Aims To evaluate long-term reconstructive changes in foveal microstructures and their associations with visual improvement in eyes with surgically closed macular holes (MHs).

Methods Twenty-eight eyes of 28 patients who underwent successful idiopathic MH repair were retrospectively studied. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography images were examined preoperatively and 1, 3, 6, 12, 24 and 36 months postoperatively. Correlations between postoperative BCVA and parameters relating to the reconstruction of the foveal photoreceptor layer including the external limiting membrane (ELM), ellipsoid zone (EZ) and cone interdigitation zone (CIZ) as well as changes in glial cells were evaluated.

Results Logarithm of the minimum angle of resolution BCVA improved continuously during 3-year follow-up (baseline 0.70±0.27, 1 month 0.36±0.34, 3 months 0.29±0.30, 6 months 0.22±0.24, 12 months 0.18±0.25, 24 months 0.14±0.22, 36 months 0.10±0.19) (p=0.015). Continuous reconstruction of the foveal microstructure was apparent throughout the 3-year follow-up. The reconstruction process was initiated by glial proliferation, followed by ELM bridging, glial elimination with EZ reconstruction and CIZ reconstruction. Better BCVA at the 3-year time-point was significantly associated with early ELM bridging, early glial disappearance and photoreceptor integrity defined as complete reconstruction of the ELM, EZ and CIZ.

Conclusions Integrity of the photoreceptor layer was correlated with better long-term visual outcomes after MH repair. Reconstruction of the foveal ELM and disappearance of glial proliferation in the early postoperative period predicted better visual recovery.