Diagnosis of Macular Pseudoholes and

Lamellar Macular Holes by Optical

Coherence Tomography

BELKACEM HAOUCHINE, MD, PASCALE MASSIN, MD, PHD, RAMIN TADAYONI, MD,
ALI ERGINAY, MD, AND ALAIN GAUDRIC, MD

● PURPOSE: To assess the usefulness of optical coherence 138:732–739. © 2004 by Elsevier Inc. All rights
tomography (OCT) for better differential diagnosis of reserved.)
macular pseudoholes (MPH) and lamellar macular holes

M
(LMH). ACULAR PSEUDOHOLE (MPH) AND LAMELLAR
● DESIGN: Observational case series. macular hole (LMH) are two different entities
● METHODS: SETTING: Institutional practice. PATIENTS: whose only common feature is the round and
We reviewed the files of 71 eyes of 70 consecutive reddish appearance of the macula. Each entity may constitute
patients who were diagnosed as having a pseudohole or a differential diagnosis for full-thickness macular hole
lamellar hole on OCT examination. All patients referred (FTMH).
for suspected pseudohole or lamellar hole on biomicros- Their pathogenesis is different. The pseudohole is attrib-
copy were evaluated by OCT. MAIN OUTCOME MEASURES: utable to the centripetal contraction of an epiretinal mem-
Each eye underwent six radial 3-mm OCT scans centered brane (ERM),1 whereas the lamellar hole usually results from
on the macula, one 6-mm vertical and one 6-mm hori- an abortive process of macular hole formation2– 4 or may be a
zontal scan. Retinal thickness was measured at the foveal
complication of chronic macular cystoid edema.5 Differenti-
center and 750 !m from the center, vertically, and
ating between these two conditions may be easy. However, in
horizontally. The diameter of the macular contour was
some cases, the appearance of the macula may be confusing,
also measured on vertical and horizontal scans.
● RESULTS: In 40 cases, OCT showed a macular profile
either because the ERM, which is always present in
characteristic of MPH: a steepened foveal pit combined pseudoholes, may be barely visible, or because a lamellar hole
with thickened foveal edges and a small foveal pit is surrounded by an ERM. Additionally, metamorphopsia
diameter. Central foveal thickness was normal or slightly may be present in both conditions.
increased (167 " 42 !m). Mean perifoveal thickness For several years, optical coherence tomography (OCT)
was greater than normal (363 " 65 !m). In 29 other has allowed the characterization of the profile and intraretinal
cases corresponding to LMH, OCT showed a profile structural changes of many macular diseases. Examples of the
characterized by a thin irregular foveal floor, split foveal OCT profiles of LMH and MPH have already been shown3,6,7
edges, and near-normal perifoveal retinal thickness. Cen- but have not yet been studied in a series of patients.
tral foveolar thickness was thinner than normal (72 " 19 The aim of this study was to assess the usefulness of OCT
!m). Mean perifoveal thickness was near normal (283 " in distinguishing lamellar holes from pseudoholes in a series of
36). Optical coherence tomography did not allow the 71 cases.
classification of the remaining two cases.
● CONCLUSIONS: Optical coherence tomography is very
useful in distinguishing MPH attributable to epiretinal
membrane contraction from LMH because of partial DESIGN
opening of a macular cyst. (Am J Ophthalmol 2004;
THIS STUDY WAS AN OBSERVATIONAL CASE SERIES.

Accepted for publication June 29, 2004.

From the Department of Ophthalmology, Hôpital Lariboisière, Assis-
tance Publique-Hôpitaux de Paris, Université, Paris, France.
Inquiries to Pascale Massin MD, PHD, Department of Ophthalmology, METHODS
Hôpital Lariboisière, 2 Rue Ambroise Paré, 75475 Paris CEDEX 10,
France; fax: 33-1-49-95-64-83; e-mail: p.massin@lrb.ap-hop-paris.fr ● SETTING: Institutional practice.

