CaseWise 22

Macular Hole following Glaucoma Drainage Device Implantation


Dr. Sheetal Bajoria, Dr. Sarang Lambat, Dr. Vinay Nangia
Suraj Eye Institute, Nagpur, India

Introduction
The use of Glaucoma drainage devices (GDDs) both as a primary treatment modality and in refractory glaucoma has increased. Associated surgical complications and ocular events are known to occur following GDD implantation. Macular complications like cystoid macular edema are known complications post glaucoma filtering surgery.1 To the best of our knowledge there are no reports of macular hole formation following Ahmed glaucoma valve surgery.
Case Report
A female, 44 years of age, came  with chief complaints of gradual diminution of vision in Left eye (LE) since 1 month. She had undergone Phacoemulsification and trabeculectomy in RE and Ahmed glaucoma valve implant in LE 1 year back. There was history of left eye cataract surgery done 7 years back. She was using eyedrop Brimonidine 0.2% with Timolol 0.5% 2 times per day in  both eyes. On examination her best corrected visual acuity (BCVA)was 6/9, N6 in the right eye and 6/36, N18 in the left eye. Anterior segment examination showed pseudophakia in both eyes and LE showed AGV tube in anterior chamber. Intraocular pressure was 18mmHg in RE and 9 mmHg in LE. Fundus examination showed vertical cup disc ratio (VCDR) 0.7 with bipolar rim thinning in RE. Left eye had a VCDR of 0.5 with inferior rim thinning and a full thickness macular hole (Fig.1a and 1b). LE spectral domain Optical coherence tomography (SD-OCT) showed full thickness macular hole (fig.2). She underwent LE pars plana vitrectomy  with internal limiting membrane peeling and SF6 gas injection. 2 weeks post surgery BCVA in LE improved to 6/9. Fundus examination showed closed macular hole and she was advised regular follow up .(Fig.4)

Fig.1a shows RE fundus photograph with VCDR 0.7 and bipolar rim thinning. Fig.1b shows  LE fundus photograph with VCDR 0.5 with inferior rim thinning and macular hole as shown by yellow dotted circle.
Fig.2 shows LE SD-OCT with  full thickness macular hole (yellow arrow)
Fig.3a shows RE RNFL scan with significant RNFL loss in supero temporal, infero temporal, infero nasal and global quadrants and borderline loss in temporal quadrant. Fig.3b shows LE RNFL scan with significant RNFL loss in infero temoral quadrant.
Fig.4 shows a good closure of macular hole with an excellent visibility of photoreceptor layer

Discussion
Macular hole closure is the factor that best predicts the visual recovery after macular hole surgery. Although there has been no prospective randomized study to confirm the efficacy of ILM peeling for macular hole surgery, the manipulation is generally believed to enhance macular hole closure. The success rate of macular hole closure is reported to be almost 90% in most studies.2,3 Restoration of central vision is important in cases of glaucoma. As with advancement of glaucoma there is loss of peripheral visual field and if macular hole develops patient may have significant visual disability. Timely intervention enabled us to treat this patient and achieve macular hole closure with restoration of vision with surgical intervention using sutureless 23G microincisional vitrectomy, ILM peeling and SF6 gas injection. The visual acuity improved from 6/36, N18 to 6/9, N8. The pre surgery intraocular pressure was 16 mmHg and postop IOP was 18 mmhg at 1 month. This case demonstrates that inspite of prior Ahmed glaucoma drainage device surgery it is possible to deal with associated with ocular morbidities that require intraocular surgery with successful visual restoration. 

References

  1. Bhakta AS, Fortun J, Thomas J, Greer A, Kishor K, Maharaj A. Visually Significant Cystoid Macula Edema After Glaucoma Drainage Implant Surgery. J Glaucoma. 2018;27(2):184‐188.DOI:10.1097/IJG.0000000000000855. 
  1. Ikuno Y, Sayanagi K, Oshima T, Gomi F, Kusaka S, Kamei M, Ohji M, Fujikado T, Tano Y. Optical coherence tomographic findings of macular holes and retinal detachment after vitrectomy in highly myopic eyes. Am J Ophthalmol. 2003 Sep;136(3):477-81. PubMed PMID: 12967801.doi:10.1016/S0002-9394(03)00269-1
  2. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991 May;109(5):654-9. PubMed PMID: 2025167. DOI:10.1001/archopht.1991.01080050068031
  3. MS, Baker BJ, Duker JS, et al. Anatomical Outcomes of Surgery for Idiopathic Macular Hole as Determined by Optical Coherence Tomography. Arch Ophthalmol. 2002;120(1):29–35. doi:10.1001/archopht.120.1.29 DOI:10.1001/archopht.120.1.29
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