little is known about the probability and timeline of this occurring.
Pars plana vitrectomy (PPV) is the current first-line treatment for iFTMH and has been shown to be safe and effective for small- and medium-sized macular holes (MHs).
Tie it all together for me.
A recent study found a minor vision loss of 0.008 logMAR per month of additional waiting for surgery and poor prognosis for iFTMH patients with delayed treatment.
As such, it is critical to understand which characteristics increase the likelihood of spontaneous closure of iFTHMs to balance avoiding an unnecessary surgical intervention with preventing worsening outcomes from delayed treatment.
Now talk about the study.
In this retrospective study, investigators analyzed the data of consecutive patients who presented with macular holes between August 2008 and 2019 to the Department of Ophthalmology at the University of Tuebingen, Tuebingen, Germany.
The primary outcome measure was the spontaneous closure of the iFTMH detected on optical coherence tomography (OCT) imaging.
Talk about the study cohort.
Investigators included 338 eyes of 324 iFTMH patients (61% women, mean age 68.9 years [40-90 years]); bilateral involvement was reported in 14 patients (4.1%).
The median time interval between diagnosis and surgery was 34 days (range 4-618).
Findings?
The research team found a spontaneous closure rate of 9.2% in iFTMH eyes, with a median time of 44 days after diagnosis.
Any traits that corresponded with iFTMH spontaneous closure?
Eyes exhibiting spontaneous closure demonstrated a higher baseline best-corrected visual acuity (BCVA, p<0.0001) and smaller iFTMH diameter (p<0.0001).
The mean BCVA improved from 0.4 logMAR (standard deviation [SD] ± 0.21) to 0.29 logMAR (SD ± 0.20) after spontaneous closure (p=0.031).
Tell me more about the iFTMH diameter.
The iFTMH diameter had a positive correlation with the time to spontaneous closure (p=0.0377).
A logistic regression model showed the hole diameter was associated with spontaneous closure (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96-0.98).
A Kaplan-Meier analysis indicated that approximately 25% of small iFTMHs (124 eyes) and 55% of iFTMHs with a diameter <150 μm (48 eyes) closed spontaneously within 2 months of diagnosis.
Did any iFTMHs reopen?
Spontaneously closed iFTMHs reopened in 16% (five eyes) of cases, with a median of 136 days after closure.
Expert opinion?
Considering the relatively short time period until reopening, the study authors explained: “In patients with small iFTMHs and relatively good vision a ‘watchful waiting’ approach with short follow-up regime may be offered to some patients after careful considerations of circumstances.”
For this study, doctors recommended patients come back for follow-up exams at 2-week intervals for 6 weeks after the initial diagnosis, and then ophthalmological exams were performed at 4-week intervals.
Take home.
These findings suggest that a higher baseline BCVA and iFTMH size and diameter correlate to the chance of spontaneous closure.
Additionally, spontaneous closure of small iFTMHs can occur within a relatively short time span after diagnosis (2-4 months).
Next steps?
As these results cannot be used to accurately predict the course of an individual patient’s disease course, further research is warranted to validate these conclusions and establish treatment recommendations for patients with small iFTMHs in clinical practice.