732 © 2004 BY ELSEVIER INC. ALL RIGHTS RESERVED. 0002-9394/04/$30.00

doi:10.1016/j.ajo.2004.06.088
FIGURE 1. Examples of measurements of lamellar macular holes (LMH) and macular pseudoholes (MPH) on optical coherence
tomography (OCT) scans. (Top left) Red-free photograph of a LMH. White arrows indicate the points at which retinal thickness
was measured, 750 !m from the center, on horizontal and vertical scans. The red cross indicates the horizontal and vertical
diameters of the LMH contour. (Top right) Horizontal OCT scan of the same case, showing the placement of calipers for measuring
retinal thickness at different locations. The red bar indicates the opening of the lamellar hole, red arrowheads indicate the retinal
thickness at the thinnest point of the macula, and blue arrowheads, the retinal thickness at a point 750 !m from the center. (Bottom
left) Red-free photograph of a MPH. White arrows indicate the points where retinal thickness was measured, 750 !m from the
center, on horizontal and vertical scans. The red cross indicates the horizontal and vertical diameters of the LMH hole. (Bottom
right) Horizontal OCT scan of the same case. The red bar indicates the length of the pseudohole opening on the horizontal scan,
red arrowheads indicate the retinal thickness at the thinnest point of the macula, and blue arrowheads, the retinal thickness at a
point 750 !m from the center. In this series of cases the opening of MPH (red bar) was smaller than this of LMH (293 " 120 !m
vs 569 " 159 !m).

● PATIENTS: We retrospectively reviewed the files of 71 and OCT scan (Carl Zeiss Meditec, Dublin, California)
eyes of 70 consecutive patients who were examined were recorded in all patients. Visual acuity was measured
between 1999 and 2002 and were diagnosed as having a on a Snellen chart and was converted into the logarithm of
pseudohole or lamellar hole on OCT examination. They the minimum angle of resolution for statistical analysis.
included 31 men and 39 women. Their mean age was 67 Biomicroscopy was always done using a contact lens to
years (range, 17– 85). These patients were referred to examine the macula. We retrospectively recorded the
our department because, on biomicroscopy, they ap- biomicroscopy diagnosis, which was noted in the patient’s
peared to have a hole in the macula. On examination, file, before the OCT examination was done.
the diagnosis of full-thickness macular hole was ruled Color fundus, as well as red-free and blue filter photo-
out, from the results of both biomicroscopy and OCT graphs, were all recorded with the TCR 50IA fundus
scans. camera (Topcon, Tokyo, Japan). OCT 1 was used for all
examinations, but the nine most recent patients were also
● OBSERVATION PROCEDURES: Best-corrected visual examined by the recent Stratus OCT 3000 (OCT 3) (Carl
acuity, biomicroscopic examination, fundus photography, Zeiss Meditec, Dublin, California), which provides better

VOL. 138, NO. 5 MACULAR PSEUDOHOLE AND LAMELLAR MACULAR HOLE 733
FIGURE 2. Two examples of macular pseudoholes. (Top left) Red-free photograph. Note the oval shape of the pseudohole; only
tiny superficial retinal folds are visible. Arrowheads indicate the direction of the 3-mm optical coherence tomography (OCT) scan.
(Bottom left) OCT 3 horizontal scan showing verticalization of the foveal pit, normal central foveolar thickness (150 !m, red
arrow), and moderately increased thickness of the surrounding macula (340 !m at 750 !m temporally from the center, white bar)
(Top right) Red-free photograph showing significant macular contraction. Arrowheads indicate the direction of the 3-mm OCT
scan. (Bottom) OCT 3 horizontal scan showing verticalization and narrowing of the foveal pit. Note the foveolar thickening (230
!m, red arrow) and thickening of the surrounding macula (380 !m at 750 !m temporally from the center, white bar).

