|Year : 2020 | Volume
| Issue : 1 | Page : 15
Closure of a full-thickness idiopathic macular hole in a young patient treated with pneumatic vitreolysis
David Paredes Saa1, Laura Paredes1, Carlos Mario Rangel2
1 Clínica Oftalmológica Paredes, Pasto, Nariño, Colombia
2 Fundación Oftalmologica de Santander Clínica Carlos Ardila Lülle (FOSCAL), Universidad Industrial de Santander (UIS), Universidad Autónoma de Bucaramanga, Floridablanca, Colombia
|Date of Submission||31-Mar-2020|
|Date of Acceptance||16-Apr-2020|
|Date of Web Publication||24-Jun-2020|
Dr. David Paredes Saa
Carrera, 42A, 18A – 56 Piso Quinto, Pasto, Nariño
Source of Support: None, Conflict of Interest: None
The idiopathic full-thickness macular hole is characterized by a total thickness anatomical defect in the foveal retina leading to a reduction of central vision. Although there are several reports about the natural course of the disease and its outcome, the spontaneous closure frequency varies widely in literature reviews. Treatment options include pars plana vitrectomy, pharmacological vitreolysis, and pneumatic vitreolysis. A 30-year-old male was referred to us with a complaint of decreased vision in his right eye and metamorphopsia for nearly 2 months without a history of trauma. The diagnosis was based on fundoscopic and optical coherence tomography (OCT). OCT revealed a large full-thickness idiopathic macular hole (422 μm) without vitreomacular traction. The intravitreal gas injection was performed. Three months later, in follow-up by OCT, total closure of the macular hole was noted. The aim is to report a case of idiopathic total thickness macular hole closure with a single application of C3F8 gas.
Keywords: Full-thickness macular hole, pneumatic C3F8 vitreolysis, vitreous-retinal interface
|How to cite this article:|
Saa DP, Paredes L, Rangel CM. Closure of a full-thickness idiopathic macular hole in a young patient treated with pneumatic vitreolysis. Pan Am J Ophthalmol 2020;2:15
|How to cite this URL:|
Saa DP, Paredes L, Rangel CM. Closure of a full-thickness idiopathic macular hole in a young patient treated with pneumatic vitreolysis. Pan Am J Ophthalmol [serial online] 2020 [cited 2020 Nov 28];2:15. Available from: https://www.thepajo.org/text.asp?2020/2/1/15/287689
| Introduction|| |
Full-thickness idiopathic macular holes are characterized by an anatomical defect in the foveal region that leads to a reduction of central vision. Although there are several reports of the natural course of the disease and its outcome, the frequency of spontaneous closure varies widely in the literature, and the vast majority progress to a larger hole.,,, Currently, the literature continues to report that pars plana vitrectomy (PPV) is the standard treatment for full-thickness macular hole correction. In recent years, less invasive methods have been extensively investigated, such as pharmacological vitreolysis with ocriplasmin and pneumatic vitreolysis.,
| Case Report|| |
A 30-year-old healthy male with an unremarkable ocular and systemic history was referred to us complaining of decreased vision and metamorphopsia in his right eye for nearly 2 months without a history of trauma. His uncorrected visual acuity was 20/100 (0.7 logarithms of the minimum angle resolution [logMAR]) in the right eye and 20/20 (0.0 logMAR) in the left eye. Best-corrected visual acuity was 20/60 (0.5 logMAR) in the right eye. Anterior segment examination revealed no further abnormalities. Fundoscopy examination revealed an image of a full-thickness macular hole with a complete posterior vitreous detachment [Figure 1].
|Figure 1: Pictures of right eye fundus (Eidon FA; CenterVue Inc) (a) color image showing full-thickness macular hole (white arrow) (b) Fundus autofluorescence imaging illustrating hyper autofluorescence of the macular hole. There is a thin ring of hypo autofluorescence surrounding the hole due to the upward edges of the macular hole|
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The optical coherence tomography examination [Figure 2]a reported a full-thickness large macular hole (422 μm) without vitreomacular traction. We also appreciated some cystic spaces on both edges of the hole. Pneumatic vitreolysis of 100% C3F8 gas (0.3 ml) was performed in the right eye without complication, and the patient was requested to maintain a prone position for 10 days. During follow-up visits, progressive closure of the macular hole [Figure 2]b-d] was registered, and the improvement of visual acuity was evident with an uncorrected visual acuity of 20/30 (0.2 logMAR) by the 3rd month postoperatively [Figure 2]e.
