Giant Atypical Macular Hole after Vitrectomy for Needle Perforation.

PRESENTATION

Secondary macular holes (MH) are associated with trauma, rhegmatogenous or tractional retinal detachment, Nd:YAG laser injury, and other retinal pathologies that result in tangential forces on the posterior pole.[12] When larger than 1,500 μm, it might be referred to as a giant MH, which is rare and more often attributed to blunt rather than open globe trauma because of its mechanism as sudden equatorial expansion.[3]

A patient presented with progressive vision loss in her right eye. Five months earlier, this eye had experienced penetrating injury (with entrance and exit wounds) by a 22-gauge needle (30 × 7 mm) during retrobulbar anesthetic block for cataract surgery. Thus, combined pars plana vitrectomy (PPV) with phacoemulsification for vitreous hemorrhage was performed. Retinal detachment (RD) was observed intraoperatively. After surgery, her BCVA was 20/400 and 20/20, in the right and left eyes, respectively. Postoperative fundus photography (Visucam®, Zeiss, Oberkochen, Germany) showed a large MH due to retinal traction and macular dehiscence [Figures 1 and 2a (white asterisk) and 2b (white dashed line)], localized MH RD [Figure 1, yellow arrowheads], severe fibrous ingrowth at the site of perforations [Figure 1, black asterisk], and laser scarring [Figure 1, white asterisks].

Figure 1

Fundus photography revealed a giant macular hole (white asterisk), adjacent retinal detachment (yellow arrowhead), severe fibrous ingrowth (black asterisk), and laser scarring (white arrowhead) postoperatively in the silicone oil-filled eye.

Figure 2

Fundus photography and infrared imaging shows atypical macular hole (a, white dashed line), surrounded by a retinal detachment area (b) of 17.76 mm2 (c, yellow line), measuring 484 × 2221 μm (d), in a silicone oil filled eye.

Infrared imaging (Spectralis®, Heidelberg Engineering, Heidelberg, Germany) revealed retinal detachment area of 17.76 mm2 [Figure 2c] and a macular hole with dimensions of 484 × 2221 μm. [Figure 2d]. Vertical and horizontal Spectral-Domain Optical Coherence Tomography scans (Spectralis®, Heidelberg Engineering, Heidelberg, Germany) showed a large macular defect, intraretinal cysts [Figure 3a and b], and adjacent retinal detachment [Figure 3b].

Figure 3

Optical coherence tomography shows a large macular defect, intraretinal cysts (a and b), and adjacent retinal detachment (b) after vitrectomy.

DISCUSSION

Globe penetration during peribulbar/retrobulbar block is rare and may occur whether the block is performed by an ophthalmologist or a non-ophthalmologist. Eyes with axial length longer than 26 mm, difficult access to the conjunctival fornix, and non-cooperative patients increase its risk. This complication is characterized by pain, sudden vision loss, hypotonia, and poor red reflex, and may be avoided by knowledge of orbital anatomy and using the proper technique.[4]

In non-idiopathic MHs, unlike idiopathic MHs, posterior vitreous attachment and variable hole dimensions are expected.[5] When a surgical approach is indicated, it aims to release tangential forces, as for idiopathic MH, and to treat associated lesions. Different from blunt trauma MHs, other secondary MHs, as associated with ocular perforation or retinal detachment, may have a poorer prognosis.[6] In these cases, both hole closure and final BCVA may be compromised despite prompt treatment because of secondary eye damage.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.