Traumatic macular hole
When to intervene?
By Osama Elnaggar MD
• Macular hole is a full-thickness defect in
neurosensory retina at fovea which leads to
severe visual impairment.
• It can be idiopathic or secondary to ocular
trauma, retinal detachment and laser.
• Idiopathic macular hole is the most
common type of macular hole.
• traumatic macular hole is less widely
reported.
• Macular hole can close spontaneously or
can be repaired by vitreoretinal surgery.
• It is also known that an idiopathic macular
hole rarely closes spontaneously with an
incidence 2.7–6.2%. and therefore mostly
requires vitrectomy.
• However, traumatic macular holes close
spontaneously in 10.7% to 44.4% .
• There are two possible mechanisms in
the pathogenesis of TMH:
• visual loss by immediate and direct foveal detachment.
• the other is due to persistent vitreomacular traction.
• The mechanism of spontaneous closure
of TMH is not understood very well.
• The proposed mechanism of
spontaneous closure of TMH :
• proliferation of glial cells or RPE cells from the
hole's edge to fill the hole bottom and stimulation
of astrocyte migration to heal the TMH .
• complete detachment of the posterior hyaloid
from the foveal area resulting in the release of an
anteroposterior traction
21 years male
blunt trauma by air bag
BCVA OD 0.8
BCVA OS 0.05
ant segment free
• no intervention was done.
• One month follow-up visit, retinal edema
resolved and VA in this eye improved from
0.05 to 0.2 .
• the OCT showed persistent macular hole
• Because of the VA improvement and
resolution of edema the patient was
advised to return to clinic in 2 to 3 months.
• Three months later, the BCVA recovered to
0.6
• OCT complete resolution of TMH .
25 years female
blunt trauma OD by fist
BCVA 0.1
ant segment free except for subcoj hg
• no intervention was done.
• One month follow-up visit, retinal edema
and VA in this eye improved from 0.1 to 0.3
.
• the OCT showed closed macular hole with
minimal shallow subretinal fluid.
• Two months later the OCT showed closed
macular hole with resolution of subretinal
fluid.
• Unfortunately VA still 0.3
• MH is a rare complication of blunt trauma;
contrary to idiopathic MHs, it usually has a
lamellar configuration .
• Spontaneous TMH closure is common, but
infrequent in patients over thirty.
• In older patients, posterior vitreous is
usually detached, making TMH in general
less frequent in older patients.
• In this retrospective study, they investigated
27 eyes with traumatic macular hole who
were followed-up for at least 6 months
without any surgical intervention.
• Clinical data and (SD-OCT) images were
compared between groups with and without
macular hole closure.
• Spontaneous closure of macular hole was
observed in 10 eyes 37% .
• TMH with spontaneous closure was
associated with a better visual outcome
compared to the macular holes that did not
close.
Two factors were noticed
• The first one : the holes with spontaneous
closure had smaller minimum diameter
(244.9±114.4 vs. 523.9±320.0μm) small
macular defect may allow easy migration of
glial cells.
• The second one: less intraretinal cysts at the
hole edges (10% vs. 76.5%) compared to the
holes that did not close spontaneously.
The presence of intraretinal cysts may be an
indicator of internal limiting membrane
traction, which may activate Müller cells
and cause accumulation of extracellular
fluid in the retina.
• Besides these two factors, young age has
been reported to be associated with
spontaneous closure of macular hole.
2
2 months later
2
4 months later
2
4 months later
• The time elapsed from the trauma to the
spontaneous closure is variable
according to different publications
• The rate of spontaneous closure is also
variable according to different
publications
• Cases with no spontaneous
closure
• Surgery for TMH can reestablish foveal
morphology in approximately 90% of cases.
• PPV, ILM peeling with gas injection may
improve final VA but there are risks of
complications such as endophthalmitis and
retinal detachment.
• Risks are similar to surgery for non traumatic
holes.
• idiopathic macular holes early surgery can
result in a better functional outcome.
Take home message
• Caution is needed before surgical
intervention in cases of TMH.
• Monitoring the VA and the anatomic
changes of the macular hole by OCT may be
the therapy of choice since spontaneous
closure is possible.
Thank you