|Figure 2: Optical coherence tomography images (RTVue OCT; Optovue Inc., Fremont, CA) illustrating the progression of the macular hole from diagnosis and evolution during treatment, (a) large full-thickness macular hole with 422 μm opening diameter, without vitreomacular traction or epiretinal membrane, (b) 20 days postoperative, (c) 30 days postoperative, (d) 45 days postoperative, (e) 90 days postoperative showing total closure of the macular hole|
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| Discussion|| |
Idiopathic macular holes occur with a prevalence of 1/3300 in individuals between the sixth and seventh decades of life. More than 97% of the total population who have macular holes are older adults, >50% occur in patients 65–74 years old, and 3% are under 55 years old. The presence of macular holes in young individuals is most commonly associated with trauma, pathological myopia, inflammation, or retinal vascular diseases. It has been described that vitreoretinal interface pathologies are caused by an abnormal or incomplete detachment of the posterior vitreous. Full-thickness macular holes are defined as a foveal lesion with interruption of all the layers of the retina from the internal limiting membrane to the retinal pigment epithelium [Table 1].
|Table 1: The international vitreomacular traction study classification system for vitreomacular adhesion, traction, and macular hole|
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This condition is characterized by an anatomical defect in the foveal retina that leads to a reduction of central vision. Although there are several reports of the natural course of the disease and its outcome, the frequency of spontaneous closure varies widely in the literature from 2.7% to 34%. However, the vast majority progress to a larger hole.,, Currently, the literature continues to report that PPV is the standard treatment for full-thickness macular hole correction. Even though the success rate of PPV as a method is high (85%–97%), it carries the risk of cataract formation in phakic patients, endophthalmitis, retinal tears, and retinal detachment. In recent years, pharmacological vitreolysis with ocriplasmin has been extensively investigated as a less invasive method. Nevertheless, it has a lower success rate compared to subsequent vitrectomy (40%) and has also been associated with undesirable side effects such as dyschromatopsia, transient visual loss, lens subluxation, and electroretinogram changes., On the other hand, a great benefit has been described with the use of intraocular gases since they can isolate and seal the affected area. They also achieve a mechanical tamponade due to the buoyancy of the gas and provide a template for the migration of glial cells, promoting the closure of the macular hole. The success rate in the closure of macular hole has been reported in 91% of cases with C3F8 gas injection and in 95% of cases in spontaneous posterior vitreous detachment in the macula. Treatment strategies depend on the severity of the disease. Currently, there is no standardized treatment for the management of an incipient disease of the vitreoretinal interface. Some options include observation, PPV, vitreolysis with ocriplasmin, and pneumatic vitreolysis. Conservative treatment can lead to a spontaneous resolution in 34% of cases. However, unresolved events can cause a severe decrease in visual acuity with significant structural repercussions.,, Macular hole surgery was first described in 1991 by Kelly and Wendel. For many years, PPV has been the standard therapeutic approach for vitreomacular traction and related pathologies. Recently, less invasive procedures have been described seeking a reduction in complications that can avoid satisfactory results. This is the reason why the safety profile of intravitreal gas injection is well established in the treatment of retinal lesions with potential advantages, including lower costs and ease of administration., Intravitreal gas injection for the treatment of vitreomacular disorders was first described in 1995 by Chan et al. He described that the gas bubble can accelerate posterior vitreous detachment, relieve vitreomacular traction, and even induce closure of full-thickness macular holes. In 2016, Han et al. in their study determined a closure rate of small, medium, and large total thickness macular holes of 85.7%, 80%, and 33.3%, respectively. Given the fact that this was a young patient where we did not want to compromise healthy structures such as a clear lens, we considered adopting a minimally invasive procedure for the treatment of the macular hole that had a low cost and at the same time that had good effectiveness. In this case, considering there is no history of trauma, ocular complications, intraocular inflammation, refractive defect or any other ocular pathology, the macular hole was classified as a large-sized full-thickness idiopathic macular hole which was satisfactorily resolved by pneumatic vitreolysis with C3F8 gas. Gassmann et al. have described that between 25% and 50% of closed holes do not achieve visual acuity better than 20/50 (0.4 logMAR), however, in this case, the surgery led to a satisfactory anatomical and functional recovery with an uncorrected visual acuity of 20/30 (0.2 logMAR), which suggest that this is a valuable alternative for the pathologies of the vitreoretinal interface.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]