Case of the Month | June 2021

Case of the Month
June 22, 2021

The Case

The patient was a 73-year-old woman referred for evaluation of a macular hole in the right eye. She said that she had gradually been having more difficulty reading. The past medical history was unremarkable. The visual acuity was 20/40- OD and 20/25 OS. The clinical examination was remarkable for a 2+ nuclear sclerotic cataract in each eye and an abnormal foveal reflex in the right eye. What treatment, if any, would you provide at this time? Would you clear this patient for cataract surgery?

The patient had vitreo-macular traction with what was essentially a small macular hole. There was separation of the middle and outer retinal layers, and the residual inner tissue was largely if not entirely posterior hyaloid. The treating physician cleared the patient for cataract surgery and chose to have the hole observed. Fortuitously, the hole spontaneously closed.

The patient returned seven weeks later and reported improved vision, but there were still difficulties reading fine print. The visual acuity was 20/40+ OD. The OCT revealed a partial separation of the posterior hyaloid from the central macula, and it was possible that the alterations of vitreo-retinal dynamics associated with cataract surgery contributed to this development. Our physician chose to continue observation, because further vitreous separation might allow the hole to close spontaneously. (Refer to OCT 6-2018 OD photo)

Six weeks later, the patient reported a further improvement in vision, though the Snellen acuity remained 20/40 and the patient noticed a small dark spot in her central vision. The OCT showed that there was a complete vitreous separation and the hole had closed. (Refer to OCT 07-2018 OD photo)

Three years later, the patient said that her vision was stable but the acuity was 20/60. The OCT revealed thinning of the retina and a small, central disruption of the ellipsoid zone. Observation was warranted. (Refer to OCT 06-2021 OD photo)

Comment

Approximately 4-11% of macular holes spontaneous close, and the figure might be higher if there were longer periods of observation before surgery or other interventions. Factors favoring in closure of small macular holes size and release of vitreo-macular traction.(1) Induction of vitreous separation by ocriplasmin resulted in close of small macular holes in 40.6% of treated patients compared to 10.6% in the placebo group in a multicenter, randomized, double-blind, phase III trial.(2) However, there have been reports of similar or greater efficacy from injection of expansile gas and face-down positioning.(3, 4)

1. Bikbova G, Oshitari T, Baba T, Yamamoto S, Mori K. Pathogenesis and management of macular hole: Review of current advances. J Ophthalmol 2019; May 2:3467381.

2. Singh R. P., Li A., Bedi R., et al. Anatomical and visual outcomes following ocriplasmin treatment for symptomatic vitreomacular traction syndrome. Br J Ophthal 2014; 98(3):356–360.

3. Mori K, Saito S, Gehlbach PL, Yoneya S. Treatment of stage 2 macular hole by intravitreous injection of expansile gas and induction of posterior vitreous detachment. Ophthalmol 2007;114(1):127-33.

4.  Han R, Zhang C, Zhao X, Chen Y. Treatment of primary full-thickness macular hole by intravitreal injection of expansile gas. Eye 2019;33(1):136-43.

Case Photos

Click the Images below to enlarge

The patient had vitreo-macular traction with what was essentially a small macular hole. There was separation of the middle and outer retinal layers, and the residual inner tissue was largely if not entirely posterior hyaloid. The treating physician cleared the patient for cataract surgery and chose to have the hole observed. Fortuitously, the hole spontaneously closed.

The patient returned seven weeks later and reported improved vision, but there were still difficulties reading fine print. The visual acuity was 20/40+ OD. The OCT revealed a partial separation of the posterior hyaloid from the central macula, and it was possible that the alterations of vitreo-retinal dynamics associated with cataract surgery contributed to this development. Our physician chose to continue observation, because further vitreous separation might allow the hole to close spontaneously. (Refer to OCT 6-2018 OD photo)

Six weeks later, the patient reported a further improvement in vision, though the Snellen acuity remained 20/40 and the patient noticed a small dark spot in her central vision. The OCT showed that there was a complete vitreous separation and the hole had closed. (Refer to OCT 07-2018 OD photo)

Three years later, the patient said that her vision was stable but the acuity was 20/60. The OCT revealed thinning of the retina and a small, central disruption of the ellipsoid zone. Observation was warranted. (Refer to OCT 06-2021 OD photo)

Comment

Approximately 4-11% of macular holes spontaneous close, and the figure might be higher if there were longer periods of observation before surgery or other interventions. Factors favoring in closure of small macular holes size and release of vitreo-macular traction.(1) Induction of vitreous separation by ocriplasmin resulted in close of small macular holes in 40.6% of treated patients compared to 10.6% in the placebo group in a multicenter, randomized, double-blind, phase III trial.(2) However, there have been reports of similar or greater efficacy from injection of expansile gas and face-down positioning.(3, 4)

1. Bikbova G, Oshitari T, Baba T, Yamamoto S, Mori K. Pathogenesis and management of macular hole: Review of current advances. J Ophthalmol 2019; May 2:3467381.

2. Singh R. P., Li A., Bedi R., et al. Anatomical and visual outcomes following ocriplasmin treatment for symptomatic vitreomacular traction syndrome. Br J Ophthal 2014; 98(3):356–360.

3. Mori K, Saito S, Gehlbach PL, Yoneya S. Treatment of stage 2 macular hole by intravitreous injection of expansile gas and induction of posterior vitreous detachment. Ophthalmol 2007;114(1):127-33.

4.  Han R, Zhang C, Zhao X, Chen Y. Treatment of primary full-thickness macular hole by intravitreal injection of expansile gas. Eye 2019;33(1):136-43.

Download PDF Version
Return to News & Events