We read with interest the article by Polkinghorne and Roufail1 on eccentric macular hole formation associated with macular hole surgery. From their series of four eyes, they described that the ‘risk appears higher in eyes operated on by vitreoretinal fellows’ and christened it the ‘fellow eye syndrome,’ which is a clever wordplay that hopefully is not derogatory or uncharitable. However, Rubinstein et al2 in their seminal report of four patients stated that ‘one experienced vitreoretinal surgeon performed all the operations (RB)’. Likewise in our experience with two patients, the development of eccentric macular hole did not occur in the hands of fellows, but in the hands of a more experienced vitreoretina fellowship-trained surgeon (KGAE). Incidentally, one of our two patients was also a myope with associated myopic chorioretinal degeneration who developed multiple eccentric macular holes after undergoing standard pars plana vitrectomy and internal limiting membrane peeling for macular hole.

Although we agree with the authors’ suggestion that the eccentric macular hole probably results ‘from excessive manipulation,’ we believe that the culprit is not necessarily the direct iatrogenic insult alone. We concur with their opinion that ‘outer retinal degenerative changes may increase the risk of eccentric macular hole formation.’1 Concomitant predisposing degenerative weaknesses as in the presence of ‘extensive drusen’1 or myopic chorioretinal degeneration (as in our case) as well as weakening of the glial structure of the retina caused by decapitation of the Muller cells3 may also play a role in the development of eccentric macular hole.