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Fourth time lucky: A case of multiple recurrence of a macular hole [13]

June 2006
The British journal of ophthalmology 90(5):659

DOI:10.1136/bjo.2006.079012

Source
PubMed

Authors:

Mira Hussin

University of Technology Malaysia

Riaz Asaria

Royal Free London NHS Foundation Trust

Nathaniel E Knox Cartwright

Royal Devon and Exeter NHS Foundation Trust

Vision restoration therapy (VRT) has been the subject of considerable controversy,1–3 and with Horton’s latest editorial3 it has now turned rather personal. The editorial is filled with numerous inaccuracies and misrepresentations and this cannot go unanswered. Just as a scientific debate should not focus on fiction but on facts, comments by critics must be evaluated with the same rigor as the original work itself. Only by keeping track of all of the scientific evidence rather than by a personal and limited review of some selected facts will we get closer to the truth. Firstly, it is a fundamental misrepresentation by Horton that we are trying to “salvage neurons” at the fringe of a lesion. Rather, we believe that VRT activates surviving neurons in areas of residual vision (ARVs)—that is, areas that are partially damaged.4–7 Repetitive use through daily training increases neuronal activation,8 which is greatly enhanced by attentional processes.9 No neuron is “salvaged.” It is correct that at the time Horton wrote his editorials no one had published studies on eye movements. But since then the first eye movement studies have been published in abstract form. It actually turns out that eye movements, when measured with an eye tracker, are not altered after VRT.10 There is also other indirect evidence, which is incompatible with the hypothesis that eye movements explain visual field improvements:

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3De Becker I, Walter M, Noel LP. Phenotypic

variations in patients with a 1630 A.T point

mutation in the PAX6 gene. Can J Ophthalmol

2004;39:272–8.

4Ritch R, Forbes M, Hetherington J Jr, et al.

Congenital ectropion uveae with glaucoma.

Ophthalmology 1984;91:326–31.

5Futterweit W, Ritch R, Teekhasaenee C, et al.

Coexistence of Prader-Willi syndrome, congenital

ectropion uveae with glaucoma, and factor XI

deficiency. JAMA 1986;255:3280–2.

6Trovo-Marqui AB, Goloni-Bertollo EM,

Teixeira MF, et al. Presence of the R1748X

mutation in the NF1 gene in a Brazilian patient

with ectropion uveae. Ophthalmic Res

2004;36:349–52.

7Azuma N, Yamada M. Missense mutation at the C

terminus of the PAX6 gene in ocular anterior

segment anomalies. Invest Ophthalmol Vis Sci

1998;39:828–30.

8Mirzayans F, Pearce WG, MacDonald IM, et al.

Mutation of the PAX6 gene in patients with

autosomal dominant keratitis. Am J Hum Genet

1995;57:539–48.

9Nelson LB, Spaeth GL, Nowinski TS, et al.

Aniridia. A review. Surv Ophthalmol

1984;28:621–42.

Fourth time lucky: a case of

multiple recurrence of a macular

hole

We present the case of a patient who has

undergone four macular hole operations for

late multiple recurrences. The same experi-

enced ophthalmologist confirmed the pre-

sence of each macular hole and performed

each operation.

Case report

A 55 year old female myope, –3.75 D right eye

and 23.5 D left eye, was referred to the

vitreoretinal clinic with a 2 month history of

right visual disturbance. On presentation, her

visual acuities were 6/9 right eye and 6/60 left

eye. Fundal examination and fluorescein

angiography showed a right stage I macular

hole and a left stage IV macular hole. As the left

macular hole was long standing, it was decided

not to operate on this eye. Two months later the

right visual acuity was reduced further to 6/36

because of progression to a stage II macular

hole and she underwent a right vitrectomy and

18% C

gas tamponade. At the time of

surgery, the posterior hyaloid was detached

and the absence of an epiretinal membrane

was confirmed but no inner limiting mem-

brane (ILM) peel was performed. Following

this and each subsequent vitrectomy, the

patient postured face down for 2 weeks.

