Spark ImageWise – 50

A Case Spontaneous Macular Hole Closure

Dr. Shashank Somani, Dr. Samyak Gupta, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia 
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.

Case Description
A female, 71 years of age, presented with progressive diminution of vision in both eyes since 1 year. On examination her best corrected visual acuity (BCVA) was counting finger at 2 m in the right eye (RE) and 6/9p in the left eye (LE). On slit lamp examination, anterior segment showed the presence of nuclear sclerosis grade 2 in both eyes (BE). Her intraocular pressure (IOP) was 22 mmHg in RE and 28 mmHg in LE. She was using combination eye drop of brimonidine tartrate and timolol maleate two times a day in LE.

Figure 1 shows right eye colour fundus photograph with Grade 2 media clarity showing a VCDR of 0.2 and fundus tessellations. Macular details are not clear due to media haze because of cataract.
Figure 2 shows left eye colour fundus photograph with grade 2 media clarity and a VCDR of 0.4. Macular details are not clear due to media haze because of cataract.
Figure 3 SD-OCT horizontal line scan passing through fovea of right eye shows a full thickness defect in the fovea (yellow arrow) with a partially separated operculum (blue arrow). This is a stage 2 macular hole. Areas of reduced optical reflectivity suggestive of cysts can be seen near both the edges of macular hole (green arrows). A thin hyper reflective membrane can be seen indistinctly attached to the fovea causing vitreo-macular traction (pink arrows). The macular hole diameter was measured to be 110um (blue box). Elongation and distortion of the photoreceptors can be seen in the area of macular hole (red arrow).
Figure 4 – SD-OCT horizontal line scan passing through fovea of left eye showing a normal fovea with a flatter contour. Central foveal thickness was 190um (green arrow). The outer nuclear layer thickness is 94um (yellow box).

She was advised to undergo Phacoemulsification with vitrectomy and ILM peeling in the right eye and  combined phacoemulsification with trabeculectomy in the LE. She underwent surgery for left eye in 2016. She was seen after 9 months and the visual acuity in the RE was same with some increase in grade of cataract. Review OCT scan showed spontaneous closure of macular hole and hence only cataract surgery was advised for the RE. Post cataract surgery her vision improved to 6/60.

Figure 5 SD-OCT horizontal line scan passing through fovea of left eye shows spontaneously closed macular hole with central foveal thickness measuring 134um (green arrow and box). There is absence of vitreomacular traction as was seen previously. The outer nuclear layer thickness is 59um (pink box). Significant distortion of interdigitation zone is seen (blue arrow).


Our patient presented to us with a grade 2 cataract and a full thickness macular hole in the right eye. Her visual acuity at the time of presentation was CF 2 meters. OCT showed presence of  stage 2 macular hole with attached operculum and vitreous attachment at the edge (Fig 3). Patient was advised surgery but she delayed the intervention. On doing a review OCT at 9 months we could notice a spontaneous attachment of the macular hole with realignment of all the retinal layers. Her visual acuity did not improve after the closure of the hole probably as the grade of cataract had also increased by that time and also there was presence of foveal thinning on OCT.

The incidence of spontaneous closure of idiopathic macular holes varies from 4% to 11.5% and depends on a lot of factors. It is more commonly seen in females of age greater that 60 years. Another important factor is the macular hole diameter which was 110um in our patient. Patients having macular hole diameter between 70 and 250 μm are known to have more chances of spontaneous closure.

Overall the factors such as release of vitreomacular traction, relative good health of tissues around the macular hole, and an innate propensity of the retinal layers to identify and connect with similar layers across the area of the macular hole, may be considered important in spontaneous macular hole closure. The reality of spontaneous closure raises many important questions about the many surgical  options that we consider and use. Would it be appropriate to use only the simplest of techniques in such patients. Are there biomarkers that will tell us which patients will respond to a simple vitrectomy. Does ILM peeling long established as a standard treatment add significantly to the success rate in macular hole surgery in such patients. Does non closure following macular hole surgery have something to do with vascular and metabolic changes that have  occurred in the photoreceptors and other layers of the retina  around the macular hole. Understanding these  parameters may help in predicting the results of macular hole surgery. 

In our patient of great concern was that inspite of spontaneous macular hole closure, and following cataract surgery the vision was 6/60. This does indicate, that even in the presence of spontaneous closure, one may not necessarily recover good vision. Fig. 5 (green arrow) shows flattening and irregular contour of the foveal surface along with thinning of the outer nuclear layer (59 microns) compared to the outer nuclear layer measurements in the LE (94 microns).  Fig. 5 (blue Arrow) Shows loss of  interdigitation  layer in the  foveal area (VA – 6/60) in RE compared to the LE (VA 6/6) where a  regular well delineated layer is visible (Fig. 4 blue Arrow). It may be mentioned that this degree of interdigitation layer loss is not often accompanied with this amount of visual loss. Also the ellipsoid zone was significantly affected  during the presence of macular hole with elongation and distortion of the photoreceptors (Fig 3, red arrow) Even though  the ellipsoid zone  looks reasonably normal following macular hole closure, functionally it may have undergone changes. Therefore one may assume that other changes in the photoreceptor layers have occurred, that may not be so clearly visible that have a role to play in vision loss in our patient.  


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  2. Kang SW, Ahn K, Ham DI. Types of macular hole closure and their clinical implications. Br J Ophthalmol. 2003;87(8):1015-1019. doi:
  3. Inoue M, Arakawa A, Yamane S, Watanabe Y, Kadonosono K. Long-term outcome of macular microstructure assessed by optical coherence tomography in eyes with spontaneous resolution of macular hole. Am J Ophthalmol. 2012 Apr;153(4):687-91 doi:

Dr. Sarang Lambat
Vitreoretinal services
Suraj Eye Institute
Email –

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