1 Introduction
Macular hole (MH) formation after rhegmatogenous retinal detachment (RRD) repair is not common, with an incidence of approximately 0.5% to 1.9%.[1–6] vitrectomy . Among these procedures, scleral bucking is most closely associated with MH development, with relatively few cases resulting from vitrectomy alone.[1,3,4] [6]
In most MH cases after vitrectomy , surgical treatments are needed for repair of hole. On the other hand, spontaneous closure of the MH is much rarer. We describe a case of MH formation and spontaneous resolution which occurred associated with branch retinal vein occlusion (BRVO) accompanying cystoid macular edema (CME) after vitrectomy for macula-on RD. The patient has provided informed consent for publication of this case.
2 Case presentation
A 66-year-old female patient visited our outpatient clinic due to blurry vision in her right eye. She had hypertension but was free from diabetes mellitus. The best-corrected visual acuity (BCVA) was 1.0 in both eyes, and the intraocular pressure was 19/16. On slit lamp examination, both eyes were pseudophakic, and there were no other specific manifestations in the anterior segment. On fundus examination, the right eye showed ghost vessels in the superior-nasal area around the disc RD, with a large retinal tear at the inferior retina. On spectral domain optical coherence tomography (SD-OCT), localized epiretinal membrane (ERM) not involving the fovea was detected, and the foveal contour was intact. On the same day, a barrier laser was used to treat the RD.
Two months after the initial visit, the RD was found to be enlarged, so surgery including 25-gauge vitrectomy and endolaser gas (18% SF6) injection was performed. One month after surgery, the BCVA of the right eye was well-maintained at 1.0, and the retina was flat. On SD-OCT, the ERM showed no progression (Fig. 1 A).
Figure 1: Spectral domain optical coherence tomography of the patient. (A) One month after surgery for rhegmatogenous retinal detachment, ERM which is not involving the fovea was observed (B) Eight months after surgery, the ERM progressed to the macular area and intraretinal cysts and a small MH were noted. (C) At 1 week after initial detection of the MH, the intraretinal cysts had increased in extent and an opened MH was observed. (D) Two weeks after MH detection, the intraretinal cysts had decreased in extent and the inner wall of the hole had contracted. (E) The intraretinal cysts disappeared and the MH was closed with a subtle subretinal space. (F) Nine months after detection, a completely closed MH was noted. ERM = epiretinal membrane, MH = macular hole.
However, during the follow-up (several months in duration), the ERM progressed and the visual acuity (VA) worsened. At 8 months after surgery, the BCVA of the right eye was 0.6. On fundus examination, a flame-shape retinal hemorrhage was observed along the superior temporal vascular arcade. (Fig. 2 ) On SD-OCT, the ERM progressed to the macular area and intraretinal cysts and a small MH were noted (Fig. 1 B). We concluded that MH and BRVO were both present. One week later, the MH enlarged, so we planned a surgery (Fig. 1 C). However, 2 weeks after detection of the MH, while waiting for surgery, SD-OCT showed that the intraretinal cysts had decreased in extent and the inner wall of the MH had contracted (Fig. 1 D). We explained current condition to the patient, and postponed surgery to monitor the status of the eye. Four weeks later, the intraretinal cysts disappeared and the MH was closed with a subtle subretinal space (Fig. 1 E).
Figure 2: Eight months after a vitrectomy for rhegmatogenous retinal detachment, a flame-shape retinal hemorrhage was observed along the supero-temporal retinal vascular arcade.
Nine months after the detection of MH, the VA of the right eye was 1.0. Despite thinning of foveal tissue, the MH was completely closed and did not recur (Fig. 1 F). Regarding the BRVO, no associated complications such as macular edema or retinal neovascularization were observed.
3 Discussion and conclusion
Idiopathic MH formation is associated with antero-posterior or tangential traction forces on the macular, mediated by the vitreous, and the incidence of MH in eyes with posterior vitreous detachment and vitrectomized eyes is relatively low.[7] vitrectomy alone.[1,3,4] vitrectomy for RRD show foveal detachment at the initial diagnosis of RRD,[6] [8,9]
MH formation after vitrectomy has a different pathophysiology to idiopathic MH due to the absence of a tractional force on the macula exerted by the vitreous. Possible mechanisms of MH formation after vitrectomy involve changes in foveolar anatomy, such as ERM formation resulting in a tangential traction force, CME accompanied by coalescence of the perifoveal cystoid spaces, changes in the elasticity of the inner limiting membrane, the traction resulting from intraretinal and preretinal cellular remodeling, and vitreofoveal traction due to residual cortical vitreous.[7,10–13]
In the current case, the fovea was attached when RRD was initially diagnosed. Thus, MH formation may be associated with progression of ERM and the occurrence of CME, but not with foveal weakening due to RRD itself. Lee et al[14]
CME after vitrectomy can result from diabetic retinopathy, postoperative inflammation (Irvine-Gass syndrome), and traction of the ERM.[14,15] vitrectomy for RRD in our case. Although the ERM showed mild progression, it was not sufficiently serious to cause intraretinal cysts. However, when we initially noticed the MH and CME, a flame-shaped hemorrhage along the vascular arcade indicative of BRVO was also noted.
