A 66-year-old woman reports a gray spot in the center of vision of her left eye; the Watzke-Allen sign is positive. OCT of the macula shows a full-thickness foveal defect with elevated cystic margins, an overlying operculum, and complete posterior vitreous separation with no residual traction. This corresponds to which stage of idiopathic macular hole?

• A Stage 1b (impending hole)
• B Stage 4 (full-thickness hole with complete posterior vitreous detachment) ✓
• C Stage 3 (full-thickness hole without posterior vitreous detachment)
• D Stage 2 (small full-thickness hole with persistent traction)

Explanation

Gass stage 4 is defined by a large full-thickness foveal hole accompanied by complete posterior vitreous detachment, often with a visible operculum lifted away from the hole. Stage 3 holes are similar in size but retain vitreofoveolar adhesion, which is the single feature separating them from stage 4 here. Stage 2 is a small eccentric full-thickness break with persistent traction, and stage 1b is a pseudocyst without a full-thickness defect. Positive Watzke-Allen sign confirms a true full-thickness hole.

Reference: Ryan's Retina, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.