Delayed spontaneous closure of traumatic macular hole in a 66-year-old patient – role of optical coherence tomography follow-up

oc000168 10.3205/oc000168 urn:nbn:de:0183-oc0001685 Case Report Delayed spontaneous closure of traumatic macular hole in a 66-year-old patient – role of optical coherence tomography follow-up Grassi Grassi Piergiacomo P MD

Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield University Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom, Phone: +39 333 5816865, Fax: +39 081 5793226Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield University Hospitals NHS Foundation Trust, Sheffield, United Kingdom

pjgrassi@libero.it author Salicone Salicone Alberto A

Unit of Ophthalmology, San Leonardo Hospital, Castellammare di Stabia NA, Italy

asalico@libero.it author German Medical Science GMS Publishing House

Düsseldorf

610 epiretinal membrane macular hole optical coherence tomography pars-plana vitrectomy spontaneous closure traumatic macular hole 20200828 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2193-1496 10 GMS Ophthalmology Cases GMS Ophthalmol Cases 41 Objective: To report a case of delayed spontaneous closure of traumatic macular hole at 5 months in a 66-year-old man. Traumatic macular holes generally do not close spontaneously after 4 months and over 30 y</PlainText></TextGroup>ears of age.</Pgraph><Pgraph><Mark1>Methods:</Mark1> A 66-year-old man presented with central blurred vision and metamorphopsia in his right eye for 3 weeks after previous ocular blunt trauma occurring 2 months earlier. Best corrected visual acuity was 6/36 in his right eye, fundus examination and OCT revealed right traumatic macular hole.</Pgraph><Pgraph><Mark1>Results:</Mark1> 4 weeks later, best corrected visual acuity was 6/18, OCT showed initial reattachment of traumatic macular hole margins. 8 weeks later, best corrected visual acuity improved to 6/9, OCT showed almost complete reattachment of the margins, residual outer retinal defect being still present. At 12 weeks after initial presentation, best corrected visual acuity was 6/6, OCT showed normal neuroretinal profile.</Pgraph><Pgraph><Mark1>Conclusion:</Mark1> Clinical monitoring of traumatic macular holes might be performed up to 5 months even in patients >30 years before considering surgery.</Pgraph></Abstract> <TextBlock linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>Macular holes (MH) are retinal defects of 200–550 µm in diameter that involve the fovea and are well-known complications of ocular contusion injury occurring in 1.4<TextGroup><PlainText>% o</PlainText></TextGroup>f closed globe injuries and 0.15% of open globe injuries <TextLink reference="1"></TextLink>. Sports-related accidents are the major cause of ocular blunt trauma, thus the higher frequency of traumatic macular holes (TMH) in younger patients <TextLink reference="2"></TextLink>. Typical signs and symptoms include acute visual loss, blurred and distorted vision and central scotoma, and immediate visual loss after injury is probably due to retinal dehiscence on concussion, whereas delayed visual loss is likely to indicate a secondary event of vitreoretinal interface changes. Optical coherence tomography (OCT) allows an objective diagnosis and monitoring of TMH and confirms its resolution, avoiding a never-without-risks surgery <TextLink reference="3"></TextLink>. Small-gauge pars-plana vitrectomy (PPV) and fluid-gas exchange is the current surgical management for TMH repair. However, spontaneous closure (SC) of MH is not rare, especially among young patients, and occurs in approximately 50% of cases, but rarely after <TextGroup><PlainText>4 m</PlainText></TextGroup>onths and over 30 years of age <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>.</Pgraph><Pgraph>An unusual case of TMH in a 66-year-old patient which spontaneously closed after 5 months with no need for further treatment is described.