Postoperatively, right visual acuity improved

to 6/6 but 8 months later the hole reopened,

and her right visual acuity dropped to 6/18. A

further vitrectomy and 20% C

gas tampo-

nade was carried out. During this, a silicon

tipped aspiration needle was used to confirm

the absence of vitreous at the macula and a

barbed blade used to show that no epiretinal

membrane was present. The hole closed and

the vision improved to 6/12. Two years later the

patient underwent uneventful right phacoe-

mulsification cataract surgery with posterior

chamber intraocular lens implantation and her

acuity was restored to 6/9. After another

2 years right visual acuity fell to 6/36, the hole

had reopened. The patient underwent a third

macular hole operation consisting of ILM peel

and 18% C

tamponade. The hole remained

closed and the vision improved to 6/9 for a

further 3 years when the hole reopened and the

vision decreased to 6/24. A fourth procedure

was performed consisting of trypan blue

assisted ILM peel to two disc diameters from

the hole and 18% C

gas tamponade.

When last seen, 16 months after surgery and

9 years after presentation, the right visual

acuity was 6/12 and the macula hole confirmed

as closed on ocular coherence tomography.

Comment

Previous studies have shown that repeat

macular hole surgery is successful in closing

recurrent macular holes and improving

vision.

Late reopening of successfully closed

macular holes has been reported to occur in

between 4.8% and 6.9% of eyes.

The success

of repeat surgery did not depend on whether

the hole reopened early or late as in this

case.

A third recurrence of a macular hole is

a less common event. The results of repeat

macular hole surgery are better in those eyes

in which one of the previous operations had

successfully closed the macula hole.

In those

eyes that had previous successful surgery the

mean final visual acuity was 20/40. By

comparison, in those eyes in which surgery

failed to close the macula hole, the success of

final closure rate was 56% and the mean final

visual acuity was 20/100.

The pathophysiology for failure of closure

and reopening remain unclear. Early failure is

thought to result from the lack of formation

of a stable glial plug that is essential for hole

closure.

The causes for late reopening remain

unclear as in this case, it may be a sponta-

neous event.

Some authors have suggested

that chronic cystoid macular oedema, catar-

act surgery, or the development of an

epiretinal membranes resulting in tractional

forces may be involved.

This was not the

case in this patient.

In summary, this case suggests that the

visual outcome can be favourable following

multiple repeat macular hole operations

especially if there has been previous success-

ful closure.

H M Hussin, R H Y Asaria, N E Knox

Cartwright, R H B Grey

Bristol Eye Hospital, Lower Maudlin Street, Bristol BS1

2LX, UK

Correspondence to: Mr Hussin M Hussin, Bristol Eye

Hospital, Lower Maudlin Street, Bristol BS1 2LX, UK;

h.m.hussin@bristol.ac.uk

doi: 10.1136/bjo.2006.079012

References

1Smiddy WE, Sjaarda RN, Glaser BM, et al.

Reoperation after failed macular hole surgery.

Retina 1996;16:13–18.

2Paques M, Massin P, Blain P, et al. Long-term

incidence of reopening of macular holes.

Ophthalmology 2000;107:760–5.

3Duker JS, Wendel R, Patel AC, et al. Late re-

opening of macular holes after initially successful

treatment with vitreous surgery. Ophthalmology

1994;101:1373–8.

4Christmas NJ, Smiddy WE, Flynn HW Jr.

Reopening of macular holes after initially

successful repair. Ophthalmology

1998;105:1835–8.

5Thompson JT, Sjaarda RN. Results of macular

hole surgery in patients over 80 years of age.

Retina 2000;20:433–8.

6Funata M, Wendel RT, de la CZ, et al.

