title: Pathogenesis of macular holes and therapeutic implications.
abstract: OBJECTIVE
  To review the literature and identify consistencies and inconsistencies in existing theories of pathogenesis and to consider some of their possible therapeutic implications.
  
  
  METHODS
  Presentation of clinical case material with a synthesis of ideas on macular holes.
  
  
  METHODS
  The literature of macular hole surgery is reviewed pertinent to pathogenic theories. Clinical examples of evolving macular holes shown on ocular coherence tomography are presented to illustrate issues.
  
  
  RESULTS
  The history of pathogenesis and macular holes is interesting in that, in many ways pathogenic theory has come full cycle. Initially, anteroposterior traction was thought to cause direct formation of a macular hole. Subsequently, degenerative and then tangential tractional etiologies were proposed. Current imaging studies have greatly advanced our understanding of anatomic features of full-thickness holes and early full-thickness hole conditions. These are most consistent with a focal anteroposterior traction mechanism, but some inconsistences in clinical cases suggest a role for degeneration of the inner retinal layers.
  
  
  CONCLUSIONS
  Degeneration of the inner retinal layers at the central fovea may predispose the eye to macular hole formation. What may otherwise be incidental tractional forces appear to initiate the hole. These tractional elements are oriented perpendicularly to the retinal surface, rather than tangentially. Further observations, especially with sequential observations from ocular coherence tomography, may yield further insights into the pathogenesis of macular holes as well as implications regarding the best repair techniques.
authors.affiliation: Department of Ophthalmology, University of Miami School of Medicine, Bascom Palmer Eye Institute, Miami, Florida 33101, USA. wsmiddy@med.miami.edu
authors.forename: William E
authors.initials: WE
authors.lastname: Smiddy
authors.forename: Harry W
authors.initials: HW
authors.lastname: Flynn
mesh_terms: D006801:Humans; D013508:Ophthalmologic Surgical Procedures; D012167:Retinal Perforations / Q000209:etiology* / Q000473:pathology / Q000601:surgery*; D041623:Tomography, Optical Coherence