</Pgraph></TextBlock> <TextBlock linked="yes" name="Case description"> <MainHeadline>Case description</MainHeadline><Pgraph>A 66-year-old man attended Eye Casualties with central blurred vision and metamorphopsia in his right eye for <TextGroup><PlainText>3 w</PlainText></TextGroup>eeks after previous ocular blunt trauma occurring <TextGroup><PlainText>2 m</PlainText></TextGroup>onths earlier. The patient was in good health taking no medications, and had no personal or family history of eye diseases, hypertension, diabetes mellitus, or dyslipidemias. Best corrected visual acuity (BCVA) was 6/36 in his right eye with positive Amsler grid testing (AGT). Fundus examination of his right eye showed loss of foveolar light reflex and a round small lesion with red base at the centre of his right macula. OCT confirmed the presence of TMH with a diameter of 232 µm, absence of epiretinal membrane (ERM), delamination in the outer nuclear layer and initial separation of the posterior hyaloid membrane from the inner retina with overlying retinal operculum (Figure 1 <ImgLink imgNo="1" imgType="figure"/>). Small full thickness MH was diagnosed according to the International Vitreomacular Traction Study Classification System, no topical/systemic medical treatments were started. 4 weeks later, BCVA in the patient’s right eye was 6/18, OCT showed initial rea<TextGroup><PlainText>ttachme</PlainText></TextGroup>nt of the TMH margins (Figure 2 <ImgLink imgNo="2" imgType="figure"/>). 8 weeks late<TextGroup><PlainText>r, r</PlainText></TextGroup>ight BCVA improved to 6/9 with slightly positive AGT. OC<TextGroup><PlainText>T showed a</PlainText></TextGroup>lmost complete reattachment of the margins of TMH, residual outer retinal defect still being present (Figure 3 <ImgLink imgNo="3" imgType="figure"/>). At 12 weeks after initial presentation, BCVA in the patient’s right eye was 6/6 with negative AGT. OCT showed normal neuroretinal profile and thickness (Figure 4 <ImgLink imgNo="4" imgType="figure"/>), BCVA and OCT remained unchanged at 8 months examination.</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>The precise mechanism of TMH formation is unclear, and the time of appearance is highly variable (directly after the ocular trauma up to 1 month), suggesting multiple mechanisms of formation. Yamashita et al. proposed two pathogenic mechanisms for TMH formation. The first is the most common, posterior vitreous detachment (PVD) is not involved, and the origin of post-contusive TMH is associated with sudden deformation of the eyeball and anterior-posterior compression with retinal stretching. These forces cause transverse tractional retinal breakdown of the macula, MH is then formed almost immediately after the trauma and causes immediate visual loss due to primary dehiscence of the fovea. In contrast, in the second mechanism visual loss is more gradual, perifoveal PVD plays a role and suggests that vitreoretinal foveal traction is responsible for the slow formation of a TMH (several days or even weeks after the injury). The gripping power forces are no longer transverse, but anterior-posterior <TextLink reference="5"></TextLink>. However, in older patients, posterior vitreous is usually detached, making TMH generally less frequent in older patients <TextLink reference="5"></TextLink>.</Pgraph><Pgraph>There are no clinical studies that demonstrate the natural history of TMH. The need to undergo surgical repair and the timing of possible intervention are not well defined <TextLink reference="1"></TextLink>, and SC of TMH has been previously reported <TextLink reference="1"></TextLink>, <TextLink reference="4"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>. Miller et al. found a 39.3% SC rate of TMH in a median of 5.7 weeks; the 39.3% of their cases underwent PPV (5 eyes out of 11 (45%) were successfully closed), and BCVA improved significantly in both eyes with TMH closed either spontaneously (P>.01) or via PPV (P=.04) <TextLink reference="7"></TextLink>. A meta-analysis of surgical outcomes in all published reports of PPV for TMH found a successful closure rate of 83% <TextLink reference="7"></TextLink>. Clinical observation through OCT allows to monitor the TMH objectively and to confirm its resolution, avoiding the risks related to surgery <TextLink reference="3"></TextLink>. However, permanent macular structural changes, TMH enlargement and retinal detachment may occur during observation. Patients <30 years old without involvement of the posterior hyaloid, no pre-existing PVD, small size of TMH and its reduction in size during the first weeks after trauma seem to be associated with SC, whereas TMH enlargement over the first weeks may indicate a poor prognosis for SC and merit further consideration of surgery <TextLink reference="1"></TextLink>, <TextLink reference="7"></TextLink>. Our case of TMH experienced delayed symptoms and, in spite of the patient’s age, complete SC after 5 months from initial ocular trauma with no need of further treatment, suggesting a perifoveal PVD mechanism and providing a compelling argument for a systematic clinical