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 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.
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.
Discussion
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.
ReadWise:
- Liang X, Liu W. Characteristics and risk factors for spontaneous closure of idiopathic full-thickness macular hole. Journal of Ophthalmology. 2019 Mar 13;2019. https://doi.org/10.1155/2019/4793764
- Kang SW, Ahn K, Ham DI. Types of macular hole closure and their clinical implications. Br J Ophthalmol. 2003;87(8):1015-1019. doi: https://dx.doi.org/10.1136%2Fbjo.87.8.1015
- 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: https://doi.org/10.1016/j.ajo.2011.09.017
Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org