Thus, we assumed that CME due to BRVO caused dehiscence of the foveal tissue, and tangential traction of the ERM opened the gap resulting in a full thickness MH. Because the BRVO was not severe, the CME improved without any specific treatment; the MH closed and the inner wall of the hole contracted.
In conclusion, we report MH formation and spontaneous closure in a patient who had a vitrectomy due to macular-on RRD. We assumed that the course of MH was associated with CME due to BRVO unrelated to the usual post-vitrectomy course. To the best of our knowledge, there has been no similar report. In vitrectomized eyes, physicians should consider the possibility of MH development in association with BRVO, along with possible spontaneous closure of the MH.
Author contributions
Conceptualization: Ki Yup Nam, Yong Seop Han
Data curation: Tae Seen Kang, Bum Jun Kim, JI Hye Kim
Investigation: Ki Yup Nam, Hyun Jyung Cho, Tae Seen Kang, Yong Seop Han
Methodology: Ki yup Nam, JI Hye Kim, Bum Jun Kim, Yong Seop Han
Project administration: Hyun Kyung Cho, Tae Seen Kang
Supervision: Hyun Kyung Cho, Tae Seen Kang
Writing – original draft: Ki Yup Nam, Yong Seop Han
Writing – review & editing: Ki Yup Nam, Hyun Kyung Cho, Tae Seen Kang, JI Hye Kim, Yong Seop Han
References
[1]. Moshfeghi AA, Salam GA, Deramo VA, et al. Management of macular holes that develop after retinal detachment repair. Am J Ophthalmol 2003;136:8959.
[2]. Garcia-Arumi J, Boixadera A, Martinez-Castillo V, et al. Macular holes after rhegmatogenous retinal detachment repair: surgical management and functional outcome. Retina 2011;31:177782.
[3]. Fabian ID, Moisseiev E, Moisseiev J, et al. Macular hole after
vitrectomy for primary rhegmatogenous retinal detachment. Retina 2012;32:5119.
[4]. Benzerroug M, Genevois O, Siahmed K, et al. Results of surgery on macular holes that develop after rhegmatogenous retinal detachment. Br J Ophthalmol 2008;92:2179.
[5]. Rishi P, Reddy S, Rishi E. Macular hole developing in a post-vitrectomized eye and its surgical outcome. Oman J Ophthalmol 2013;6:1356.
[6]. Schlenker MB, Lam WC, Devenyi RG, et al. Understanding macular holes that develop after repair of retinal detachment. Can J Ophthalmol 2012;47:43541.
[7]. Zhang W, Grewal DS, Jaffe GJ, et al. Spontaneous closure of full-thickness macular hole with epiretinal membrane in vitrectomized eyes: case series and review of literature. Ophthalmic Surg Lasers Imaging Retina 2017;48:18390.
[8]. Golan S, Barak A. Third time spontaneous closure of myopic macular hole. Retin Cases Brief Rep 2015;9:134.
[9]. Ozdemir E, Ozdek S. Recurrent opening and closure of macular hole after pars plana
vitrectomy for rhegmatogenous retinal detachment. Retin Cases Brief Rep 2018;doi: 10.1097/ICB.0000000000000699. Online ahead of print.
[10]. Smiddy WE. Spontaneous macular hole closure with appearance of epiretinal membrane: implications for therapy. Ophthalmic Surg Lasers Imaging 2008;39:2378.
[11]. Gross JG. Late reopening and spontaneous closure of previously repaired macular holes. Am J Ophthalmol 2005;140:5568.
[12]. Fekrat S, Wendel RT, de la Cruz Z, et al. Clinicopathologic correlation of an epiretinal membrane associated with a recurrent macular hole. Retina 1995;15:537.
[13]. Christmas NJ, Smiddy WE, Flynn HW Jr. Reopening of macular holes after initially successful repair. Ophthalmology 1998;105:18358.
[14]. Lee SH, Park KH, Kim JH, et al. Secondary macular hole formation after
vitrectomy . Retina 2010;30:10727.
[15]. Mori T, Kitamura S, Sakaguchi H, et al. Two cases of repeating recurrences and spontaneous closures of macular holes in vitrectomized eyes. Jpn J Ophthalmol 2018;62:46772.
