Spark ImageWise 15 – Retina

Idiopathic Macular Hole

Dr. Sarang Lambat, Dr. Vinay Nangia 
Suraj Eye Institute, 559 New Colony, Nagpur 

Case Description
A female, 60 years of age, came with sudden blurring of vision in right eye since 3 months. She was a known hypertensive under treatment. Her best corrected visual acuity was finger counting 3 meter in right eye (OD) and 6/9 in the left eye (OS). Anterior segment examination revealed grade 2 nuclear sclerosis in both eyes (OU). Intraocular pressure recorded by Goldmann applanation tonometer was 22 mmHg in OD and 18 mmHg in OS. Fundus examination revealed a full thickness macular hole (FTMH) in OD and OS fundus was normal. Patient underwent fundus photography and SDOCT.

Figure 1: Fundus photograph of the right eye shows presence of a full thickness macular hole (yellow arrow) (a). SDOCT horizontal line scan passing through the fovea shows presence of a full thickness (Stage 2) macular hole (yellow arrow). There is persistent attachment of the hyaloid at the temporal edge of the hole (green arrow). The edges of the retina show presence of cystoid changes (red arrow) (b).
Figure 2: Fundus photograph of the left eye showing a hazy media due to cataract with a normal disc and macula (a). SDOCT horizontal line scan passing through fovea shows a normal foveal contour with no interface abnormalities. A small RPE bump is seen temporal to fovea suggestive of a druse (b).

Patient underwent right eye Phacoemulsification with IOL implantation with pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and gas injection. 1 month post surgery the macular hole was closed. We could appreciate 2 para-central retinal holes infero-temporal to the fovea which could be ascribed to the area of peel initiation. The BCVA in the right eye improved from CF 3 meter to 6/12. 

Figure 3: The infrared photograph also shows presence of 2 retinal holes infero-temporal to the fovea (red arrow) which represent the area of attempted peel initiation (a). SDOCT of the right eye shows closed macular hole with hyperreflectivity of the outer nuclear layer, (white arrow) loss of external limiting membrane  (yellow arrow) and ellipsoid zone disruption (green arrow) at the fovea (b). Infrared and SDOCT scans showing the para-central full thickness retinal holes (c-f)

Discussion

This patient had a stage 2 macular hole with cataract. Post surgery, a type 1 closure of the hole was achieved which was well evident on SOCT at 1 month follow up. PPV with posterior hyaloid removal, ILM peeling, long acting gas tamponade and face down positioning is still the gold standard for a successful closure of idiopathic macular hole. For larger holes which have less chances of closure, inverted ILM peeling is now increasingly being done.
This patient also developed paracentral retinal holes infero-temporal to fovea. The holes occurred in the area of initiation of the ILM peeling. There have been reports of such paracentral hole formation in cases of FTMH undergoing vitrectomy with ILM peel. The authors suggested that this postoperative finding might be a consequence of Muller cell damage causing weakening of the glial structures of the retina leading to hole formation. 

ReadWise

  1. Chen YC, Yang CM, Chen SN. Internal Limiting Membrane Flap in the Management of Retinal Detachment due to Paracentral Retinal Breaks. J Ophthalmol. 2019 Jan 21;2019:4303056. doi: 10.1155/2019/4303056. PMID: 30805208; PMCID: PMC6360606.
  2. Gelman R, Stevenson W, Prospero Ponce C, Agarwal D, Christoforidis JB. Retinal Damage Induced by Internal Limiting Membrane Removal. J Ophthalmol. 2015;2015:939748. doi: 10.1155/2015/939748. Epub 2015 Sep 3. PMID: 26425355; PMCID: PMC4573889..

Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org

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