Posttraumatic horseshoe-shaped macular tear.

Dear Sir,

We read with interest the article “An unusual complication of blunt ocular trauma: A horseshoe-shaped macular tear with spontaneous closure” by Karaca et al.[1] We congratulate the authors for their report, and describe a similar case with an alternate management and outcome.

An 18-year-old boy presented with decreased vision in his right eye following trauma with a cricket ball 2 days before. On examination, his best-corrected visual acuity (BCVA) was counting fingers at half meter with accurate projection of rays. Slit lamp showed corneal epithelial edema, dispersed hyphema, traumatic mydriasis and pigment on the anterior lens capsule. Applanation tonometry revealed an intraocular pressure (IOP) of 58 mmHg; he was started on maximum antiglaucoma medication. Once the media became clearer, dilated fundus examination showed resolving vitreous hemorrhage, a cup: disc ratio of 0.3:1 and a horseshoe-shaped tear at the macula with surrounding pigmentary alterations [Fig. 1]. The retinal periphery was unremarkable. The left eye was within normal limits with a BCVA of 20/20.

Figure 1

Fundus photograph of the right eye showing a horseshoe-shaped tear at the macula (arrows) with preretinal hemorrhage inferiorly

After detailed informed consent, the patient underwent 23 gauge pars plana vitrectomy with induction of posterior vitreous detachment and instillation of 14% C3F8 gas with postoperative prone positioning for a week. At 3 months follow-up, BCVA was 20/80. The macula showed a closed tear with pigmentary alterations and foveal atrophy that was confirmed on optical coherence tomography [Fig. 2]. IOP was maintained within normal limits on brinzolamide.

Figure 2

(a) Fundus photograph of the right eye 3 months postoperatively showing a closed macular tear, pigmentary alterations, and foveal atrophy. (b) Spectral domain optical coherence tomography demonstrating macular thinning and scarring

Full-thickness macular holes can occur following blunt trauma. Two mechanisms of hole formation have been proposed, one causing immediate visual loss due to primary dehiscence of the fovea while the other leading to delayed visual loss due to foveal dehiscence secondary to persistent vitreofoveal adhesion.[2] Spontaneous hole closure is not uncommon, and an observation period has been recommended, especially in young patients with small holes, good initial visual acuity and posterior vitreous adhesion to the hole edges. However, the timing of the closure is unpredictable and may result in variable visual recovery.[23] Successful hole closure with substantial visual recovery has been described following vitrectomy for traumatic macular holes.[45] While the consequences of waiting for spontaneous closure have not been elaborated, photoreceptor damage maybe more likely, longer the delay.

A horseshoe tear at the macula following trauma is a rare occurrence. Unequal vitreous attachment from all sides of the macula could be responsible for this configuration as postulated by Karaca et al.[1] In contrast to their case, our case had considerable improvement in BCVA following surgery. It is possible that that early vitrectomy could have facilitated the hole closure, preventing irreversible photoreceptor damage.