Clinicopathologic study of bilateral macular holes

treated with pars plana vitrectomy and gas

tamponade. Retina 1992;12:289–98.

7Thompson JT, Sjaarda RN. Surgical treatment of

macular holes with multiple recurrences.

Ophthalmology 2000;107:1073–7.

Vision restoration therapy and

raising red flags too early

Vision restoration therapy (VRT) has been

the subject of considerable controversy,

1–3

and

with Horton’s latest editorial

it has now

turned rather personal. The editorial is filled

with numerous inaccuracies and misrepre-

sentations and this cannot go unanswered.

Just as a scientific debate should not focus on

fiction but on facts, comments by critics must

be evaluated with the same rigor as the

original work itself. Only by keeping track of

all of the scientific evidence rather than by a

personal and limited review of some selected

facts will we get closer to the truth.

Firstly, it is a fundamental misrepresenta-

tion by Horton that we are trying to ‘‘salvage

neurons’’ at the fringe of a lesion. Rather, we

believe that VRT activates surviving neurons

in areas of residual vision (ARVs)—that is,

areas that are partially damaged.

4–7

Repetitive

use through daily training increases neuronal

activation,

which is greatly enhanced by

attentional processes.

No neuron is ‘‘sal-

vaged.’’

It is correct that at the time Horton wrote

his editorials no one had published studies on

eye movements. But since then the first eye

movement studies have been published in

abstract form. It actually turns out that eye

movements, when measured with an eye

tracker, are not altered after VRT.

There is

also other indirect evidence, which is incom-

patible with the hypothesis that eye move-

ments explain visual field improvements:

NFixation performance in standard auto-

mated perimetry is an accepted quality

control measure and our patients typically

show .90% stable fixation, which is

measured by counting the number of hits

at fixation. Because this does not change

after VRT (it usually improves slightly, see

Kasten et al,

Poggel et al,

Reinhard et al,

Mueller et al,

and Sabel et al

)itis

unlikely that patients moved their eyes

more after VRT.

NHorton erroneously believes that temporal

field loss prevents blind spot measure-

ments. This is true only for one eye. In our

studies, the position of the blind spot

remains unchanged in monocular mea-

surement after VRT.

Thus, neither

eccentric fixation occurred after VRT nor

are there more large saccades after VRT.

The position of the blind spot is a reliable

parameter of eccentric fixation.

NIf eye movements were responsible for the

visual field shifts, then the entire visual

field border should shift in parallel. In

most patients this is not the case. The

border of the visual field may shift in one

place (say the lower quadrant) and remain

invariant in another (upper quadrant).

Also, highly localised border shifts are

induced by attention cues,

and horizontal

border shifts may occur in the absence of

border shifts at fixation. All of these

observations are not compatible with the

proposal that eye movements cause the

visual field border shifts. In fact, in the

periphery the border shifts tend to be more

pronounced, which is explained by the

cortical magnification factor—that is, by

visual cortex architecture.

Accepted for publication 30 January 2006

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H M Hussin, R H Y Asaria, N E Knox Cartwright, et al.

recurrence of a macular hole

Fourth time lucky: a case of multiple

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Surgical treatment of macular holes with multiple recurrences 1 1 The authors have no proprietary interest in any of the products mentioned in this article

