Traction-Induced Structural Failure States in Macular Hole Formation Revealed by Volume-Rendered Swept-Source OCT.

Abstract

To analyze macular hole development using three-dimensional visualization of vitreomacular architecture volume-rendered optical coherence tomography (OCT) and to interpret observed anatomic configurations using structural and mechanical principles. This retrospective observational study included eyes with developing macular holes imaged using a swept-source OCT. Volumetric datasets of the macula and overlying vitreous were processed with extended dynamic-range processing and rendered to permit three-dimensional visualization of vitreous attachment, deformation, and retinal structural changes. Anatomic configurations were evaluated descriptively. Terminology was applied to denote OCT-based structural failure states without implying a fixed temporal sequence. Seventeen eyes of thirteen patients were analyzed. Persistent vitreous attachment to the central macula was associated with a range of distinct anatomic configurations, including inner macular cavitation, combined inner cavitation with outer retinal separation, outer macular holes with preserved inner retina, inner lamellar holes, and full-thickness macular holes. Volume rendering demonstrated asymmetric vitreous attachment, catenary-like vitreous geometry, tears in the posterior cortical vitreous, vitreous prolapse, and frequent retinal flaps that were not readily apparent on conventional planar imaging. Longitudinal imaging showed variable transitions between structural configurations associated with changes in vitreous attachment rather than a uniform progression through predefined stages. Volume-rendered swept-source OCT enables direct visualization of vitreomacular architecture during macular hole development. The observed anatomic configurations are best understood as traction-induced structural failure states of the central macula rather than as a linear temporal staging sequence. This framework better accounts for the diversity, asymmetry, and nonuniform evolution of macular hole morphology observed in vivo.