CLINICAL SCIENCES The Visual Performance and Metamorphopsia of Patients With Macular Holes Yoshihiro Saito, MD; Yoshiko Hirata, MD; Atsushi Hayashi, MD; Takashi Fujikado, MD; Masahito Ohji, MD; Yasuo Tano, MD Background: Most patients attain better visual acuity divided the subjective changes into 2 types of metamor- with the elimination of metamorphopsia after success- phopsia; of the 54 eyes, pincushion distortion (bowed ful closure of a macular hole (MH) by vitrectomy. toward the center) was found in 33 (61%), and unpat- terned distortion (no specific pattern) was found in 21 Objective: To determine the presurgical visual func- (39%). Pincushion distortion was significantly associ- tion of eyes with an MH. ated with an MH of shorter duration (#6 months) (P = .03) and an early stage (stage 2) of MH formation Methods: We examined 54 eyes of 51 patients with an (P = .02). A scotoma was hard to detect, and patients had idiopathic MH using the Amsler chart. We evaluated difficulty describing their scotomata and distortions. In the types of subjective metamorphopsia and compared the montage test, patients with early MHs chose por- them with the clinical factors associated with MHs. In a traits modified with a pincushion type of distortion. prospective study, we performed a montage test on a separate group of 16 patients with unilateral idiopathic Conclusions: We found concentric pincushion meta- MHs. The patients were asked to choose, while viewing morphopsia without subjective scotomata, which we sug- with their better eye, the computer-modified picture gest arises from an eccentric displacement of the photo- that best matched the unmodified image seen by the eye receptors. This accounts for the main characteristic of the with the MH. visual performance of patients with idiopathic MHs. Results: From the results of the Amsler chart test, we Arch Ophthalmol. 2000;118:41-46 ELLY AND Wendel1 and the hole. The presence of these alter- others2-4 have reported on ations would be expected to produce a cen- the effect of the closure of tral absolute scotoma surrounded by an idiopathic macular holes area of metamorphopsia. When we exam- (MHs) on the recovery of ine the patients’ subjective symptoms, Kvisual function after pars plana vitrec- however, only a few patients have a sco- tomy and gas tamponade. After the suc- toma and the most consistent complaint cessful closure of the holes, many is that objects appeared distorted, frag- patients gain better visual acuity with the mented, or both (ie, metamorphopsia). disappearance of the presurgical meta- One of the methods used to detect morphopsia.5-7 However, relatively little functional visual changes is the Amsler attention has been paid to the quality of chart test.11,12 It is a rapid and sensitive visual function in the presence of MHs, technique for evaluating 10° of the cen- ie, the presurgical visual function. tral visual field in patients with macular The visual loss in eyes with a full- changes.13 Recently, it has been used to de- thickness MH is thought to be caused by tect the early signs of macular changes in the absence of the neurosensory retina in the fellow eye of patients with visual loss the area of the anatomical defect and by the from age-related macular degeneration. reduction of retinal function in the sur- Johnson and Gass14 conducted Amsler rounding area of retinal detachment.8 Pre- chart testing in patients with MHs and re- From the Departments of operative microperimetry with a scanning ported that metamorphopsia was the main Ophthalmology, Osaka laser ophthalmoscope has demonstrated an symptom. University Medical School, Osaka (Drs Saito, Hirata, absolute scotoma with a relative scotoma In this study, we studied in more de- Hayashi, Fujikado, Ohji, and in the surrounding concentric isopters that tail the visual performance of patients with 9,10 Tano), and Hyogo Prefectural corresponded to the anatomical defect. idiopathic MHs using the Amsler chart. We Nishinomiya Hospital, Histological studies have shown the found that the characteristic central meta- Nishinomiya (Dr Saito), Japan. absence of all retinal layers in the area of morphopsia was a pincushion distortion, ARCH OPHTHALMOL / VOL 118, JAN 2000 WWW.ARCHOPHTHALMOL.COM 41 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 pincushion distortion that made lines bowed toward the center (Figure 1, A), and the second was unpatterned PATIENTS AND METHODS metamorphopsia (Figure 1, B) that had no specific pat- tern. Of the 54 eyes, pincushion distortion was found in Between January 9, 1995, and December 19, 1997, 33 (61%) and unpatterned metamorphopsia was found in we examined 54 eyes of 51 patients with an idio- 21 (39%). The Table shows the clinical features associ- pathic MH using the Amsler chart. The research fol- ated with the metamorphopsia as determined by Amsler