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We would like to congratulate Uwaydat et al. on their large series of spontaneously closed macular holes (MH), which adds new information to the literature.(1) It reinforces the observation that traumatic MH can spontaneously close and that a period of observation in these eyes, where the results of surgery are not clear, is a worthwhile option. However, we disagree with their conclusion that eyes with recent onset small primary MHs should also be observed. The authors don’t suggest a time period for observation but found that the median time for closure for these small holes was 4.4 months.
The report by Uwaydat et al. has 40 authors and the 60 cases of idiopathic MH were collected over at least a two-year period. Assuming a conservative number of 25 MH cases seen per surgeon per annum, this would give a spontaneous closure rate of ~3%, which is similar to the published literature as the authors review in their article.
MH are known to enlarge with time, even in the short term. Madi et al, reported that 83% enlarged, by a median of 105 microns in 8 weeks. (2) Similarly, Berton et al recently estimated that holes less than 250 microns enlarge by a mean of 1.67 microns per day, resulting in a similar 100-micron increase in 2 months.(3)
The anatomical and visual outcomes of surgery are dependent on MH diameter and duration. Holes greater than 300 microns, and with a duration more than four months are less likely to regain 0.3 logMAR or better.(4)...
The anatomical and visual outcomes of surgery are dependent on MH diameter and duration. Holes greater than 300 microns, and with a duration more than four months are less likely to regain 0.3 logMAR or better.(4)
Surgery achieves closure rates of over 98% for small and medium sized holes, and a risk of a worse visual outcome than preoperatively is very low.(4)
Taking this information together, observing a 200 micron hole with a 2-month duration, for even 2 months would likely result in a 100-micron size increase, and a four-fold reduction in the chances of achieving 0.3logMAR or better, set against a 5% chance of observing spontaneous closure.
The spontaneous closure rate in smaller holes is likely to be higher than previously stated however, it is not a common observation, and delaying surgery carries real risks for the patient. Although the options should be discussed with the patient, we advocate prompt surgery for all primary macular holes, including small ones, as the best means of achieving good functional results.
1. Uwaydat, S. H. et al. Clinical characteristics of full thickness macular holes that closed without surgery. Br. J. Ophthalmol. (2021) doi:10.1136/bjophthalmol-2021-319001.
2. Madi, H. A., Dinah, C., Rees, J. & Steel, D. H. W. The Case Mix of Patients Presenting with Full-Thickness Macular Holes and Progression before Surgery: Implications for Optimum Management. Ophthalmol. J. Int. d’ophtalmologie. Int. J. Ophthalmol. Zeitschrift fur Augenheilkd. 233, 216–221 (2015).
3. Berton, M., Robins, J., Frigo, A. C. & Wong, R. Rate of progression of idiopathic full-thickness macular holes before surgery. Eye (Lond). 34, 1386–1391 (2020).
4. Steel, D. H. et al. Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort. Eye (Lond). 35, 316–325 (2021).