Ophthalmologica, Basel 177: 188-191 (1978)
Macular Hole in Diabetic Maculopathy Tsugio Amemiya and Hidehiko Yoshida
Introduction
During the past 10 years, diabetic ma culopathy has received much attention [2, 4,6,8,10-12], It shows long-standing ed ema, hemorrhages and exudates in the ma cula. Fibrous proliferation in diabetic re tinopathy causes traction on the retina. Thus diabetic maculopathy with fibrous prolifera tion could produce a macular hole. How ever, macular holes in diabetic maculopathy have not yet been reported. This paper describes 3 cases of macular holes due to diabetic maculopathy with fi brous proliferation.
Cases Case I
A 57-year-old Japanese woman visited our de partment. complaining of visual disturbances in both eyes. She had had diabetes mellitus for 10 years. Her visual acuity was 0.8 in the right eye, and 1.0 in the left eye. Iridcs and pupils looked normal. Slight spoke-like opacities were found in both lenses. Funduscopy revealed many micro aneurysms, punctate hemorrhages and circinate hard exudates with aneurysms in the retina, es pecially in the macula of the right eye, and many
microaneurysms, punctate hemorrhages and soft and hard exudates in the macula of the left eye. Punctate hemorrhages and hard exudates were also seen along the superior and inferior nasal retinal vessels in the posterior pole of the left eye. Fluo rescein angiography revealed no obvious leakage from the microaneurysms or retinal vessels in both eyes. Fasting blood sugar was 195 mg/dl, and glu cose in the urine was 12g/day. 4 months later, both retinas showed an increase in punctate hem orrhages. The right eye was treated with xenon photocoagulation with great improvement. 7 months after the patient was first seen, mo derately massive vitreous hemorrhage occurred in the upper part of the left optic disk. Funduscopy of the left eye revealed circinate hard exudates around the fovea, many microaneurysms, punctate hemorrhages and hard exudates in the macula. The fluorescein angiogram demonstrated many mi croaneurysms. slight leakage around them, and leakage at the superior and inferior margin of the optic disk and from the superior temporal retinal vein. Xenon arc photocoagulation was applied to the leakage sites of the left eye. Following this photocoagulation, vitreous hemorrhage in the left eye was gradually resorbed and became a fibrous proliferation which extended to the temporal side of the optic disk (fig. 1). Although microaneurysms and punctate hemorrhages in the left eye decreased gradually, slight edema and hard exudates re mained in the macula. The fasting blood sugar level was kept at 169 mg/dl. 2 years and 9 months after photocoagulation of the left eye, the patient complained of sudden central scotoma of the left
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
Department of Ophthalmology, Faculty of Medicine. Kyoto University. Kyoto
Macular Hole in Diabetic Maculopathy
eye. The visual acuity was 0.3 in the right eye and 0.04 in the left. A macular hole and slight retinal detachment around it were found by funduscopy and confirmed with slit-lamp microscopy using a three-mirror contact lens. The macula also showed several punctate hemorrhages and hard exudates. Xenon arc photocoagulation was applied to the area surrounding the macular hole. The patient was followed for 18 months after photocoagula tion of the macular hole, which became scarified with disappearance of the punctate hemorrhages, microaneurysms, exudates and macular edema. The visual acuity was 0.2 in the right eye and 0.01 in the left. Case 2 A 72-year-old Japanese man, who had had diabetes for 10 years and who had been control led by oral medication during that period, had a 1-year history of reduced visual acuity in the left eye. About 2 months prior to visiting our clinic, the patient consulted an ophthalmologist who di agnosed diabetic retinopathy, which was treated with xenon arc photocoagulation.