lowed the tenets of the Declaration of Helsinki, in- chart testing. A pincushion distortion was significantly as- formed consent was obtained from all participants, sociated with an MH of shorter duration (#6 months) and and the research was approved by the Departmental with an earlier stage of MH (stage 2). Review Board of Osaka University, Osaka, Japan. Because there was metamorphopsia in all of the pa- There were 16 men and 35 women whose mean ± SD tients, the central scotoma was usually difficult to delin- age was 64.3 ± 6.5 years (range, 45-77 years). Fun- eate. Although most of the patients complained of loss dus examinations were performed with a double of central vision, a scotoma or the disappearance of the aspheric indirect lens (Super Field; Volk Optical Inc, Mentor, Ohio) or a +78-diopter lens. When there was fixation dot was hard to detect. The patients stated that a question about the MH, microperimetry with a scan- when they gazed a little away from the central dot, it be- ning laser ophthalmoscope was used to separate a came easier to find the dot. pseudo-MH from a true full-thickness MH.10 For the montage test, we modified the classic Mona Using Gass classification,16 there were 16 eyes Lisa portrait as follows: unmodified (Figure 2, A), a sco- with stage 2, 32 eyes with stage 3, and 6 eyes with toma in the face (Figure 2, B), a pincushion distortion stage 4 MHs. The duration of the MH, based on the between the eyebrows (Figure 2, C), and a pincushion patient’s complaint, was 0.2 to 48 months (mean ± SD, distortion with a small central area removed from the left 5.0 ± 9.1 months). The preoperative visual acuities eye (Figure 2, D). When viewed, all of the patients ranged from 0.02 to 0.80. promptly denied seeing a central scotoma in Figure 2, We examined the results of the Amsler tests of the patients retrospectively, and evaluated the type B. The patients had difficulty describing their scoto- of metamorphopsia. The type of metamorphopsia was mata and distortions precisely; however, all patients se- compared with the duration of the MH, the stage of lected the pincushion photograph as their perception with the MH, and the preoperative visual acuity. The Am- the eye with the MH (Figure 2, C and D). The difference sler chart examinations were carried out by the in their description was in the location, size, or both of method recommended by Amsler,11 with a working the pincushion lesion in the photographs. Two patients distance of 0.3 m and the use of the same spectacle stated that the pincushion area appeared darker than other correction as used to test the reading acuity. Statis- parts of the photograph. tical analysis was performed using the x2 test or the Fisher exact test. Between January 12, 1998, and December 18, COMMENT 1998, a separate group of 16 patients with unilateral idiopathic MHs (stage 2, 4 patients; stage 3, 10 pa- Our results indicated that approximately 70% of the pa- tients; and stage 4, 2 patients) was studied to deter- tients with a fresh MH (duration, #6 months) have meta- mine the visual perception of patients with an MH. morphopsia of the pincushion type. After a comprehen- The patients consisted of 4 men and 12 women (mean sive study of the development of an MH, Gass15,16 age, 66 years; range, 55-83 years). The duration of established a classification of MHs, including the en- the MH was less than 6 months. largement of retinal tissue resulting from a tangential trac- These patients were shown 4 photographs 17 3 tion of the vitreous. Smith and associates also implied (10 13 cm) of a painting (Leonardo da Vinci’s Mona that the enlargement of the MH occurs without tissue loss Lisa), an unmodified picture and 3 that had been modified using computer software (Adobe Photo- around the macula. We have obtained evidence support- shop; Adobe Systems Inc, San Jose, Calif). While view- ing the hypothesis by Gass, namely, an enlargement of ing the pictures with their unaffected eye, they were the MH with displacement of the photoreceptors. asked to select the portrait that best resembled the Can these observations on patients with an MH tell unmodified photograph seen by the affected eye. us anything about the retinal pathological characteris- tics? Assume a vertical line is imaged on the retina a few degrees from the fovea (Figure 3, A). If the line is to be perceived as bowing inward at the center, ie, a pincush- ie, a distortion bowed toward the center of the hole. We ion type of distortion, the center of the line must be clos- suggest that this results from the displacement of the pho- est to the fovea and the eccentric points of the line must toreceptors due to the tangential traction by the poste- fall on retinal points of increasing distance from the ver- rior vitreous.15 We also allowed patients to view computer- tical meridian (Figure 3, B).