Macular Pseudohole

Key points of this disease

• Macular pseudohole (MPH) is a condition in which an epiretinal membrane (ERM) that avoids the fovea contracts centripetally, causing the foveal edge (wall of the depression) to rise steeply, making it appear like a macular hole. There is no full-thickness hole in the retina ^{1, 2, 3)}.
• In 1976, Allen and Gass first described it as “contraction of a perifoveal epiretinal membrane simulating a macular hole” and named it pseudohole. All reported cases had normal to nearly normal visual acuity ¹⁾.
• OCT is definitive for diagnosis. It shows an epiretinal membrane that avoids the fovea and a steep, narrow foveal depression with elevated edges, without a full-thickness defect (macular hole) or loss of foveal tissue (lamellar macular hole) ^{2, 3)}.
• The Watzke-Allen sign is negative (slit light is not interrupted), which helps differentiate it from a true macular hole (positive).
• Visual acuity is often relatively preserved, and symptoms are mainly mild metamorphopsia and blurring due to the epiretinal membrane ^{1, 5)}.
• The course is relatively stable; even the type with a torn edge remains a “pseudohole” and rarely progresses to a true lamellar macular hole ⁴⁾.
• If symptoms are mild, observation is recommended. If metamorphopsia or visual loss becomes problematic, vitrectomy (epiretinal membrane and internal limiting membrane peeling) is performed similarly to epiretinal membrane, achieving good visual improvement ^{5, 6, 7)}.

1. What is macular pseudohole?

Macular pseudohole (MPH) refers to a condition in which deformation of the fovea due to an epiretinal membrane (ERM) makes it appear as if there is a macular hole. As the name “pseudo” suggests, it looks like a hole on ophthalmoscopy, but there is no actual full-thickness defect in the retina itself ^{1, 2)}. In Japanese, it is sometimes called “pseudo macular hole.”

In 1976, Allen and Gass reported four cases of contraction of a parafoveal epiretinal membrane that resembled a macular hole, and named this condition a pseudohole. All four patients had normal to nearly normal visual acuity at initial examination; over 3–4 years, findings remained unchanged in two cases, the membrane contraction progressed to a macular pucker-like appearance in one case, and the membrane spontaneously detached and the pseudohole disappeared in one case ¹⁾.

Currently, it is understood that an epiretinal membrane that stretches while avoiding the fovea undergoes centripetal (tangential, inward) contraction, pulling the surrounding tissue of the foveal depression toward the center, causing the edge of the depression to rise vertically (verticalization) and forming a narrow, steep foveal depression. There is no loss of foveal tissue or full-thickness裂隙 ^{2, 3)}.

Positioning among vitreoretinal interface diseases

There are several morphological changes of the fovea associated with epiretinal membranes, and in 2020 Hubschman et al. provided an international consensus definition based on OCT findings. Here, macular pseudohole was clearly distinguished from lamellar macular hole (LMH) and ERM foveoschisis (ERM-FS) ³⁾.

• Macular pseudohole (MPH): Characterized by an epiretinal membrane that avoids the fovea and a steepened foveal profile (with increased macular thickness). No tissue defect ³⁾.
• Lamellar macular hole (LMH): A lesion with tissue defect, requiring an irregular foveal contour, a foveal cavity with excavated edges, and loss of foveal tissue ³⁾.
• ERM foveoschisis (ERM-FS): Characterized by an epiretinal membrane and retinal splitting at the level of the Henle fiber layer ³⁾.

Macular pseudohole and ERM-FS are changes due to traction from an epiretinal membrane, whereas lamellar macular hole is a degenerative lesion with tissue defect, which is a major pathophysiological difference ³⁾. For details, see also the articles on macular hole, epiretinal membrane, and retinal proliferation.

Epidemiology

Macular pseudohole occurs in eyes with epiretinal membrane. A report found pseudohole in 54 of 369 cases (approximately 15%) evaluated for epiretinal membrane ⁴⁾, indicating it complicates a certain proportion of epiretinal membranes. The age of onset is similar to that of epiretinal membrane, typically in older adults; one comparative study reported a mean age of 71.1±7.8 years in the macular pseudohole group ⁶⁾. For risk factors of epiretinal membrane (aging, posterior vitreous detachment, etc.), refer to the article on epiretinal membrane.