Upon examination at our Department, fundus copy revealed fibrous proliferation in the upper part of the optic disk of the left eye, slight scar ring of the retina under fibrous proliferation, pos sibly caused by photocoagulation, and very slight diffuse retinal detachment in the posterior pole. In the retina of the right eye, a microaneurysm was found near the central fovea. Slight posterior subcapsular lenticular opacities were seen. The visual acuity was 0.5 in the right eye and 0.05 in the left. 2 months after the patient was first seen at our Department, the fibrous proliferation in the left eye had flattened and shrunken, and the detached retina was reattached except in the lower part of the macula. The macular area was slightly edematous. There were hard exudates outside the central part of the macula. On examination, 1 month later, funduscopy demonstrated a macular hole and slight retinal detachment at the lower part of the macula, although the patient had no subjective ocular complaints. Since then, the pa tient has been followed for 1 year, with the ma cular hole left untreated, and there have been no significant changes in the left retina, but a marked progression of the cataract. The fasting blood sug ar level was kept at 85-90 mg/dl. Case 3 A 56-year-old Japanese man, who had had dia betes for 20 years without treatment, was first seen with reduced visual acuity which had lasted for 3 years in the right eye and for 11 months in the left. He had narrowing of the lower half of the visual fields, which increased gradually. His moth er had diabetes meliitus. On examination, his visual acuity was hand movement in the right eye and 0.1 in the left. Funduscopy revealed severe proliferative retino pathy with total retinal detachment in the right eye. The fundus of the left eye showed a macular hole with total retinal detachment and fibrous proliferation which extended along the upper and lower temporal retinal vessels and the upper nasal retinal vessels. Fasting blood sugar was 130 mg/dl.
Discussion
Macular holes result from vitreous shrink age and traction on the macula with edema,
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
Fig. 1. Macular and optic disk region of left eye of a 57-year-old Japanese woman (case 1). Proliferative membranes are seen temporal and superior to the optic disk. Exudates and hemor rhages are present in the macula.
189
Amemiya/Yoshida
190
been reported. Macular holes should receive as much attention as a complication of dia betic maculopathy as fibrous proliferation. In the first case, the macular hole was treated with photocoagulation, while the other 2 cases were observed without treat ment. In the first case, photocoagulation re sulted in worse visual acuity, but led to marked improvement of diabetic retinopathy. In the second case, the macular hole did not change even without treatment, although the retina had already been severely dam aged. In cases of macular hole in diabetic maculopathy without subjective ocular signs and with more than 0.1 of visual acuity, no treatment is needed. In cases of macular hole in diabetic maculopathy with subjec tive ocular symptoms and less than 0.1 of visual acuity, photocoagulation is recom mended. In addition, progressive maculo pathy is expected to improve with photo coagulation.
Summary Three patients with diabetic maculopathy had macular holes. It is suggested that shrinkage or traction of the fibrous proliferation on the ede matous and exudative macula led to the forma tion of these macular holes. Photocoagulation is recommended in patients with macular holes with progressive diabetic retinopathy and visual acuity of less than 0.1.
Zusammenfassung Drei Patienten mit Makulaloch litten an einer diabetischen Makulopathie. Es wird vorgeschla gen. die Schrumpfung oder den Zug der fibrinö sen Wucherung auf der ödematösen und exsuda tiven Makula als Ursache des Makulalochs auf zufassen. Die Lichtkoagulation wird empfohlen
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
hemorrhage, exudate or degeneration due to vascular diseases, senile degeneration, trau ma, inflammation or hereditary disposition [1,5,7,9,13], In diabetic retinopathy, es pecially diabetic maculopathy, with proli ferative changes, macular holes should de velop easily. However, they have not been reported yet in the literature. Maculopathy with proliferative changes and a history of more than 10 years of dia betes were present in the 3 cases reported here. In the first case there was fibrous proli feration contiguous to the optic disk follow ing vitreous hemorrhage, and this prolifera tion extended to the temporal part of the optic disk. The traction of the fibrous proli feration on the edematous macula may have caused the macular hole. In the second case, a proliferative lesion contiguous to the optic disk was scarified by photocoagulation. The shrinkage of this scar may have led to trac tion on the macular area which resulted in the development of a macular hole. Al though the details of the clinical course of the third case were not known, the presence of severe fibrous proliferation around the optic disk and total retinal detachment sug gests traction of fibrous proliferation on the macular area. These facts suggest that shrinkage or traction of the fibrous proli feration on the edematous and exudative macula plays an important role in the for mation of macular holes. The fibrous proli feration develops around the macula in 93% of cases with diabetic retinopathy and is connected with the optic disk [3], The fi brous proliferation shrinks and results in secondary retinal detachment [3], There fore, it is apparent that shrinkage or trac tion of the fibrous proliferation leads to ma cular holes. In spite of this, macular holes in diabetic maculopathy have almost never
Macular Hole in Diabetic Maculopathy
Résumé Trois patients souffrant de maculopathie dia bétique présentaient des trous maculaires. Les au teurs pensent que la formation de ces trous ma culaires est due à la contraction ou à la traction de la prolifération fibreuse sur la macula œdéma teuse et exsudative. Ils recommandent la photo coagulation chez les patients présentant des trous maculaires avec rétinopathie diabétique progres sive et une acuité visuelle inférieure à 0,1.
