Spontaneous closure of macular hole after pars plana vitrectomy: Report of two cases

Abstract

The spontaneous closure of a full-thickness macular hole (MH) developed after vitrectomy is very uncommon. We report a small series of cases (two patients) with this presentation. The first patient developed a MH 1 month after vitrectomy for an epirrretinal membrane and, the second one, 3 weeks after vitrectomy for rhegmatogenous retinal detachment. The MHs resolved spontaneously 2 months and 1 month after their documentation by optical coherence tomography(OCT), respectively. In this case report, we review the literature on spontaneous closure of MHs and discuss possible mechanisms for this rare event.

Full text

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Spontaneous closure of macular hole after
pars plana vitrectomy: report of two cases
Fechamento espontâneo de buraco de mácula em olhos
previamente vitrectomizados: relato de dois casos
Ana Claudia de Franco Suzuki1, Leandro Cabral Zacharias1, Mário Junqueira Nóbrega2, Rony Carlos Pretti1,
Walter Yukihiko Takahashi1
1Medical School of the São Paulo University, São Paulo/SP, Brazil.
2University of the Joinville Region, Joinville/SC, Brazil.
Work conducted at the Ophthalmology Unit, Medical School of the São Paulo University, São Paulo/SP, Brazil.
The authors declare no conflicts of interest
Received for publication: 4/2/2013 - Accepted for publication: 22/9/2013
ABSTRACT
The spontaneous closure of a full-thickness macular hole (MH) developed after vitrectomy is very uncommon. We report a small
series of cases (two patients) with this presentation. The first patient developed a MH 1 month after vitrectomy for an epirrretinal
membrane and, the second one, 3 weeks after vitrectomy for rhegmatogenous retinal detachment. The MHs resolved spontaneously
2 months and 1 month after their documentation by optical coherence tomography(OCT), respectively. In this case report, we
review the literature on spontaneous closure of MHs and discuss possible mechanisms for this rare event.
Keywords: Retinal perforations, Vitrectomy/methods, Optical coherence tomography, Epiretinal membrane, Retinal detachment,
Case reports
RESUMO
O fechamento espontâneo de buraco de mácula de espessura total é um fenômeno raro, especialmente em olhos vitrectomizados.
Descrevemos nesse relato dois casos com essa apresentação. No primeiro caso, notou-se o buraco de mácula 1 mês após vitrectomia
por membrana epirretiniana e, no segundo, 3 semanas após vitrectomia por descolamento de retina regmatogênico. O fechamento
desses buracos ocorreu espontaneamente 2 meses e 1 mês após sua documentação, respectivamente. Feita a revisão bibliográfica e
propostas teorias para explicar esta evolução atípica, o entendimento deste fenômeno pôde nos ajudar a refinar a indicação cirúrgi-
ca desta patologia.
Descritores: Perfurações retinianas, Vitrectomia/métodos, Tomografia de coerência óptica, Membrana epirretiniana,
Descolamento retiniano, Relatos de casos
CASE REPORT
Rev Bras Oftalmol. 2014; 73 (6): 389-91
DOI: 10.5935/0034-7280.20140080

390
INTRODUCTION
Idiopathic macular hole (IMH) was first described in the late
19th century and it typically occurs in women in their sixth or
seventh decade of life.Gass et al.suggested in 1988 that the
condition could be linked to traction of the posterior vitreous
surface and proposed a classification according to its
biomicroscopic features(Table 1). Stages 1A (early macular hole)
and 1B (occult) were subsequently included in this classifica-
tion.1
Approximately 50% of stage 1 macular holes (MHs)
resolveafter spontaneous vitreous-foveal separation.Most stage
2 MHs progress to stages 3 and 4, as shown byKim et al. in a
prospective, randomised study on 21 eyeswith stage 2 MH, where
71% progressed to later stages.2
Pars plana vitrectomy (PPV) for closing IMH was first
described by Kelly and Wendel in 1991(3) .Surgical treatment is
currently indicated in cases of full-thickness IMH, and more than
90% of cases resolve with surgery, with visual acuity improving
in up to 70% of cases.4
Duration of symptoms, MH size, preoperative visual acu-
ity (VA), and the ratio between MH rim and diameter on OCT
are factors that affect the visual prognosis after vitrectomy.The
postoperative integrity of the photoreceptor layer is also impor-
tant for the functional outcome.5
Spontaneous closure of full-thickness IMH is rare, with a
reported prevalence of 4-6%.Spontaneous closure is more com-
mon in traumatic MH (especially in young patients).Suggested
mechanisms include spontaneous release of vitreous traction;
epiretinal membrane (ERM) contraction; glial or retinal pigment
epithelial proliferation; or retinal tissue bridging, forming a frame-
work that closes the hole.6
MH relapse after vitrectomy occurs in 4.5 to 9.5% of
cases.7 Spontaneous closure is rare, as the vitreous traction com-
ponent is no longer present.This phenomenon is even more un-
common in MHs found after PPV due to other retinal conditions.8
This paper will describe two cases of full-thickness MH
occurring after vitrectomy that resolved spontaneously.
Case 1
Male, 62-year-old patient with progressive loss of VA in
the left eye (LE) for 6 months.Corrected VA was 20/60 in the
LE; retinal mapping found macular folds and an image sugges-
tive of MH.The Watzke-Allen test was negative, and OCT found
a lamellar MH (Figure 1A).PPV was performed to remove the
ERM and the internal limiting membrane followed by air tam-
ponade, without complications.
One month after surgery the patient complained of a cen-
tral scotoma in the LE.His VA was 20/50, with a positive Watzke-
Allen test and OCT showing a full thickness macular microhole
Figure 1: Preoperatively (A):ERM + lamellar macular hole; 1 month
after surgery (B):full-thickness macular hole; 3 months after surgery
(C):tissue bridge; 5 months after surgery:no macular abnormalities
Figure 3: Retinography (A) and OCT (B) after 1 year of follow-up
Figure 2: Three weeks after PPV (A), full-thickness MH; 7 weeks
after PPV (B), spontaneous closure of the MH
Rev Bras Oftalmol. 2014; 73 (6): 389-91
Suzuki ACF, Zacharias LC, NóbregaMJ, Pretti RC, Takahashi WY
Staging Biomicroscopic Features
1 1A Loss of foveal depression and presence of a yellow spot in the fovea, loss of normal foveal reflex,
no posterior vitreous detachment
1B Loss of foveal depression, yellow ring with bridging interface of vitreous cortex, no posterior vitreous
detachment
2 Small central full-thickness retinal defect, with or without pre-foveal opacity (pseudo-operculum)
formed by the contracted pre-foveal cortical vitreous, no posterior vitreous detachment
3 Central full-thickness retinal defect with a diameter greater than or equal to 400ìm, elevated rim;
posterior vitreous still attached,no Weiss ring,with or without pre-foveal opacity (pseudo-operculum)
4 Central full-thickness retinal defect with a diameter greater than or equal to 400 ìm, elevated rim; detached
posterior vitreous (a Weiss ring is frequently observed)
Source:Translated and adapted fromGass JD.Reappraisal of biomicroscopic classification of stages of development of a macular hole.Am J Ophthalmol.
1995;119(6):752-9.
Table 1
Stages of macular hole according to the Gass classification

