|Year : 2017 | Volume
| Issue : 3 | Page : 145-147
Early spontaneous reopening of traumatic macular hole
Ramesh Venkatesh, Manisha Agarwal, Prachi Gurav
Department of Retina and Vitreous, Dr. Shroff's Charity Eye Hospital, Delhi, India
|Date of Web Publication||11-Oct-2017|
Dr. Shroff's Charity Eye Hospital, 5027, Kedarnath Road, Daryaganj, Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Traumatic macular holes (MHs) are known to close spontaneously. Reopening of traumatic MHs is not reported frequently. The early spontaneous reopening of a traumatic MH is not known. We report a case of early onset spontaneous reopening of a traumatic MH. Ophthalmologists should be aware of this rare complication.
Keywords: Early, internal limiting membrane, macular hole, reopening, trauma
|How to cite this article:|
Venkatesh R, Agarwal M, Gurav P. Early spontaneous reopening of traumatic macular hole. J Clin Ophthalmol Res 2017;5:145-7
|How to cite this URL:|
Venkatesh R, Agarwal M, Gurav P. Early spontaneous reopening of traumatic macular hole. J Clin Ophthalmol Res [serial online] 2017 [cited 2022 Jul 4];5:145-7. Available from: https://www.jcor.in/text.asp?2017/5/3/145/216435
Macular holes (MHs) commonly are idiopathic but can occur secondary to trauma. Traumatic MHs may close spontaneously in 40% cases. The proposed mechanisms for spontaneous closure are the contracture of the epiretinal membrane (ERM) and fibroglial cell proliferation. We report a rare case of the early reopening of a traumatic MH. To the best of our knowledge, this is the first case to report in literature for a traumatic MH.
| Case Report|| |
A 21-year-old male student presented with diminution of vision in the right eye (RE) for the last 12 days after being hit by a plastic scale. His uncorrected visual acuity was 20/200 and with pin hole improved to 20/80, <N36. His best corrected visual acuity with −0.50DS −0.50DC 180° in the RE was 20/80, <N36 and visual acuity in the left eye was 20/20, N6. On examination, anterior segment was normal in both the eyes. Pupils were round, regular, and reacting to light in both eyes. Fundus examination of the RE showed a clear media with full-thickness MH (FTMH). The vitreous gel was well-formed with the absence of visible posterior vitreous detachment (PVD). On peripheral examination of the retina, no abnormalities were identified at the vitreous base or at the vitreoretinal interface. Optical coherence tomogram (OCT) examination using the Optovue, RTVue-100 machine showed an FTMH in the RE with the absence of PVD. The basal hole diameter was measured using manual calipers as the maximal hole diameter at the retinal pigment epithelium-photoreceptor junction. Similarly, the internal hole diameter was measured as the maximal hole diameter at the narrowest point of the MH. The basal hole and internal hole diameters of the MH were 925 μ and 324 μ, respectively [Figure 1]a,[Figure 1]b,[Figure 1]c. He was advised no surgical intervention. He presented 4 weeks posttrauma with an improvement in the RE vision. On examination, the vision in the RE was 20/40, N12. On OCT evaluation, the inner margins of the MH had apposed with a reduction in the basal hole diameter. No PVD or ERM was identified on OCT at this visit [Figure 2]. No surgical intervention was planned at this visit. Six-week posttrauma, the patient presented with a decrease in the RE vision. The vision in the RE had reduced to 20/80, N12. Anterior segment of both eyes was normal. Fundus examination of the RE showed a well-defined FTMH. There was no evidence of PVD or ERM formation. Repeat OCT scan was performed using the “tracking” mechanism through the same area of the macula which showed an FTMH in the right eye. The change analysis mode of the RTVue-100 machine was used to compare the scans between the previous and current scan. Both the basal hole diameter and internal hole diameter were increased to 1150 μ and 394 μ, respectively [Figure 3] a,[Figure 3]b,[Figure 3]c. Informed consent was taken and he underwent pars plana vitrectomy (PPV) using the 25G system with complete 360° internal limiting membrane peeling and 20% sulfur hexafluoride (SF6) gas tamponade in the RE at 6-week posttrauma. Intravitreal triamcinolone acetonide was used to stain the vitreous and assist in PVD induction. At 4-week postsurgery, his MH in the RE had closed with a Type 1 closure. His visual acuity improved to 20/30 [Figure 4].
|Figure 1: Color fundus, fundus autofluorescence picture, and optical coherence tomogram findings of the right eye at 2-week posttrauma. (a) Color fundus (right eye) showing a full thickness macular hole. (b) Fundus autofluorescence (right eye) showing area of central hyperautofluorescence corresponding to the size of the macular hole. (c) Optical coherence tomogram image of the right eye at presentation. Basal diameter of the macular hole is 925 μ|
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|Figure 2: Optical coherence tomogram findings of the right eye at 4-week posttrauma|
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|Figure 3: Color fundus, fundus autofluorescence picture, and Optical coherence tomogram findings of the right eye at 6-week posttrauma. (a) Color fundus (right eye) showing an increased size of the full thickness macular hole. (b) Fundus autofluorescence (right eye) showing an increasing area of central hyperautofluorescence corresponding to the increased size of the macular hole. (c) Optical coherence tomogram image of the right eye. Basal diameter of the macular hole is 1150 μ. There is increase in the size of the intraretinal cysts|
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|Figure 4: Optical coherence tomogram findings of the right eye at 4-week postsurgery|
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| Discussion|| |
MHs are most commonly idiopathic but can occur secondary to trauma. The anatomical and visual prognosis is said to be poorer for the traumatic MHs. While spontaneous closure for idiopathic MHs is 2.7%–6.2%, the rates of spontaneous closure in traumatic MHs are relatively higher. Spontaneous closure of the traumatic MHs is known to occur in 40% cases. In our case, the MH also showed a spontaneous closure after 2 weeks of presentation; however, there was a spontaneous reopening of the MH at 6-week follow-up which is rare. Reports in literature suggest that spontaneous closure of MHs is however correlated with younger age group, the absence of PVD, small internal hole diameter and less intraretinal cystic changes.,,, The presence of above features in the case would be considered “good prognostic” factors for the spontaneous closure of MH. On review of the literature, we found one similar case reported by Kameda et al. which showed a spontaneous reopening of a traumatic MH. However, in their case, the reopening of the MH happened after 2 years while in our case the MH reopened as early as 6 weeks. In the case reported by Kameda et al., MH surgery was done 3 months after the reopening. However, in our case, the patient was a student and had difficulty with near work especially reading. Hence, we decided to operate the MH early.
It has been reported that the idiopathic MHs may reopen following a successful closure after a vitrectomy surgery due to ERM formation, cataract surgery, and cystoid macular edema.,, However, none of these factors were present in our case. The most probable reason for the reopening of the MH could be the spontaneous induction of PVD. In our case, there was no evidence of PVD during the PPV surgery. The serial OCT images in our case suggested the enlargement of intraretinal fluid-filled cystic spaces which might have led to a mechanical separation of the edges of the MH and its subsequent reopening at 6 weeks. This may suggest the early reopening of the macula hole was associated with an increase in the intraretinal cystic changes. The early surgical intervention in such cases can be avoided expecting a spontaneous closure of a reopened traumatic MH. However, in patients having near work problems, one can still consider for an early surgical intervention for the MH closure. Successful closure of the reopened MH was achieved following surgery in our case.
| Conclusion|| |
Reopening of traumatic MHs is an extremely rare occurrence. Ophthalmologists should be aware of it occurring as a possible complication of a spontaneously closed traumatic MH.
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Conflicts of interest
There are no conflicts of interest.
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