|Year : 2019 | Volume
| Issue : 1 | Page : 5
A case of bilateral macular hole in a young HIV-positive patient
Jemal Zeberga Shifa1, Alemayehu Mekonnen Gezmu2, Gezahen Negusse Ayane1, Mamo Woldu Kassa3
1 Department of Surgery, University of Botswana, Gaborone, Botswana
2 Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
3 Department of Anaesthesia and Critical Care, University of Botswana, Gaborone, Botswana
|Date of Submission||15-Jul-2019|
|Date of Acceptance||13-Aug-2019|
|Date of Web Publication||05-Sep-2019|
Dr. Alemayehu Mekonnen Gezmu
Department of Paediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, P.Bag 00713, Gaborone
Source of Support: None, Conflict of Interest: None
A 22-year-old female patient was diagnosed to have HIV and treated by highly active antiretroviral therapy (HAART) since 2012 had developed a reduction of vision in both eyes secondary to cataract. The cataract was extracted from both eyes with no immediate postoperative complication. During follow-up, it was recognized that she had had bilateral Stage 3 macular hole in both eyes. The visual acuity in both eyes was 6/60 which did not improve with application of pinhole. Pars plana vitrectomy was done and sealed the macular hole in the left eye. The visual acuity remained the same in both eyes despite surgical intervention.
Keywords: Macular hole, optical coherence tomography, young patient
|How to cite this article:|
Shifa JZ, Gezmu AM, Ayane GN, Kassa MW. A case of bilateral macular hole in a young HIV-positive patient. Pan Am J Ophthalmol 2019;1:5
|How to cite this URL:|
Shifa JZ, Gezmu AM, Ayane GN, Kassa MW. A case of bilateral macular hole in a young HIV-positive patient. Pan Am J Ophthalmol [serial online] 2019 [cited 2020 Feb 20];1:5. Available from: http://www.thepajo.org/text.asp?2019/1/1/5/265868
| Introduction|| |
Idiopathic macular holes (IMHs) are round full-thickness vertical retinal defects in the foveal neurosensory retina. IMH predominantly occurs in individuals aged >65 years. The prevalence of IMH has been estimated at around 0.1%–0.8% of adults aged >40 years, whereas the age-adjusted incidence has been reported as 7.8/100,000 of the general population per year. Approximately two-thirds of patients are women, and the condition is unilateral in around 80% of cases. The review of literature revealed no cases of macular hole seen in young HIV-positive patients.
| Case Report|| |
A 22-year-old African female was diagnosed to have HIV infection and was started on highly active antiretroviral treatment (HAART). The patient had presented to our clinic with reduction of central vision in both eyes. On examination, the visual acuity of the patient was only counting fingers from 3 m in both eyes. The intraocular pressure was measured and found to be 14 mmHg in the right eye and 16 mmHg in the left eye. The cornea was clear. The anterior chamber was deep with no keratic precipitate, cells, and flares. The posterior segment was not seen clearly due to the opacity of the lens in both eyes. Ultrasound of both eyes was done before surgery which showed no sign of vitreous opacity or retinal detachment. The diagnosis of bilateral cataract was made, and cataract surgery with intraocular lens implantation was done. The outcome of cataract surgery was good with visual acuity of 6/60 in both eyes. No postoperative infection and inflammation were noted. On follow-up of the patient, we had found a bilateral macular hole on bimicroscopic slit-lamp examination with 90 diopter Volk lens with interfering beam of slit lamp. There was no sign of vitritis. The diagnosis was later confirmed by optical coherence tomography (OCT) [Figure 1] and [Figure 2]. For this reason, the patient was referred to the Republic of South Africa for ophthalmic surgery as a case of IMH. Vitrectomy was done on the left eye. The postoperative OCT showed a sealed macular hole [Figure 2]. However, the vision on the left eye had shown no improvement. Surgical intervention on the right eye was not done, and the patient is on regular follow-up for progression of disease. There was no history of trauma, myopia, and retinal detachment noted before the cataract surgery. Currently, the visual acuity in both eyes was 6/60 which had not improved after evaluation through pinhole examination.
| Discussion|| |
Macular hole had little attention before 1990 by most ophthalmologists because the pathogenesis was obscure and cure impossible. Our understanding of the pathogenesis of macular holes has evolved significantly over the past two decades, resulting in the development of a new classification that accounts for premacular hole clinical appearances and gives insight into macular hole formation. In addition, OCT is now widely available for diagnosis and treatment planning. Surgery helps reverse the visual loss in most cases.,
Macular holes most commonly affect healthy individuals in their sixth or seventh decade of life. The mean age of onset is 65 years, but patients as young as the third decade have been reported. Women are affected more commonly than men, in a 2: 1 ratio. About 10%–20% of cases eventually are affected bilaterally but rarely simultaneously.,,
The Gass classification system explains the clinically observed appearance of macular holes in four stages and their precursor lesions. Although Gass clinical interpretations of the various stages are widely accepted, OCT classification studies imply that the retinal changes that occur in Stage 1 holes differ slightly from this clinical classification.,
Patients with unilateral Stage 1 macular holes are typically asymptomatic with binocular viewing. Those with symptoms have painless metamorphopsia, decreased vision, or both. Progressive shrinkage of the perifoveal vitreous cortex in Stage 1 eyes leads to Stage 2. Stage 2 holes have a small (100–300 μm), full-thickness neural retinal defect. Stage 3 macular hole is the result of continued vitreofoveal traction. At Stage 3, the hole is developed fully and has the classic macular hole appearance. This consists of a round, 350–600-μm full-thickness neural retinal defect with smooth edges and a small, surrounding, doughnut-shaped cuff of subretinal fluid with persistent hyaloid attachment. A Stage 4 macular hole has all the features of a Stage 3 hole but with complete posterior separation of the vitreous from the fovea.,
The cause of underlying trauma-related macular holes and IMHs is different. Trauma-related macula holes are suspected to be related to the transmission of concussive force in the countercoup manner, which results in the immediate rupture of the macula at the thinnest point. Whereas, vitreous traction was implicated as a cause for IMH. Our patient had no history of trauma to eyes, and we strongly considered her cause to be idiopathic. However, in our patient, immune recovery uveitis can be considered as a possible cause of bilateral macular hole.
| Conclusion|| |
Macular hole can occur in young with underlying medical illness. The possibility of HIV infection and associated immune recovery uveitis may be implicated as a possible cause of macular hole. However, this statement needs to be proven with further study.
The patient had given verbal and written consent for publication of her case. Utmost care was taken to keep the identity of the patient confidential on the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752-9.
Hee MR, Puliafito CA, Wong C, Duker JS, Reichel E, Schuman JS, et al.
Optical coherence tomography of macular holes. Ophthalmology 1995;102:748-56.
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-9.
Wendel RT, Patel AC, Kelly NE, Salzano TC, Wells JW, Novack GD. Vitreous surgery for macular holes. Ophthalmology 1993;100:1671-6.
Brown GC. Macular hole following rhegmatogenous retinal detachment repair. Arch Ophthalmol 1988;106:765-6.
Moshfeghi AA, Salam GA, Deramo VA, Shakin EP, Ferrone PJ, Shakin JL, et al.
Management of macular holes that develop after retinal detachment repair. Am J Ophthalmol 2003;136:895-9.
Cohen SM, Gass JD. Macular hole following severe hypertensive retinopathy. Arch Ophthalmol 1994;112:878-9.
[Figure 1], [Figure 2]