391
(Figure 1B).The patient did not want to undergo a new proce-
dure for personal reasons.Three months after surgery his
correctedVA was 20/25, and OCT found a tissue bridge over the
MH, opening only in the deeper layers (Figure 1C).Five months
after surgery the patient had no complaints, his correctedVA was
20/20, and his macula showed no abnormalities (Figure 1D).
Case 2
Female 44-year-old patient with myopia (-6 dioptres) and
a history of radial keratotomy with a corrected VA of 20/25 in
both eyes.She presented with an acute loss of vision in the LE
(finger count at 2 metres), being diagnosed with rhegmatogenous
retinal detachment with upper peripheral tears, being submitted
to PPV.
Three weeks after the procedure her VA was 20/300 in
the LE, and a full-thickness MH with intraretinal cysts was ob-
served (Figure 2A).One month later, the MH resolved sponta-
neously and her VA improved to 20/50 (Figure 2B).After one
year her VA remained unchanged (Figure 3).
DISCUSSION
Spontaneous closure of a MH is rare but well described in
the literature, and it is probably secondary to the release of vit-
reous traction due to spontaneous posterior vitreous detachment
or glial proliferation.Retinal tissue bridging is especially impor-
tant in cases of small MHs.6
Inoue et al.6 observed that the macular anatomy returned
to normal within 3 years of follow-up in 6 patients with sponta-
neous MH closure assessed with OCT.VA improved in all pa-
tients, but with a worse final VA in cases of persistent foveal
detachment after MH closure or delayed restoration of the in-
ner and outer photoreceptor layers.
Recurrent MH after vitrectomy is uncommon and it rarely
resolves spontaneously.Vitreomacular traction would not be an
important causal factor in such cases, as the posterior vitreous
would already be detached.In 2011 Yonekawa et al.9 reported
the spontaneous closure of a recurrent myopic MH after
vitrectomy.The authors describe another 5 cases of full-thick-
ness MH after vitrectomy that resolved spontaneously, three of
which were associated with ERM.
In MHsresolving spontaneously after vitrectomy for reti-
nal conditions, the process could be related to degeneration of
the inner retinal layers due toatrophy or coalescence of cystoid
oedema.Proliferation and contraction of retinal glial elements
could cause these MHs to increase in size.10
Ogawa et al.11 reported a MHarising 7 months after PPV
due to ERM.Expectant management was adopted, as the pa-
tient had a good VA.Spontaneous closure of the MH occurred 2
months after diagnosis (OCT showed residual foveal detachment,
which disappeared after a month).
In a case series, Tsilimbaris et al.8 reported three MHs that
resolved spontaneouslyin vitrectomised eyes:one due to penetrat-
ing trauma and two due to retinal detachment.The MHs were
diagnosed 14 months, 10 days, and 2 months after PPV,
respectively,and spontaneous resolution occurred 2 years, 6
months, and 9 months after diagnosis.
These reports show that spontaneous MH closure in
vitrectomised eyes is a rare but possible phenomenon.In one of
the cases, retinal tissue bridging was observed, with initial clo-
sure of the inner retinal layers followed by the outer
layers.Understanding these phenomena can help clarify the gen-
esis of IMH, thus improving surgical indications and surgical tech-
niques.
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Rev Bras Oftalmol. 2014; 73 (6): 389-91
Spontaneous closure of macular hole after pars plana vitrectomy: report of two cases
Corresponding author:
Leandro Cabral Zacharias
Universidade de São Paulo, Faculdade de Medicina.
Av. Dr Eneas de Carvalho Aguiar, 255, 6o Andar
Cerqueira Cesar
05403-000 - Sao Paulo, SP - Brazil
Telephone: (011) 30697871
Email: lczacharias@gmail.com