2. Main Symptoms and Clinical Findings

Subjective Symptoms

Macular pseudohole often preserves relatively good visual acuity, and asymptomatic cases are not infrequently discovered incidentally. When symptomatic, the symptoms are primarily due to the underlying epiretinal membrane.

• Metamorphopsia (distortion): Reflects deformation of the fovea due to traction from an epiretinal membrane.
• Mild visual impairment and blurring: In a report summarizing surgical cases, the median preoperative visual acuity was 20/63 (range 20/32 to 20/860)⁵⁾.
• Asymptomatic: Because the full-thickness structure of the fovea is preserved, the strong central scotoma typically seen in true macular holes does not occur¹⁾.

Clinical Findings

On ophthalmoscopy and slit-lamp microscopy, a well-defined, reddish, round or oval lesion surrounded by a glistening epiretinal membrane is observed at the fovea, resembling a macular hole. However, unlike a true full-thickness macular hole, it is often not accompanied by a surrounding cuff of subretinal fluid or yellow deposits, and visual acuity is relatively preserved ^{1, 4)}.

The Watzke-Allen sign is useful for differentiation. When a slit beam is directed at the lesion, patients with a true full-thickness macular hole perceive a narrowing or break in the center of the beam (positive), whereas those with a macular pseudohole perceive a continuous beam of uniform width (negative). However, final confirmation is made by OCT.

Q What is the difference between a macular pseudohole and a macular hole (true hole)?

A

A macular hole is a full-thickness defect (hole) in the retina at the fovea, causing decreased central vision and central scotoma. In contrast, a macular pseudohole is caused by contraction of the epiretinal membrane, where the edge of the fovea appears elevated like a hole, but there is no actual retinal defect^{1, 2)}. Therefore, vision is relatively preserved, and the Watzke-Allen sign is negative. OCT can clearly distinguish whether there is a full-thickness defect (macular hole), a tissue defect (lamellar macular hole), or no defect with only elevated edges (macular pseudohole)^{2, 3)}.

3. Causes and Risk Factors

The direct cause of a macular pseudohole is centripetal contraction of an epiretinal membrane that stretches around the fovea. Therefore, the risk factors are the same as those for epiretinal membrane^{2, 3)}.

• Aging and posterior vitreous detachment (PVD): The main cause of idiopathic epiretinal membrane.
• Underlying diseases of secondary epiretinal membrane: retinal tear, rhegmatogenous retinal detachment, after intraocular surgery, uveitis, retinal vascular occlusion, etc.

Details on the epidemiology and pathogenesis of epiretinal membrane are summarized in the article Epiretinal Membrane.

Lifestyle Precautions

Most lamellar macular holes are age-related changes associated with epiretinal membrane, and it is difficult to prevent them directly through lifestyle habits. Although vision is often preserved, if you notice metamorphopsia (distortion) or decreased vision, see an ophthalmologist early and undergo OCT to distinguish it from a true macular hole.

4. Diagnosis and Examination Methods

OCT (Optical Coherence Tomography)

OCT is definitive for diagnosing lamellar macular hole ²⁾. Differentiation from true macular hole or split-thickness macular hole is easy using OCT.

Typical OCT findings are as follows ^{2, 3)}.

• Epiretinal membrane sparing the fovea: A hyperreflective membranous structure is seen outside the fovea, and the fovea itself is not covered by the membrane.
• Steep and narrow foveal depression: The edge of the fovea rises vertically (verticalization), and the width of the depression narrows.
• Thickening of the foveal edge: The parafoveal retina thickens due to traction.
• No full-thickness or split-thickness defect: The bottom of the fovea (outer retina) remains continuous without tissue loss. This is the key difference from macular hole and split-thickness macular hole.

Foveal thickness is normal to slightly increased. In one comparative study, foveal thickness in lamellar macular hole was 233±94 μm, tending to be thinner than in epiretinal membrane (434±97 μm). This is thought to be because the steep foveal depression is preserved in lamellar macular hole ⁶⁾. For diagnosis, it is important to confirm continuously with volume scan, not just a single cross-section, and ensure there is no full-thickness defect.

Differential Diagnosis from Major Diseases

There are multiple lesions that appear “hole-like” in the fovea associated with epiretinal membrane, all of which are distinguished by OCT.