resolution of the image. All thickness measurements were (Figure 1). The mean diameter of pseudoholes or lamellar
made on OCT 1 scans. holes was calculated as the average of their horizontal and
vertical diameters, using calipers placed on the edge of the
● MAIN OUTCOME MEASURES: Six radial scans 3 mm hole (Figure 1). At the end of the analysis it appeared that
long, one vertical scan 6-mm long, and one horizontal scan the cases could be assigned to two different patterns based
6 mm long were performed for each patient. The scans on the primary clinical diagnosis. The Mann-Whitney
were centered on the fixation point. All examinations nonparametric test was used for statistical comparison of
were performed by two of us (B.H. and A.E.) as part as the continuous variables. Institutional Review Board Ethics
usual examination of patients referred for macular surgery. Committee approval was not required for this study.
Optical coherence tomography scans were subse-
quently reviewed retrospectively. Measurements of retinal
thickness were obtained manually, using the software RESULTS
calipers. One measure was made at the thinnest point at
the base of the pseudohole or lamellar hole (Figure 1), and ON BIOMICROSCOPY, 49 OF THE 71 EYES WERE DIAGNOSED
therefore this point was not necessarily the exact center of as having MPH. This diagnosis was based on the presence
the foveola. Because the foveal base of lamellar holes was of a well-delineated round or oval image of the macula and
often irregular, all six radial scans were examined to find in eyes which had a definite ERM with retinal folds. Ten
the scan that crossed the thinnest part of the base. Retinal eyes were diagnosed as having LMH combined with a
thickness was also measured 750 !m from the center of the pseudo-operculum. The diagnosis of LMH was based on
macula nasally and temporally on the horizontal line the presence of a round or petal-shaped reddish lesion with

734 AMERICAN JOURNAL OF OPHTHALMOLOGY NOVEMBER 2004

FIGURE 3. Different optical coherence tomography (OCT) profiles of macular pseudoholes (MPH) (5 mm horizontal scans, on
OCT 3). (Top) MPH with an epiretinal membrane bridging superfical retinal folds. Foveolar thickening (180 !m, red arrow) and
thickening of the surrounding macula (370 !m at 750 !m temporally from the center, white bar). (Middle) MPH with intraretinal
cystic spaces in the edges of the pseudohole. Normal foveolar thickness (160 !m, red arrow) and thickening of the surrounding
macula (430 !m at 750 !m temporally from the center, white bar). (Bottom) MPH with thick epiretinal membrane and deep retinal
folds. Normal foveolar thickness (165 !m, red arrow) and thickening of the surrounding macula (410 !m at 750 !m temporally
from the center, white bar).

flat edges which was sharply circumscribed. The reddish thickness was 362 " 71 !m on the nasal side, and 364 "
center seemed slightly depressed, although the depression 77 !m on the temporal side (average, 363 " 65 !m). By
was not always detectable. Paler thin tracts occasionally comparison, the normal values for central foveal thickness
divided this reddish image. A pseudo-operculum was some- are 146 " 20 !m and for nasal and temporal perifoveal
times visible in front of the macula. The remaining 12 thickness, measured with OCT1 software mapping, 253 "
cases were impossible to classify on biomicroscopy. 9 and 233 " 8, respectively.8 On OCT profiles, the ERM
On OCT, two profiles were observed among the 71 eyes. was sometimes partially detached from the underlying
Forty eyes (group 1) had a profile corresponding to a MPH. retinal surface or was associated with cystic changes of the
In this group, the fovea was characterized by a steepened edges of the MPH (Figure 3). The best-corrected visual
contour and a smaller than normal foveal pit diameter, acuity of these cases ranged from 20/100 to 20/20 (median,
increased parafoveal retinal thickness, and normal or 20/40).
slightly increased centrofoveal thickness (Figure 2). The Twenty-nine cases (group 2) had a profile corresponding
mean diameter of the foveal pit in this group was 293 " to a LMH. In this group, the fovea was characterized by
120 !m. At the center of the pseudohole mean thickness irregular thinning of the center combined with normal or
was 167 !m " 42 (range, 114 to 295). Mean perifoveal moderately increased perifoveal retinal thickness. Eighteen

VOL. 138, NO. 5 MACULAR PSEUDOHOLE AND LAMELLAR MACULAR HOLE 735
FIGURE 4. Lamellar macular holes. (Top left) Red-free photograph: note the round contour of the macular center. Arrowheads
indicate the orientation of the scan. (Bottom left) Horizontal 5 mm optical coherence tomography (OCT) 3, scan, showing, in front
of the macula, the partially detached posterior hyaloid. The foveal floor is thinner than normal at its center (50 !m, red arrow),
and the edges of the lamellar hole are horizontally split. At a point 750 !m temporally from the center (white bar), retinal thickness
is 290 !m. (Top right) Red-free photograph. Note the bilobate contour of the lamellar hole. Arrowheads indicate the orientation
of the 3-mm scan. (Bottom right) Three-millimeter OCT scan showing the irregular foveal base. At its thinnest point, the foveal
floor thickness is 50 !m (red arrow), and the edges of the lamellar hole are horizontally divided by an extensive intraretinal split.
At a point 750 !m temporally from the center, (white bar), the retinal thickness is 260 !m.