monitoring of TMH within at least 5 months after trauma even in patients >30 years, contrary to what most of the literature supports <TextLink reference="7"></TextLink>. Since OCT allows an objective monitoring and provides objective data about MH evolution and confirms their resolution, clinical monitoring should be based on OCT and should be performed for 3 to 5 months before considering surgery <TextLink reference="3"></TextLink>. This may not be applicable for a subset of TMH with severe traction on the edges, where an earlier surgical intervention may be suggested by the increase in size and enlargement of TMH from presentation to last follow-up examination since it indicates a poor prognosis for SC <TextLink reference="1"></TextLink>. Importantly, an intact ellipsoid zone in closed holes seems to correlate with better final BCVA regardless of how TMH closure occurs (observation or vitrectomy). Surgery within 6 months of the onset of TMH may not affect the final outcome, and SC mainly occurs during the few months after trauma. </Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>A close clinical and instrumental monitoring post TMH without ERM and poor vitreal adherence might be appropriate in order to verify a possible SC <TextLink reference="8"></TextLink>, even in patients over 30 years of age and after several weeks from ocular trauma.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Authors’ contributions</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Concept and design of the study: Alberto Salicone</ListItem><ListItem level="1">Acquisition of data: Alberto Salicone, Piergiacomo Grassi</ListItem><ListItem level="1">Analysis and interpretation of data: Piergiacomo Grassi</ListItem><ListItem level="1">Writing of original draft: Alberto Salicone, Piergiacomo Grassi</ListItem><ListItem level="1">Critical revision, review and editing: Piergiacomo Grassi</ListItem></UnorderedList></Pgraph><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Miller JB</RefAuthor> <RefAuthor>Yonekawa Y</RefAuthor> <RefAuthor>Eliott D</RefAuthor> <RefAuthor>Kim IK</RefAuthor> <RefAuthor>Kim LA</RefAuthor> <RefAuthor>Loewenstein JI</RefAuthor> <RefAuthor>Sobrin L</RefAuthor> <RefAuthor>Young LH</RefAuthor> <RefAuthor>Mukai S</RefAuthor> <RefAuthor>Vavvas DG</RefAuthor> <RefTitle>Long-term Follow-up and Outcomes in Traumatic Macular Holes</RefTitle> <RefYear>2015</RefYear> <RefJournal>Am J Ophthalmol</RefJournal> <RefPage>1255-8</RefPage> <RefTotal>Miller JB, Yonekawa Y, Eliott D, Kim IK, Kim LA, Loewenstein JI, Sobrin L, Young LH, Mukai S, Vavvas DG. Long-term Follow-up and Outcomes in Traumatic Macular Holes. Am J Ophthalmol. 2015 Dec;160(6):1255-8. DOI: 10.1016/j.ajo.2015.09.004</RefTotal> <RefLink>https://doi.org/10.1016/j.ajo.2015.09.004</RefLink> </Reference> <Reference refNo="2"> <RefAuthor>Johnson RN</RefAuthor> <RefAuthor>McDonald HR</RefAuthor> <RefAuthor>Lewis H</RefAuthor> <RefAuthor>Grand MG</RefAuthor> <RefAuthor>Murray TG</RefAuthor> <RefAuthor>Mieler WF</RefAuthor> <RefAuthor>Johnson MW</RefAuthor> <RefAuthor>Boldt HC</RefAuthor> <RefAuthor>Olsen KR</RefAuthor> <RefAuthor>Tornambe PE</RefAuthor> <RefAuthor>Folk JC</RefAuthor> <RefTitle>Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery</RefTitle> <RefYear>2001</RefYear> <RefJournal>Ophthalmology</RefJournal> <RefPage>853-7</RefPage> <RefTotal>Johnson RN, McDonald HR, Lewis H, Grand MG, Murray TG, Mieler WF, Johnson MW, Boldt HC, Olsen KR, Tornambe PE, Folk JC. Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery. Ophthalmology. 2001 May;108(5):853-7. DOI: 10.1016/S0161-6420(00)00650-3</RefTotal> <RefLink>https://doi.org/10.1016/S0161-6420(00)00650-3</RefLink> </Reference> <Reference refNo="3"> <RefAuthor>Souteyrand G</RefAuthor> <RefAuthor>Sillaire I</RefAuthor> <RefAuthor>Thomas V</RefAuthor> <RefAuthor>Deriot JB</RefAuthor> <RefAuthor>Roquet W</RefAuthor> <RefAuthor>Bacin F</RefAuthor> <RefTitle>Documentation par OCT-3 de la résolution spontanée d’un trou maculaire post-traumatique</RefTitle> <RefYear>2008</RefYear> <RefJournal>J Fr Ophtalmol</RefJournal> <RefPage>422-6</RefPage> <RefTotal>Souteyrand G, Sillaire I, Thomas V, Deriot JB, Roquet W, Bacin F. Documentation par OCT-3 de la résolution spontanée d’un trou maculaire post-traumatique [OCT-3 documentation of spontaneous resolution of blunt macular hole injury: a case study]. J Fr Ophtalmol. 