Recognised risk factors for the formation of idiopathic full thickness macular holes (IFTMH) include age, female, sex, and high myopia.^1,2 However, we noticed that patients with IFTMH within our population, tended to have shorter than normal axial lengths. An age and sex matched case-control study was therefore performed to test this hypothesis and determine whether biometric factors may be associated with formation of IFTMH.

Methods

Consecutive patients undergoing surgery for IFTMH had age, sex, axial length in millimetres (mm), and corneal keratometry (K) measurements in dioptres (D) recorded.

For each case three age and sex matched controls were randomly identified from a cataract surgery database (Medisoft). Biometric measurements were made in all cases and controls using the IOL-Master (Zeiss, Jena). Mean corneal curvature was calculated by averaging the two K readings.

Descriptive statistics and conditional logistic regression method for analysis of matched pair data were used to infer estimates.

Results

Thirty five consecutive cases and 105 controls were identified with a mean age of 67.3 years (35–77 years) and a female to male ratio of 24:11. The mean (SD) axial length in the cases was 22.94 (0.96) mm whereas in controls it was 23.48 (1.44) mm. The axial lengths of the cases also fell within a narrower range than those of the controls (fig 1). Mean K readings in cases was 44.04 D (range 41.87–46) and 43.44 D in controls. (range 40.56–47.92).

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Figure 1

 Axial lengths (mm) of patients with macular holes compared with age and sex matched controls.

Evidence suggests that the longer the axial length the less the odds of being a case; odds ratio (OR) 0.67 (p = 0.036, CI 0.47 to 0.77) and the higher the dioptre power of the curvature the higher the odds of being a case as opposed to a control; OR 1.50 (p = 0.02, CI 1.07 to 2.01).

Comment

As in previous studies our population sample demonstrates an increased risk of IFTMH in females with most cases clustering in the 60–70 year age group.^3,4 The mean axial length in controls was also found to be similar to results in the published literature.^5,6

Mean spherical equivalence (MSE) was measured by the Eye Disease Case Control Study Group⁷ and although their findings were statistically insignificant, their regression analysis found an increased likelihood of hypermetropia in the IFTMH cases. Our cases clustered in a relatively narrow range of axial lengths (21 mm–25.31 mm in the cases compared to 20.64 mm–29.48 mm in the controls) with the maximum axial length in the cases being 25.31 mm (fig 1). In Japanese literature, high myopia is a prominent, recognised risk factor and in one study the overall mean MSE was −0.66 D.² From our study it appears myopic macular holes are encountered much less frequently in a predominantly white population.

We believe the significant corneal dioptric differences found may be a result of the natural process of emmetropisation of a shorter eye, or alternatively be an independent risk factor.

IFTMH are thought to arise from retinal surface traction which in turn arises from an abnormal and incomplete posterior vitreous detachment.⁸ Our results suggest that eyes with shorter than average axial lengths and therefore lower volume vitreous cavity are either at increased risk of developing such incomplete and abnormal vitreous detachments or, in the presence of such an incomplete vitreous detachment, of developing a macular hole. We are not aware that shorter axial length has previously been shown to be significantly associated with IFTMH.