These images from the study show spontaneous closure of an idiopathic full-thickness macular hole with bridging phenomenon in a 57-year-old woman 52 days after diagnosis. Reopening is possible in such cases; therefore, close follow-up is important. Photo: Neubauer J, et al. Graefes Arch Clin Exp Ophthalmol. April 8, 2024. Click image to enlarge.

Although surgery to repair a macular hole is generally safe and effective, spontaneous closure of idiopathic full-thickness macular holes (FTMHs) has been reported numerous times over the years. Few studies have investigated the spontaneous closure of idiopathic FTMH using OCT imaging, however. A recent study conducted in Germany investigated the factors related to the spontaneous closure and the time course of this phenomenon in particular. It found a significant correlation between hole diameter and spontaneous closure.

The study cohort comprised 338 FTMH eyes of 324 patients (199 women) with a mean age of 68.9. Bilateral involvement was observed in 14 patients (4.1%) at the first visit or during the follow-up period. The time interval between the diagnosis and surgery had a median of 34 days. Of the patients without spontaneous closure (n=307), 279 (90.9%) agreed to have surgery. A total of 28 patients (28 eyes, 9.1%) refused surgery. The median follow-up time of these patients was 149 days. In the spontaneous closure group, two out of 31 patients refused surgery.

Spontaneous closure of the idiopathic FTMH was detected in 9.2% of eyes with a median time of 44 days after diagnosis. Eyes with spontaneous closure had an average hole diameter of 98.9µm and demonstrated a higher BCVA and smaller macular hole diameter. The mean BCVA improved from 0.4 logMAR to 0.29 logMAR after spontaneous closure. The macular hole diameter was positively correlated with the time to spontaneous closure. A logistic regression model showed the hole diameter was associated with spontaneous closure (odds ratio: 0.97). The Kaplan–Meier-Curve revealed that approximately 25% of small FTMH with a diameter < 250µm (n = 124) and 55% of FTMH with a diameter < 150µm (n = 48) closed spontaneously within two months.

“In our study population, we found re-opening of spontaneously closed FTMH in five patients with a median of four months after closure,” the researchers noted in their paper. “Considering the relatively short time span until reopening, the continuation of the regular follow-up examinations is important.” In this study, patients were advised to have follow-up examinations at two-week intervals for six weeks after the initial diagnosis.

The team did explain that the time of diagnosis based on the OCT examination is not the time at which the FTMH develops. An alternative to their approach could have involved using the onset of symptoms as the time of diagnosis. The researchers decided against this, as not all patients were able to state the onset of symptoms precisely enough.

“This study revealed spontaneous closure of small FTMHs in a relatively high percentage of patients within two months of diagnosis in our cohort,” they highlighted. “Considering that the established standard therapy for FTHMs is a surgical approach, this information could be relevant to clinical practice and future studies.”

While their data cannot be used to predict the course of an individual patient's disease with high accuracy, future investigations are required to help establish validated clinical treatment recommendations for patients with small idiopathic FTMHs.