Non-surgical Treatment for Full Thickness Macular Holes
Date
2025
Authors
Lee, Yong Min (Shane)
Editors
Advisors
Chan, Weng Onn
Selva, Dinesh
Bahrami, Bobak
Selva, Dinesh
Bahrami, Bobak
Journal Title
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Thesis
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Abstract
Background/Aim Full-thickness macular holes (FTMH) are retinal defects involving the photoreceptor layer, leading to central vision loss. The current gold standard for treatment is pars plana vitrectomy with inner limiting membrane (ILM) peel, and gas tamponade with post-operative positioning. However, the risks associated with vitreoretinal surgery such as suprachoroidal haemorrhage, endophthalmitis, retinal tears or detachment, iatrogenic trauma leading to secondary FTMH, and accelerated cataract formation have driven interest in non-surgical alternatives. Additionally, visual field defects and paracentral scotomas can persist despite successful anatomical closure, further highlighting the need for less invasive treatments. Non-surgical options may appeal to patients to avoid the risks of anaesthesia and surgery, provided these alternatives are supported by strong evidence. This thesis reviews the current literature on non-surgical interventions for FTMH and presents an analysis regarding the efficacy of topical dorzolamide in idiopathic FTMH. Methods A systematic literature search was conducted on PubMed, Embase, Scopus, and the Cochrane Library from January 1, 1973, to September 13, 2023. Data extracted included the type of non-surgical therapy, number of patients, baseline patient characteristics, and treatment outcomes. A case of bilateral secondary FTMH closure with topical dorzolamide prompted further investigation into its efficacy. A single-centre, randomised, double-blind, placebo-controlled clinical trial was subsequently designed, investigating the effect of topical dorzolamide on idiopathic small FTMHs (<400 μm). Participants were randomised to receive either topical dorzolamide 2% or placebo, administered three times daily for eight weeks. Optical coherence tomography (OCT) was performed monthly. Patients with persistent FTMH at the end of the trial underwent standard surgical treatment with pars plana vitrectomy, ILM peel, and gas tamponade. The primary outcome was anatomical closure of the FTMH at eight weeks. Results The initial literature search identified 3,352 articles, of which 83 met the inclusion criteria after screening. These studies described seven non-surgical treatment modalities for FTMH: carbonic anhydrase inhibitors (CAIs), non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, laser therapy, intravitreal gas, anti-VEGF agents, and ocriplasmin injections. While numerous case reports and small studies documented successful FTMH closures, there was limited high-quality evidence supporting the superiority of any single non-surgical approach. Our own clinical experience with successful bilateral FTMH closure using topical CAIs was consistent with select reports in the literature, leading to the development of a prospective clinical trial. Between March 6, 2020, and June 16, 2023, 32 eligible patients with idiopathic small FTMHs were enrolled and randomised to receive either topical dorzolamide 2% or placebo. At the eight-week follow-up, anatomical closure was observed in 3 of 16 patients (18.8%) in both the dorzolamide and placebo groups. There was no statistically significant difference in closure rates between groups (p = 1.00). Similarly, no significant difference was found in the mean change in best-corrected visual acuity (BCVA; p = 0.909) or in the change in FTMH diameter (p = 0.225). No serious adverse events were reported in either group. Conclusion Non-surgical FTMH management approaches have been investigated in the literature offering potential benefits, especially for smaller holes and specific patient groups. Non-surgical strategies for FTMH management, including topical dorzolamide, show potential but remain inconclusive. Surgical approaches, including vitrectomy with ILM peel remain the gold standard treatment for FTMH. Further research is necessary to optimise non-surgical treatment protocols, particularly for small FTMHs and patients seeking alternatives to surgery.
School/Discipline
Adelaide Medical School : Ophthalmology and Visual Sciences
Dissertation Note
Thesis (MPhil) -- University of Adelaide, Adelaide Medical School : Ophthalmology and Visual Sciences, 2025
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