Article

Jun 2000

To evaluate the results of a third macular hole surgery in eyes with recurrent macular holes and two prior macular hole surgeries. Retrospective consecutive noncomparative case series. Sixteen eyes of sixteen patients with two prior macular hole surgeries with recurrent macular hole. A third vitreous surgery was performed in each eye using a long-acting gas bubble. Closure of the macular hole and change in visual acuity. The macular hole was closed in 12 of 16 eyes (75%) at 3 months after the third surgery. Visual acuity improved 2 or more Snellen lines in 9 of 16 eyes (56%), and 5 of 16 eyes (31%) achieved 20/40 or better vision. Six eyes (37.5%) had cataract surgery after the third macular hole surgery, and visual acuity results were similar in eyes with or without cataract surgery. Successful closure of the macular hole improved the visual acuity from 20/80 -1 to 20/50 +1 (P < 0.001). Eyes in which one of the previous surgeries had been temporarily successful in closing the macular hole improved from a mean of 20/80 to 20/40 (P = 0.003). Eyes in which both prior macular hole surgeries had been primary failures had minimal benefit with a preoperative visual acuity of 20/100 +1 and a postoperative visual acuity of 20/100 +2 (P = 0.67). Repeat macular hole surgery should be considered in eyes with recurrent macular holes and two prior surgeries when the macular hole was temporarily closed by at least one of the two previous surgeries. Successful closure of a macular hole in such cases usually results in significant visual acuity improvement.

Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade

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Feb 1992
RETINA-J RET VIT DIS

The clinicopathologic findings of light and electron microscopic examination of a 78-year-old woman who underwent successful bilateral pars plana vitrectomy for bilateral stage III macular holes are reported. Examination disclosed anatomical repair of the full-thickness macular holes by glial cell proliferation in the left eye. The hole apparently collapsed with no glial cell proliferation in the right eye. The photoreceptors adjacent to the healed macular holes appeared normal. Defects in the internal limiting membrane in the foveal area were noted in both eyes.

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Article

Sep 1994
OPHTHALMOLOGY

In more than 50% of eyes with idiopathic, full-thickness macular holes, vitrectomy results in clinical closure of the hole and improvement in visual acuity. Other than cataract formation, late complications of the procedure have not been reported. Over a 4-year period, 167 eyes underwent successful vitreous surgery for idiopathic macular holes documented by clinical closure of the hole and an improvement in visual acuity of at least two Snellen lines. The authors retrospectively studied eight of these eyes. All initially had successful surgery; however, they subsequently had spontaneous late re-opening of the macular hole with acute diminution in vision. Late re-opening developed in these eyes between 2 and 22 months after initial surgery. The mean time for re-opening was 12.5 months. Three of eight eyes underwent a second vitrectomy, which was successful in improving visual acuity in two eyes. Another patient manifested the growth of an epiretinal membrane that apparently sealed the re-opened macular hole and improved vision. Late re-opening can complicate initially successful macular hole surgery and may occur in at least 4.8% (8 of 167) of initially successful operations. Re-opening has been documented as late as 22 months after initial surgery. Repeat vitrectomy with gas injection may result in reclosure of the hole and improvement in vision.

Reoperation after failed macular hole surgery

Article

Feb 1996
RETINA-J RET VIT DIS

The authors determined the anatomic and visual success rates of vitrectomy in patients who have failed previous macular hole surgery. Standardized Early Treatment Diabetic Retinopathy Study (ETDRS)-style best-corrected visual acuity was measured in each patient pre- and postoperatively. Surgery was performed at two centers using a standardized protocol, as previously reported, using 1330 ng bovine-derived transforming growth factor-beta 2 (TGF-beta 2) and 16% perfluoropropane internal gas tamponade. Endpoint analyses were conducted for anatomic closure of the hole, visual improvement of three or more ETDRS lines, and final visual acuity of > or = 20/63 and > or = 20/40. Forty-eight failing macular hole surgery were reoperated. The anatomic results showed closure of the hole in 40 (83%) cases at the end of the mean follow-up interval of 7.4 months. The visual acuity improved in greater than or equal to three lines in 52%, was > or = 20/63 in 54%, and was > or = 20/40 in 25% of reoperated eyes. The only factor associated with a better final visual acuity was preoperative visual acuity better than 20/80. Nuclear sclerosis leading to cataract extraction was observed in 13 (30%) of 43 initially phakic eyes. Macular hole closure was induced in this subset of reoperated patients. Visual improvement occurred often, although in a lower percentage than has been reported for primary surgical eyes. Repeat vitrectomy should be considered in patients with persistent macular hole after failure of primary surgery.