cases (62%) had an epiretinal membrane on biomicros- visual acuity of this group ranged from 20/200 to 20/20
copy. The mean diameter of their foveal aperture was 569 (mean, 20/40).
" 159 !m. At the center of the lamellar hole, that is, at The macular center was significantly thinner in LMH
the thinnest retinal point, the retina was always thinner than in MPH (P # .0001). The perifoveal retina was also
than normal, with a mean of 70 " 18 !m (range, 34 to significantly thicker in MPH than in LMH (P # .0001), on
98). Mean perifoveal thickness was 287 " 37 !m on the both the nasal and the temporal sides (Figure 6). There
nasal side and 279 " 40 !m on the temporal side. The was also a significant intergroup difference in the mean
foveal floor was irregular and was surrounded by edges split diameter of the macular aperture (P # .0001), which was
horizontally by a cleft separating inner and outer retina larger in the LMH group (Figure 7).
(Figure 4). However, this cleft may only be visible on some Lastly, note that of the 40 eyes diagnosed as MPH on
of the radial scans because of the frequent asymmetry of OCT, 35 were also diagnosed as MPH on biomicroscopy, 2
the lamellar macular hole. Additionally, a pseudo-opercu- were diagnosed as LMH, and 3 were impossible to classify. Of
lum was attached to the incompletely detached posterior the 29 cases diagnosed as lamellar holes on OCT, 14 were
hyaloid in 7 of the 29 LMH cases (Figure 4). Because their diagnosed on biomicroscopy as MPH, 8 as LMH, and 7 were
foveal base was irregular, the OCT image of the lamellar impossible to classify. In the two remaining cases, the diag-
hole varied, depending on whether the OCT scan crossed nosis was uncertain, both on biomicroscopy and OCT,
the thinnest part of the hole (Figure 5). The best-corrected because central foveolar thickness was within the normal

736 AMERICAN JOURNAL OF OPHTHALMOLOGY NOVEMBER 2004

FIGURE 5. Different optical coherence tomography profiles of a lamellar macular hole according to the direction and length of the
scan. Scans a, b, and c are 3 mm long. On scan d, 6-mm long, an epiretinal memebrane is visible temporal to the macula (arrows).
The macular profile may differ, depending on the orientation of the scan; the most typical profile is represented by scan b.

range, but the macular edges had a lateral split highly and this difficulty may affect a possible surgical decision.
suggestive of a lamellar hole. Although ERM peeling is usually indicated in MPH when
it is justified by visual impairment, there is so far no proof
that this surgery is useful in LMH. Functional tests are not
DISCUSSION very useful for differentiating between LMH and MPH,
because the Watzke-Allen test is negative in both cases, no
MACULAR PSEUDOHOLES AND LMH ARE TWO WELL-KNOWN scotoma is detected on SLO microperimetry,14 and both
differential diagnoses of FMTH. As FTMH became a conditions lead to similarly impaired vision. In our series,
treatable condition, more attention was paid to its char- median visual acuity was 20/40 for both LMH and MPH;
acteristics, and Gass9,10 has thoroughly analyzed the crite- one case of MPH (2.5%) had visual acuity of less 0.3,
ria which allow impending or FTMHs to be distinguished compared with 2 cases of LMH (7%). Metamorphopsia was
from lesions simulating a macular hole. In most cases, also sometimes present in both conditions.
careful biomicroscopy slit-lamp examination with a con- MPH and LMH are, however, two completely different
tact lens makes it possible to diagnose FTMH. The entities. Macular pseudoholes is the result of ERM con-
Watzke-Allen test11 may be useful when it is frankly traction, which results in the verticalization of the foveal
positive (i.e., when the slit is seen to be interrupted), but slopes, as suspected by Allen and Gass,1 and which is now
there are still some false-positive cases.12 The laser aiming visible on OCT, whereas LMH results from an aborted
beam test may also be helpful, as well as Scanning Laser process of macular hole formation.3,15 In LMH there is
Ophthalmoscope (SLO) microperimetry.13,14 Optical co- avulsion of part of the macular tissue, but in MPH there is
herence tomography, however, easily shows the complete constriction of the entire macular tissue.
absence of foveal tissue, even in a very small area, in case Differentiating between MPH and LMH may still be
of FTMH. Once the diagnosis of FTMH has been ex- difficult in some cases, especially when the LMH is
cluded, it may still be difficult to determine whether a surrounded by an ERM or when the ERM causing the
round contour of the macula is because of LMH or MPH, MPH is thin, transparent, and not associated with obvious