5
6
7
8
9
References 10 1 Bangerter, A.: Zur Diagnose, Differentialdiagnose und Therapie des cystoiden Maculaodems (Maculacysten). Ophthalmologica, Basel 109: 102-122 (1945). 2 Cheng, H.; Blach, R. K.; Hamilton, A. M., and Kohner, E. M.: Diabetic maculopathy. A preli minary report. Trans, ophthal. Soc. U.K. 92: 407-411 (1972). 3 Fukuda, M.; Tamura, T.; Abe, T„ and Kasahara, T.: Clinical study of proliferative dia betic retinopathy (in Japanese with English summary). Acta Soc. ophthal. jap. 80: 1514— 1525 (1976). 4 Gass, J. D. M.: A fluorescein angiographic study of macular dysfunction secondary to re tinal vascular disease. IV. Diabetic retinal
11
12
13
angiopathy. Archs Ophthal., Chicago 80: 583591 (1968). Kiisel: Beitrag zur Genese der Retinitis atro phicans centralis (Kuhnt). Klin. Mbl. Augen heil k. 44: 464-469 (1906). Merin, S.; Yanko, L„ and Ivry, M.: Treatment of diabetic maculopathy by argon-laser. Br. J. Ophthal. 58: 85-91 (1974). Norn, M. S.: Central retinoschisis. A case de veloped after central vein thrombosis. Acta ophthal. 39: 817-823 (1961). Patz, A.; Schatz, H.: Berkow, J. W.; Gittelsohn, A. M.. and Ticho, U.: Macular edema. An over looked complication of diabetic retinopathy. Trans. Am. Acad. Ophthal. Oto-lar. 77; 34-42 (1973). Reis, W.: Zur Ätiologie und Genese der Loch bildung in der Macula lutea [Retinitis atrophi cans centralis (Kuhnt)]. Z. Augcnheilk. 15: 3751 (1906). Rubinstein, K. and Myska, V.: Treatment of diabetic maculopathy. Br. J. Ophthal. 56: 1-5 (1972). Spalter, H. F.: Photocoagulation of circinate maculopathy in diabetic retinopathy. Am. J. Ophthal. 71: 242-250 (1971). Schatz, H. and Patz, A.: Cystoid maculopathy in diabetics. Archs Ophthal., Chicago 94: 761768 (1976). Zentmayer: Hole at the macula. Ophthal. Rec. 18: 198-200 (1909).
Tsugio Amemiya, MD, Department of Ophthalmology. Faculty of Medicine, Kyoto University, Sakyo-ku, Kyoto-shi 606 (Japan)
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
in Fällen von Makulaloch mit progressiver diabe tischer Retinopathie und einem Visus schlechter als 0.1.
191
Macular Hole in Diabetic Maculopathy Tsugio Amemiya and Hidehiko Yoshida
Introduction
During the past 10 years, diabetic ma culopathy has received much attention [2, 4,6,8,10-12], It shows long-standing ed ema, hemorrhages and exudates in the ma cula. Fibrous proliferation in diabetic re tinopathy causes traction on the retina. Thus diabetic maculopathy with fibrous prolifera tion could produce a macular hole. How ever, macular holes in diabetic maculopathy have not yet been reported. This paper describes 3 cases of macular holes due to diabetic maculopathy with fi brous proliferation.
