Expert perspectives on the evolution of retina practice, procedures, technologies and instrumentation.


The Evolution of Macular Hole Surgery

Carlos A. Medina, MD, and Robert T. Wendel, MD


Image courtesy Jason S. Calhoun, Mayo Clinic Jacksonville, Florida. Retina Image Bank 2013; Image 7267. © American Society of Retina Specialists.

Macular hole (MH) is a full-thickness defect of retinal tissue involving the anatomic fovea, thereby affecting central visual acuity. MHs were first described in the medical literature in the late 19th century. However, it was not until the latter half of the 20th century that MHs began to be understood and studied in greater detail.

In 1988, J. Donald Gass, MD, postulated that contraction of the premacular vitreous cortex and tangential vitreous traction cause detachment of central photoreceptors and subsequent MHs.1 Gass also defined the stages of MH development, providing a foundation for understanding the condition. His classification relied on biomicroscopic examination with a contact lens and proposed the mechanistic etiology as tangential traction.

J. Donald M. Gass, MD, image courtesy Bascom Palmer Eye Institute.

Dr. Gass also proposed a prospective study to assess the feasibility of vitrectomy intervention to peel the prefoveal vitreous cortex in eyes with an impending MH. These observations renewed interest in MHs and led to publications using vitrectomy surgery for impending MHs to prevent full-thickness macular hole (FTMH) formation.2,3

In 1989, Robert T. Wendel, MD, and Neil E. Kelly, MD, first described and presented the surgical treatment of FTMHs at the American Academy of Ophthalmology Annual Meeting in New Orleans. They subsequently defined the surgical technique as: peeling the cortical vitreous, creating a vitreous detachment, peeling membranes (internal limiting membrane and if present, epiretinal membrane), performing a gas-fluid exchange, and having the patient maintain facedown positioning for 1 week.

The original manuscript was submitted to several journals with no success, and only after several attempts was it accepted by the Archives of Ophthalmology in May 1991.4 At that time, the main concern centered on whether these were FTMHs. The reviewers suggested that pseudomacular holes were being mistaken for FTMHs despite careful clinical examination.  

Diagnosis at that time relied on biomicroscopy with a contact lens and the Watzke-Allen slit beam and/or laser-aiming beam tests for accuracy, as clinical optical coherence tomography (OCT) was not yet available. A year later, Dr. Wendel and Dr. William R. Green published a report showing postmortem clinicopathological correlation of FTMH closure in a patient with bilateral MHs who was successfully treated with surgery.5

Soon, other authors published similar MH closure rates with MH surgery.6Despite initial skepticism from the medical community, Wendel and Green’s surgical technique resulted in significant success in treating the condition. By 1993, the authors reported a 73% closure rate in a series of 170 eyes.7  

With the success of Wendel and Kelly’s technique, the interest in MH surgery continued to grow. By 1995, entire scientific sessions at national and international meetings were dedicated to MH surgery topics. The role of adjuvants, including autologous serum, TGF b1, autologous plasma, bovine thrombin, autologous platelet concentrate, bovine TGF b2, absorbable cross-linked gelatin, cryo-precipitated fibrinogen, and others became somewhat controversial.

Drs. Robert T. Wendel and Neil E. Kelly receive the 1998 ASRS Founders Award. Image courtesy Robert T. Wendel, MD.

During this era, the development of membrane peeling also became an important topic of discussion. OCT technology in the mid to late 1990s allowed for improved visualization and diagnosis of MHs.8 OCT technology made it clear that anterior-posterior traction also plays a role in MHformation.9

Today, the MH surgical technique has evolved to include small-gauge instruments and additional tools and techniques, such as stains like indocyanine green (ICG), to aid in visualizing the internal limiting membrane during removal.

Now that we have over 3 decades of experience in treating patients with MHs, our understanding of the condition has significantly improved, leading to an increase in the success rate of surgery.

Currently, success rates range between 90% and 98%, with most patients experiencing visual improvement of 2 to 3 lines. The use of OCT technology for early diagnosis, coupled with prompt treatment utilizing small-gauge vitrectomy surgery and modern surgical visualization systems, has not only increased success rates, but also lowered complication rates from vitrectomy surgery. Surgery is now considered a relatively common treatment for a MH with central visual loss.



1. Gass JDM. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol. 1988;106(5):629-639. doi:10.1001/archopht.1988.01060130683026


2. Michels RG, Glaser BM, de Bustros S, Smiddy WE. Vitrectomy forim pending idiopathic macular holes. Am J Ophthalmol. 1988;105(4):371-376.doi:10.1016/0002-9394(88)90300-5


3. de Bustros S. Early stages of macular holes. To treat or not totreat. Arch Ophthalmol. 1990;108(8):1085-1086.doi:10.1001/archopht.1990.01070100041029


4. KellyNE, Wendel RT. Vitreous surgery for idiopathic macular holes: results of a pilot study. Arch Ophthalmol. 1991;109(5):654-659. doi:10.1001/archopht.1991.01080050068031


5. Funata M, Wendel RT, de la Cruz Z, Green WR. Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina. 1992;12(4):289-298.doi:10.1097/00006982-199212040-00001


6.   Orellana J, Lieberman RM. Stage III macular hole surgery. Br J Ophthalmol. 1993;77(9):555-558. doi:10.1136/bjo.77.9.555


7. Wendel RT, Patel AC, Kelly NE, Salzano TC, Wells JW, Novack GD. Vitreous surgery for macular holes. Ophthalmology.1993;100(11):1671-1676.


8. Hee MR, Puliafito CA, Wong C, et al.  Optical coherence tomography of macular holes. Ophthalmology. 1995;102(5):748-756. doi:10.1016/s0161-6420(95)30959-1


9. Gaudric A, Haouchine B, Massin P, Paques M, Blain P, Erginay A. Macular hole formation: new data provided by optical coherence tomography. Arch Ophthalmol. 1999;117(6):744-751. doi:10.1001/archopht.117.6.744


10.Tanner V, Chauhan DS, Jackson TL, Williamson TH. Optical coherence tomography of the vitreoretinal interface in macular hole formation. Br J Ophthalmol.2001;85(9):1092-1097. doi:10.1136/bjo.85.9.1092