Discussion
This patient has a full thickness macular hole (FTMH) in her left eye. Without the presence of posterior vitreous separation, this would be classified as a Stage 3 FTMH. The question remains: What's going on with the right eye? Is that eye developing a macular hole, too?

She has about a 15 percent chance of developing an FTMH in her right eye. Unfortunately, luck is not on her side; that is exactly what is beginning to occur. She has developed a Stage 1, or "impending," macular hole. The prognosis for visual recovery is excellent, as Stage 1 holes have a 50 percent chance of spontaneously aborting.

The visual prognosis in the left eye is not as good and depends upon whether she has surgery. Even then, the chance of a successful outcome is less because of the long duration of the macular hole.   

Macular holes were first described more than 100 years ago. Throughout this century there has been considerable controversy regarding their pathogenesis. It was strongly believed the anteroposterior tractional forces that occurred during a posterior vitreous detachment caused the macular holes to develop. However, in 1988 Dr. Donald Gass showed that macular holes developed as a result of tangential traction from shrinking of the posterior cortical vitreous.¹ In this landmark paper, Dr. Gass described four stages of macular hole development:

• Stage 1. A yellow spot or ring develops in the macula as a result of loss of the foveal depression.

• Stage 2. A small full thickness defect develops, either in the center of the macula or along the edge of the fovea, and continues to open in a "can-opener" fashion.

• Stage 3. A fully developed FTMH ensues, with a full thickness neurosensory defect and a cuff of fluid around the rim of the hole.

• Stage 4. The same as a Stage 3 hole but with a complete posterior vitreous detacment (PVD), as evidenced by a visible Weiss's ring. 

For years ophthalmologists were unable to successfully treat FTMH. Then Drs. Neil Kelly and Robert Wendel published their landmark paper in 1991 showing complete hole closure in 58 percent of patients who had vitrectomy with peeling of the posterior cortical vitreous and fluid-gas exchange for FTMH.2 Of those who achieved anatomic success, 73 percent had a visual improvement greater than 2 lines. Since the first reports on vitrectomy for FTMH, success rates as high as 90 to 100 percent have been reported. Also, patients with more recent onset macular holes have been shown to have a greater chance for successful closure and visual improvement than those with holes of longer duration. 

So, how should we manage this mountain climber? It's probably best to closely observe the right eye. Although some studies have shown that vitrectomy can be successful with impending, stage 1 macular holes, few doctors recommend this. The impending hole can recover spontaneously; and in cases where it does progress to a full thickness macular hole, vitrectomy has a high success rate.