Reopening of macular holes after initially successful repair

Article

Nov 1998
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To evaluate the frequency and prognosis of reopening of a macular hole after initially successful repair in a defined patient cohort. Retrospective consecutive noncomparative case series. Seventeen cases of reopened macular holes among 390 cases of idiopathic macular holes that previously had undergone macular hole surgery were studied. Assessment of demographics, visual acuity, preoperatively, postoperatively, after reopening of macular hole and after reoperation, if applicable, and precipitating factors. There were 17 (4.8%) of 353 cases in which the macular hole reopened after initial successful surgical closure. The mean visual acuity before reopening was 20/48 and was 20/133 after reopening. Twelve eyes underwent reoperation with improvement to a mean visual acuity of 20/54. The five eyes that were not reoperated on maintained a mean visual acuity of 20/200. Ten of the eyes had undergone cataract surgery between macular hole surgeries, but in only one did the reopening appear to occur in association with this procedure. Reopening of a previously successfully operated macular hole is uncommon and seems to be a spontaneous event. Reoperation generally yields results similar to those present before the reopening. Reopening of a macular hole associated with cataract surgery is rare.

Long-term incidence of reopening of macular holes

Article

May 2000
OPHTHALMOLOGY

To report the incidence of macular hole reopening after initial successful surgery. A noncomparative retrospective case series. From a series of 137 consecutive cases of idiopathic macular holes operated on between August 1993 and May 1996, the authors analyzed the charts of 116 cases of successful surgery. A single university-based ophthalmology department. Pars plana vitrectomy, posterior hyaloid peeling, fluid-air and air-gas exchange with a nonexpansile 17% C2F6 mixture followed by face-down positioning. Eighty-eight patients (64%) received autologous platelets as a biologic adjuvant. The anatomic success rate at the first postoperative month was 116 of 137 (85%). One hundred and six patients (91%) were followed up for more than 2 years. Macular anatomic status. Mean follow-up was 27 months. Eleven eyes of 11 patients (9.5%) had reopening of the macular hole. The mean period between hole surgery and reopening was 15.4 months (range, 8-29). In 8 of these 11 cases, reopening occurred after cataract extraction. In two cases, an epiretinal membrane was noted. In another case cystoid macular edema was present. The final anatomic success rate with one surgical procedure was 105 of 137 (77%). Eight reopened holes were reoperated on and all were anatomic successes at 1 month. However, four patients experienced a second reopening. Macular hole reopening occurred in 9.5% of cases (11 of 116). The cause of reopening might have been any anatomic stress such as epiretinal membrane formation or macular edema. However, in most of our reopened cases, no definite cause was evident. Four patients experienced recurrent reopening.

Results of macular hole surgery in patients over 80 years of age

Article

Feb 2000
RETINA-J RET VIT DIS

To evaluate the results of macular hole surgery in patients over 80 years of age to determine if surgery is beneficial in an elderly patient population. Twenty consecutive patients over age 80 with idiopathic macular holes and 20 nonconsecutive controls younger than 80 years treated for idiopathic macular holes were compared in a retrospective, consecutive case-control series. The macular hole was closed 3 months after surgery in 19/20 eyes (95%) of patients over age 80 years and 17/20 eyes (85%) of patients under 80 years. The mean preoperative visual acuity was 20/160 in patients over 80 years and 20/160-1 in patients under 80 years. The mean visual acuity at 3 months was 20/63 in eyes of patients over 80 years and 20/80 in eyes of patients under 80 years (P = 0.3). The mean visual acuity was 20/50-2 in eyes of patients over 80 years and 20/63-2 in eyes of patients under 80 years at the final examination (P = 0.403). Macular hole surgery is beneficial in patients over 80 years of age, with very similar results to those of patients younger than 80 years of age. Age should not be the primary criterion for recommending macular hole surgery.