Lesion	OCT key features	Foveal tissue defect
Macular pseudohole (MPH)	ERM sparing fovea + steep edges	None3)
Full-thickness macular hole (FTMH)	Full-thickness foveal defect	Full-thickness defect
Lamellar macular hole (LMH)	Irregular contour, excavated cavity, tissue defect	Present (partial thickness)3)
ERM foveoschisis (ERM-FS)	ERM + splitting at Henle fiber layer level	None (splitting predominant)3)

Matoba R, Morizane Y. Epiretinal membrane: an overview and update. Jpn J Ophthalmol. 2024;68(6):603-613. Figure 4. PMCID: PMC11607056. License: CC BY 4.0.

OCT B-scan comparison of lamellar macular hole (a), ERM foveoschisis (b), and macular pseudohole (c). Corresponds to the differential diagnosis in section “4. Diagnosis and Examination Methods.” Macular pseudohole (c) shows no full-thickness or partial-thickness tissue defect, but rather an epiretinal membrane with retinal folds (arrowheads) and a vertically steepened foveal profile (asterisk).

Q What is the most important test for diagnosing macular pseudohole?

A

OCT (optical coherence tomography). It can noninvasively confirm the absence of a full-thickness defect (macular hole) or partial-thickness tissue defect (lamellar macular hole) in the fovea, and can visualize the characteristic features of macular pseudohole: an epiretinal membrane that spares the fovea and a steeply rising foveal edge ^{2, 3)}. It is important to confirm not only with a single cross-sectional image but also with a volume scan to avoid missing a true macular hole.

5. Standard Treatment

Observation

For macular pseudohole with preserved vision and mild or no symptoms, observation is the standard. Macular pseudohole often follows a relatively stable course, and even when the edge is torn, it tends to remain a pseudohole and rarely progresses to a true lamellar macular hole ⁴⁾. Regular OCT is used to monitor changes in foveal morphology and visual acuity.

Vitrectomy

If metamorphopsia or visual impairment interferes with daily activities, vitrectomy (pars plana vitrectomy + epiretinal membrane peeling + internal limiting membrane peeling) is considered, similar to epiretinal membrane surgery ⁷⁾. Surgery is elective and not urgent.

Surgical outcomes are favorable.

• In a study of 50 eyes with epiretinal membrane and macular pseudohole, the median postoperative visual acuity was 20/40, with 62% (31/50 eyes) achieving a 2-line or greater improvement, and 80% (40/50 eyes) reaching 20/50 or better. The presence of a pseudohole did not significantly affect postoperative visual prognosis, and even in cases where the pseudohole persisted (30% at 6 months), visual acuity improved ⁵⁾.
• Regardless of the foveal edge morphology (vertical and smooth vs. stretched and torn), surgery has been reported to improve macular morphology and visual acuity ⁴⁾.
• In a recent comparative study, the best-corrected visual acuity after surgery for macular pseudohole improved from logMAR 0.293±0.25 to 0.058±0.17 ⁶⁾.

Precautions and Complications in Treatment

• Since surgery for macular pseudohole follows the same principles as epiretinal membrane surgery, complications are similar. In phakic eyes, cataract progression occurs in almost all cases postoperatively, and rarely, retinal tears, retinal detachment, or iatrogenic macular hole may occur. For details, refer to the article on epiretinal membrane.
• Surgery is selected based on the degree of visual acuity loss and metamorphopsia, as well as the impact on the patient’s daily life. If visual acuity is good and symptoms are mild, observation without surgery is chosen.

Q Is surgery always necessary for a lamellar macular hole?

A

No. If visual acuity is preserved and symptoms are mild or absent, observation is the basic approach. Lamellar macular holes are relatively stable and are known to rarely progress to true full-thickness macular holes⁴⁾. When metamorphopsia or visual loss interferes with daily life, vitrectomy can be considered similarly to epiretinal membrane, and good visual improvement can be expected^{5, 6)}. The need for surgery is determined based on symptoms and impact on daily life.

Q Will a lamellar macular hole become a true macular hole in the future?

A

In most cases, lamellar macular holes follow a relatively stable course. Even in types where the foveal rim is stretched and torn, it has been reported that they remain as “pseudoholes” and rarely progress to true full-thickness macular holes⁴⁾. However, traction from the epiretinal membrane may rarely progress, so regular follow-up with OCT is recommended. If distortion or visual difficulty suddenly worsens, seek medical attention promptly.

