Spontaneous closure of macular hole following blunt trauma.

Ocular trauma can result in macular hole and it can lead to complete loss of central vision. We are reporting a case of traumatic macular hole associated with retinal hemorrhages and choroidal ruptures with spontaneous resolution and total vision recovery.

Introduction

Macular holes can develop following intraocular inflammatory diseases, trauma, vitreous detachment, among others. The posttraumatic macular hole (TMH) may be due to vitreomacular tractions, subfoveal hemorrhage or by the physical response to the injury. Optical coherence tomography (OCT) can identify slight retinal changes as Grade 1 macular holes. Macular holes following ocular trauma can be thoroughly evaluated by OCT and when the hole persists vitreoretinal surgery can be recommended.[1234]

When indicated, TMH surgery has traditionally been successfully performed by pars plana vitrectomy with gas tamponade and patient face-down positioning.[5] Young patients with TMH should wait at least 6 months from the date of the ocular trauma due to the possibility of spontaneous closure.[6] Herein, we report a case of TMH associated with subfoveal hemorrhage and choroidal rupture that recovered spontaneously the macular anatomy and visual acuity.

Case Report

We report a 38-year-old female with sudden decreased of vision in her left eye following blunt trauma by a punch. Her best-corrected visual acuity was 20/20 in the right eye and hands movements in the left. Slit-lamp examination of the affected eye showed conjunctival injection, clear and compact cornea, no evidence of superficial damage to the eyeball, and no lens injury. Left eye fundus examination and fundus color retinography showed subretinal macular hemorrhage. OCT revealed full thickness macular hole and hyperreflective subretinal deposits corresponding to the submacular hemorrhage [Figure 1].

Figure 1

(a) Retinal hemorrhage involving the fovea. (b) Optical coherence tomography shows full-thickness traumatic macular hole with hyperreflective subretinal deposits corresponding to hemorrhage

No intervention was done. In the follow-up visit, the visual acuity in the right eye improved from hand movement to 20/60 and the OCT showed persistent macular hole and partially absorption of the hemorrhage. Fundoscopy revealed a linear whitish lesion concentrically to the optic disc suggesting choroidal rupture. Because of the visual acuity improvement and good absorption of hemorrhage, the patient was advised to return to clinic in 3 months. Three months later, the visual acuity recovered to 20/20. OCT and fundus photographs registered complete resolution of TMH and retinal hemorrhage absorption [Figure 2].

Figure 2

(a) Color retinography demonstrating complete hemorrhage absorption and a hypopigmented lesion concentrically to the optic disc, suggesting choroidal rupture (white arrow). (b) Optical coherence tomography showing macular hole closure with alignment of all retinal layers

Discussion

There are two possible mechanisms in the pathogenesis of TMH: One causes visual loss by immediate and direct foveal detachment; the other is due to vitreous-macular traction. The spontaneous closure of the TMH may occur and observation can be the treatment of choice.[1234] Yamashita et al. published a case series of 18 eyes with TMH where 44% of the eyes showed spontaneous hole closure. They suggested that observation for a period of at least 4 months may be the management of choice.[5] In the described case, during the follow-up without surgical intervention, the macular hole resolved gradually and the visual acuity recovered within 3 months.

Technological advances in equipment and the continuous development of less invasive techniques for vitrectomy surgery lead to retinal surgeons perform intraocular procedures with better anatomic and visual results with fewer complications. Even when dealing with a procedure with little complication rates, the vitrectomy for macular holes presents risks. Proper surgical technique for the post-TMH has not been established. Ghoraba et al. showed that vitrectomy with gas tamponade is more successful in the anatomical closure of TMHs than silicone oil tamponade.[6] Surgery for full thickness macular holes can reestablish foveal morphology in approximately 90% of cases. Pars plana vitrectomy may improve final visual acuity but there are risks of complications such as endophthalmitis and retinal detachment. Risks are similar to surgery for nontraumatic holes.[789] Because of the chance of spontaneous closure without surgical intervention, it was decided to observe through fundus examination, OCT and visual acuity monitoring. Three months after the trauma, the patient presented with macular hole closure and excellent visual acuity.

Conclusion

Caution is needed before surgical intervention in cases of TMH. Monitoring the visual acuity and the anatomic changes of the macular hole by OCT may be the therapy of choice since spontaneous closure is possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.