Study Proposes Five Stages of Macular Hole Closure

With this model as a reference, clinicians may be better informed to employ less invasive interventions, such as anti-inflammatory therapy, before considering a repeat surgical procedure. Photo: Raman Bhakhri, OD. Click image to enlarge. Patients are typically instructed to maintain face-down positioning after macular hole repair surgery to allow the gas tamponade to do its job. However, the healing mechanisms in these cases aren’t that well understood—partially owing to the fact that the gas tamponade itself creates optical artifacts and light scatter—and some studies suggest that face-down positioning might not be needed after all. In an attempt to clarify the healing process and visual recovery, researchers in Italy and Buenos Aires examined the early postoperative structural changes in gas-filled eyes using high-resolution OCT. They identified five discrete stages that could be used to inform care.The prospective study included 32 eyes with idiopathic full-thickness macular holes undergoing standard 25-gauge pars plana vitrectomy with inverted ILM flap and gas tamponade. Patients were assessed pre- and postoperatively with high-resolution swept-source OCT.All eyes had successful SS-OCT imaging despite having a gas-filled vitreous cavity. The researchers reported macular hole closure in 67%, 88% and 94% of eyes at one day, one week and one month, respectively.They observed early intraretinal hyperreflectivity in 94% of eyes, which correlated with successful closure. Absence of this finding was seen in delayed cases. They also found that ELM regeneration was linked to better BCVA. Over three months, average BCVA improved significantly from 0.89 to 0.47 logMAR.The researchers concluded in their paper that these two biomarkers are early predictors of macular hole closure. “These findings suggest that Müller cell activation and gliosis play an active role in scaffolding photoreceptor realignment, recapitulating developmental foveation,” they wrote. “Early SS-OCT biomarkers may therefore guide individualized postoperative management.”The authors proposed a five-step model of macular hole healing that could serve as a framework for understanding its clinical evolution. The steps, reproduced in the table below, include initial flap contact; scaffold formation; remodeling; restoration of outer retinal bands; and late foveal refinement. The researchers note that this model, developed from a single-center cohort based only on morphologic OCT findings without cellular or molecular correlation, requires external validation to confirm its reproducibility.Table 1. A Five-Step Model of Macular Hole ClosureStepsTimingMacular Hole StatusOCT Findings1. Initial flap contactUp to one hourOpenILM flap covering MH; fluid absorption; reduced MH diameter2. Scaffold formationOne hour to one dayPartial bridgingIncreased hyperreflectivity (kissing sign); cyst reabsorption3. RemodelingOne day to one weekClosed/nearly closedConsolidated bridging; outer retinal restoration (partial ELM)4. Restoration of outer retinal bandsOne week to one monthClosedELM further established; less hyperreflectivity; ONL thickens; foveal contour starts to restore5. Late foveal refinementOne month or moreClosedEllipsoid zone and interdigitation zone begin to reappear; smooth foveal contour Click here for the journal source. Francone A, Govetto A, Peñalva J, et al. Postoperative dynamics of full-thickness macular holes: insights from high-resolution optical coherence tomography under gas tamponade. Ophthalmology Sci. January 2026. [Epub ahead of print]. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.