VOL. 138, NO. 5 MACULAR PSEUDOHOLE AND LAMELLAR MACULAR HOLE 737
FIGURE 6. Mean retinal thickness at the macular center and 750 !m nasally and temporally. The retina is significantly thinner
at the macular center in lamellar macular hole (LMH) than in macular pseudoholes (MPH) (P < .0001). Parafoveal thickness is
significantly greater in MPH than in LMH, both nasally and temporally (P < .0001.).

the macula in the 29 LMH cases was 70 " 18 !m, whereas

the normal value for central foveal thickness is 146 !m "
20.7 This thinning fits well with the mechanism of LMH
formation, which involves the avulsion of the roof of a
foveal cyst without the opening of the outer layer of the
retina.3,4,15 Furthermore, in 7 (24%) of our 29 cases, a
small pseudo-operculum was seen in front of the macula,
on either biomicroscopy or OCT or both. This evolution
has now been well documented by OCT.3,4,18 The edges of
the foveal defect were usually split by a cleft between the
inner and outer retina on the OCT profile. On OCT scans
similar clefts are already present on OCT scans, in foveal
cysts, which are known to be the precursors of either LMH
or FTMH.2,4,6 Moreover, the OCT profile of these cases is
identical to the histologic appearance of LMH described by
Frangieh19 and by Guyer,20 which includes a lateral cleft
FIGURE 7. The mean horizontal and vertical diameters of the
between the Henle fibers and the inner nuclear layer.
macular aperture are significantly greater in LMH than in There are therefore enough convergent indications to
MPH; P < .0001. allow the characterization of the OCT profile of LMH.
In our 40 MPH cases, the mean thickness of the macular
center was 167 " 42 !m, that is, nearly normal or slightly
retinal folds. The fact that LMH may be surrounded by a increased. The MPH profile on OCT has already been
thin ERM is not surprising, as such membranes are also described by ourselves and others.21,22 The present study
present in 30% to 66% of cases of FTMH.16,17 shows, in a larger series of cases, that MPH is characterized
Optical coherence tomography has been especially help- by thickening of the macular area and verticalization of the
ful in distinguishing between these cases, and the present foveal slope, so that the foveal pit acquires a cylindrical
study indeed showed two clearly different profiles. In LMH, appearance, as suggested by Allen and Gass.1
the foveal center was thinner than normal, and its profile Optical coherence tomography makes it easy to differ-
was irregular. The mean thickness of the thinnest point of entiate MPH not only from FTMH but also from LMH.

738 AMERICAN JOURNAL OF OPHTHALMOLOGY NOVEMBER 2004

Here, only eight (28%) of the 29 LMH cases revealed by 6. Hee MR, Puliafito CA, Wong C, et al. Optical coherence
OCT were correctly diagnosed by biomicroscopy. Macular tomography of macular holes. Ophthalmology 1995;102:
pseudoholes were correctly diagnosed on biomicroscopy in 748 –756.
7. Massin P, Paques M, Masri H, et al. Visual outcome of
35 (87%) of the 40 MPH.
surgery for epiretinal membranes with macular pseudoholes.
There may be several limitations to this study. First, Ophthalmology 1999;106:580 –585.
because it is a retrospective study, there may have been 8. Massin P, Vicaut E, Haouchine B, Erginay A, Paques M,
selection of the more informative cases, and the interpre- Gaudric A. Reproducibility of retinal mapping using optical
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