What gass did not say: how many ways to create a macular hole

Thanks to Dr. Gass' proposal for staging macular holes, we could have insights into the pathogenesis and progression of idiopathic macular holes back in the era without optical coherence tomography (OCT). This staging system is based on the foveal appearance, the size of the macular hole, and the presence or absence of vitreous separation as observed through biomicroscopy. According to the staging progression, anteroposterior traction from the posterior hyaloid plays a significant role in the development of a macular hole. Although most of Dr. Gass' descriptions remain relevant after the development of OCT, we have observed some cases of macular holes that do not fit into the Gass’ classification. The International Vitreomacular Traction Study (IVTS) Group has developed a new classification system based on OCT findings, such as macular hole size and the vitreomacular relationship. However, this system still considers partial or complete vitreomacular separation a necessary condition for the development of a macular hole. Interestingly, we have noticed that in some cases, there is no vitreomacular separation at the macular area, whereas in others, the macular hole develops only after posterior hyaloid detachment. These observations suggest that some macular holes might not develop through the classical route described by Dr. Gass. The traction force resulting in macular hole formation may be tangential, originating either from the undetached posterior hyaloid, the internal limiting membrane, or the epiretinal membrane. In this talk, we will explore aspects of the pathogenesis of idiopathic macular holes that Dr. Gass did not say.