2008 Apr;31(4):422-6. DOI: 10.1016/s0181-5512(08)71439-6</RefTotal> <RefLink>https://doi.org/10.1016/s0181-5512(08)71439-6</RefLink> </Reference> <Reference refNo="4"> <RefAuthor>Nasr MB</RefAuthor> <RefAuthor>Symeonidis C</RefAuthor> <RefAuthor>Tsinopoulos I</RefAuthor> <RefAuthor>Androudi S</RefAuthor> <RefAuthor>Rotsos T</RefAuthor> <RefAuthor>Dimitrakos SA</RefAuthor> <RefTitle>Spontaneous traumatic macular hole closure in a 50-year-old woman: a case report</RefTitle> <RefYear>2011</RefYear> <RefJournal>J Med Case Reports</RefJournal> <RefPage>290</RefPage> <RefTotal>Nasr MB, Symeonidis C, Tsinopoulos I, Androudi S, Rotsos T, Dimitrakos SA. Spontaneous traumatic macular hole closure in a 50-year-old woman: a case report. J Med Case Reports. 2011;5:290. DOI: 10.1186/1752-1947-5-290</RefTotal> <RefLink>https://doi.org/10.1186/1752-1947-5-290</RefLink> </Reference> <Reference refNo="5"> <RefAuthor>Yamashita T</RefAuthor> <RefAuthor>Uemara A</RefAuthor> <RefAuthor>Uchino E</RefAuthor> <RefAuthor>Doi N</RefAuthor> <RefAuthor>Ohba N</RefAuthor> <RefTitle>Spontaneous closure of traumatic macular hole</RefTitle> <RefYear>2002</RefYear> <RefJournal>Am J Ophthalmol</RefJournal> <RefPage>230-5</RefPage> <RefTotal>Yamashita T, Uemara A, Uchino E, Doi N, Ohba N. Spontaneous closure of traumatic macular hole. Am J Ophthalmol. 2002 Feb;133(2):230-5. DOI: 10.1016/s0002-9394(01)01303-4</RefTotal> <RefLink>https://doi.org/10.1016/s0002-9394(01)01303-4</RefLink> </Reference> <Reference refNo="6"> <RefAuthor>Faghihi H</RefAuthor> <RefAuthor>Ghassemi F</RefAuthor> <RefAuthor>Falavarjani KG</RefAuthor> <RefAuthor>Saeedi Anari G</RefAuthor> <RefAuthor>Safizadeh M</RefAuthor> <RefAuthor>Shahraki K</RefAuthor> <RefTitle>Spontaneous closure of traumatic macular holes</RefTitle> <RefYear>2014</RefYear> <RefJournal>Can J Ophthalmol</RefJournal> <RefPage>395-8</RefPage> <RefTotal>Faghihi H, Ghassemi F, Falavarjani KG, Saeedi Anari G, Safizadeh M, Shahraki K. Spontaneous closure of traumatic macular holes. Can J Ophthalmol. 2014 Aug;49(4):395-8.</RefTotal> </Reference> <Reference refNo="7"> <RefAuthor>Miller JB</RefAuthor> <RefAuthor>Yonekawa Y</RefAuthor> <RefAuthor>Eliott D</RefAuthor> <RefAuthor>Vavvas DG</RefAuthor> <RefTitle>A review of traumatic macular hole: diagnosis and treatment</RefTitle> <RefYear>2013</RefYear> <RefJournal>Int Ophthalmol Clin</RefJournal> <RefPage>59-67</RefPage> <RefTotal>Miller JB, Yonekawa Y, Eliott D, Vavvas DG. A review of traumatic macular hole: diagnosis and treatment. Int Ophthalmol Clin. 2013 Oct;53(4):59-67. DOI: 10.1097/IIO.0b013e3182a26efe</RefTotal> <RefLink>https://doi.org/10.1097/IIO.0b013e3182a26efe</RefLink> </Reference> <Reference refNo="8"> <RefAuthor>Haouchine B</RefAuthor> <RefAuthor>Massin P</RefAuthor> <RefAuthor>Tadayoni R</RefAuthor> <RefAuthor>Erginay A</RefAuthor> <RefAuthor>Gaudric A</RefAuthor> <RefTitle>Diagnosis of macular pseudoholes and lamellar macular holes by optical coherence tomography</RefTitle> <RefYear>2004</RefYear> <RefJournal>Am J Ophthalmol</RefJournal> <RefPage>732-9</RefPage> <RefTotal>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 Nov;138(5):732-9. DOI: 10.1016/j.ajo.2004.06.088</RefTotal> <RefLink>https://doi.org/10.1016/j.ajo.2004.06.088</RefLink> </Reference> </References> <Media> <Tables> <NoOfTables>0</NoOfTables> </Tables> <Figures> <Figure format="png" height="393" width="592"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: OCT horizontal scan at presentation, showing TMH with a diameter of 232 µm, irregular retinal profile, absence of epiretinal membrane, delamination in the outer nuclear layer, Bruch’s membrane attached to the retinal pigment epithelium, initial separation of the posterior hyaloid membrane from inner retina with overlying retinal operculum</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="394" width="595"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: OCT horizontal scan at 4 weeks follow-up, showing initial reattachment of the TMH margins</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="393" width="595"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Figure 3: OCT horizontal scan at 8 weeks follow-up, showing almost complete reattachment of the margins of TMH, residual outer retinal defect being still present</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="393" width="594"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Figure 4: OCT horizontal scan at 12 weeks follow-up, showing normal neuroretinal profile and thickness and complete closure of the TMH</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>4</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>