6. Pathophysiology and Detailed Mechanism

A lamellar macular hole is caused by centripetal (tangential, inward) contraction of an epiretinal membrane that stretches around the fovea. When the membrane pulls the perifoveal tissue toward the center, the edges of the foveal depression become vertically elevated, making the depression narrow and steep. At the same time, the parafoveal retina thickens. During this process, the full-thickness structure of the fovea is preserved, and no tissue gaps or defects occur^{2, 3)}.

In this regard, lamellar macular holes differ from the following conditions in pathophysiology:

• Full-thickness macular hole: In addition to tangential traction, anteroposterior traction acts, causing a true full-thickness dehiscence at the fovea.
• Lamellar macular hole (degenerative type): A degenerative lesion with loss of foveal tissue, accompanied by irregular contour, excavated cavity, and tissue defect³⁾.

The morphology of the foveal rim in lamellar macular holes has been reported to include a vertical, smooth type and a type stretched and torn by asymmetric traction, but both are treated as pseudoholes without tissue defects⁴⁾.

7. Recent Research and Future Perspectives

Classification is being refined

The following mainly concerns understanding of pathophysiology and refinement of classification (nomenclature). The management of lamellar macular holes themselves (observation and epiretinal membrane surgery for symptomatic cases) is established.

Terminology and Classification Unification

In the past, terms such as pseudohole, lamellar hole, and foveal detachment due to ERM were used interchangeably, leading to inconsistencies in study populations. The 2020 OCT-based international consensus definition by Hubschman et al. clearly distinguishes macular pseudohole, lamellar macular hole, and ERM-associated foveoschisis, and has since become the standard for research and clinical documentation ³⁾.

Comparative studies with related lesions

Based on the consensus definition, studies comparing epiretinal membrane, macular pseudohole, ERM-associated foveoschisis, and lamellar macular hole under the same criteria are progressing. Among these, macular pseudohole is positioned as a group with relatively preserved foveal structure and better postoperative visual acuity ⁶⁾. More precise delineation of the natural course and surgical indications for each lesion is expected in the future.

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8. References

1. Allen AW Jr, Gass JD. Contraction of a perifoveal epiretinal membrane simulating a macular hole. Am J Ophthalmol. 1976;82(5):684-691. doi:10.1016/0002-9394(76)90002-7. PMID:998690.
2. Haouchine B, Massin P, Tadayoni R, Erginay A, Gaudric A. Diagnosis of macular pseudoholes and lamellar macular holes by optical coherence tomography. Am J Ophthalmol. 2004;138(5):732-739. doi:10.1016/j.ajo.2004.06.088. PMID:15531306.
3. Hubschman JP, Govetto A, Spaide RF, Schumann R, Steel D, Figueroa MS, Sebag J, Gaudric A, Staurenghi G, Haritoglou C, Kadonosono K, Thompson JT, Chang S, Bottoni F, Tadayoni R. Optical coherence tomography-based consensus definition for lamellar macular hole. Br J Ophthalmol. 2020;104(12):1741-1747. doi:10.1136/bjophthalmol-2019-315432. PMID:32107208.
4. Gaudric A, Aloulou Y, Tadayoni R, Massin P. Macular pseudoholes with lamellar cleavage of their edge remain pseudoholes. Am J Ophthalmol. 2013;155(4):733-742.e4. doi:10.1016/j.ajo.2012.10.021. PMID:23312734.
5. Massin P, Paques M, Masri H, Haouchine B, Erginay A, Blain P, Gaudric A. Visual outcome of surgery for epiretinal membranes with macular pseudoholes. Ophthalmology. 1999;106(3):580-585. doi:10.1016/S0161-6420(99)90119-7. PMID:10080217.
6. Kubota N, Miyata K, Mori Y, Nakano Y, Goto H, Okamoto F. Clinical characteristics and optical coherence tomography findings in epiretinal membrane, macular pseudohole, epiretinal membrane-foveoschisis, and lamellar macular hole. PLoS One. 2025;20(5):e0323933. doi:10.1371/journal.pone.0323933. PMID:40434985; PMCID:PMC12118851.
7. Bailey ST, Vemulakonda GA, Kim SJ, Kovach JL, Lim JI, Ying GS, Flaxel CJ, American Academy of Ophthalmology Preferred Practice Pattern Retina/Vitreous Committee. Idiopathic Epiretinal Membrane and Vitreomacular Traction Preferred Practice Pattern®. Ophthalmology. 2025;132(4):P197-P233. doi:10.1016/j.ophtha.2024.12.019. PMID:39918520.