Cases Case I
A 57-year-old Japanese woman visited our de partment. complaining of visual disturbances in both eyes. She had had diabetes mellitus for 10 years. Her visual acuity was 0.8 in the right eye, and 1.0 in the left eye. Iridcs and pupils looked normal. Slight spoke-like opacities were found in both lenses. Funduscopy revealed many micro aneurysms, punctate hemorrhages and circinate hard exudates with aneurysms in the retina, es pecially in the macula of the right eye, and many
microaneurysms, punctate hemorrhages and soft and hard exudates in the macula of the left eye. Punctate hemorrhages and hard exudates were also seen along the superior and inferior nasal retinal vessels in the posterior pole of the left eye. Fluo rescein angiography revealed no obvious leakage from the microaneurysms or retinal vessels in both eyes. Fasting blood sugar was 195 mg/dl, and glu cose in the urine was 12g/day. 4 months later, both retinas showed an increase in punctate hem orrhages. The right eye was treated with xenon photocoagulation with great improvement. 7 months after the patient was first seen, mo derately massive vitreous hemorrhage occurred in the upper part of the left optic disk. Funduscopy of the left eye revealed circinate hard exudates around the fovea, many microaneurysms, punctate hemorrhages and hard exudates in the macula. The fluorescein angiogram demonstrated many mi croaneurysms. slight leakage around them, and leakage at the superior and inferior margin of the optic disk and from the superior temporal retinal vein. Xenon arc photocoagulation was applied to the leakage sites of the left eye. Following this photocoagulation, vitreous hemorrhage in the left eye was gradually resorbed and became a fibrous proliferation which extended to the temporal side of the optic disk (fig. 1). Although microaneurysms and punctate hemorrhages in the left eye decreased gradually, slight edema and hard exudates re mained in the macula. The fasting blood sugar level was kept at 169 mg/dl. 2 years and 9 months after photocoagulation of the left eye, the patient complained of sudden central scotoma of the left
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
Department of Ophthalmology, Faculty of Medicine. Kyoto University. Kyoto
Macular Hole in Diabetic Maculopathy
eye. The visual acuity was 0.3 in the right eye and 0.04 in the left. A macular hole and slight retinal detachment around it were found by funduscopy and confirmed with slit-lamp microscopy using a three-mirror contact lens. The macula also showed several punctate hemorrhages and hard exudates. Xenon arc photocoagulation was applied to the area surrounding the macular hole. The patient was followed for 18 months after photocoagula tion of the macular hole, which became scarified with disappearance of the punctate hemorrhages, microaneurysms, exudates and macular edema. The visual acuity was 0.2 in the right eye and 0.01 in the left. Case 2 A 72-year-old Japanese man, who had had diabetes for 10 years and who had been control led by oral medication during that period, had a 1-year history of reduced visual acuity in the left eye. About 2 months prior to visiting our clinic, the patient consulted an ophthalmologist who di agnosed diabetic retinopathy, which was treated with xenon arc photocoagulation.
Upon examination at our Department, fundus copy revealed fibrous proliferation in the upper part of the optic disk of the left eye, slight scar ring of the retina under fibrous proliferation, pos sibly caused by photocoagulation, and very slight diffuse retinal detachment in the posterior pole. In the retina of the right eye, a microaneurysm was found near the central fovea. Slight posterior subcapsular lenticular opacities were seen. The visual acuity was 0.5 in the right eye and 0.05 in the left. 2 months after the patient was first seen at our Department, the fibrous proliferation in the left eye had flattened and shrunken, and the detached retina was reattached except in the lower part of the macula. The macular area was slightly edematous. There were hard exudates outside the central part of the macula. On examination, 1 month later, funduscopy demonstrated a macular hole and slight retinal detachment at the lower part of the macula, although the patient had no subjective ocular complaints. Since then, the pa tient has been followed for 1 year, with the ma cular hole left untreated, and there have been no significant changes in the left retina, but a marked progression of the cataract. The fasting blood sug ar level was kept at 85-90 mg/dl. Case 3 A 56-year-old Japanese man, who had had dia betes for 20 years without treatment, was first seen with reduced visual acuity which had lasted for 3 years in the right eye and for 11 months in the left. He had narrowing of the lower half of the visual fields, which increased gradually. His moth er had diabetes meliitus. On examination, his visual acuity was hand movement in the right eye and 0.1 in the left. Funduscopy revealed severe proliferative retino pathy with total retinal detachment in the right eye. The fundus of the left eye showed a macular hole with total retinal detachment and fibrous proliferation which extended along the upper and lower temporal retinal vessels and the upper nasal retinal vessels. Fasting blood sugar was 130 mg/dl.
Discussion
Macular holes result from vitreous shrink age and traction on the macula with edema,
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
Fig. 1. Macular and optic disk region of left eye of a 57-year-old Japanese woman (case 1). Proliferative membranes are seen temporal and superior to the optic disk. Exudates and hemor rhages are present in the macula.
189
Amemiya/Yoshida
190
been reported. Macular holes should receive as much attention as a complication of dia betic maculopathy as fibrous proliferation. In the first case, the macular hole was treated with photocoagulation, while the other 2 cases were observed without treat ment. In the first case, photocoagulation re sulted in worse visual acuity, but led to marked improvement of diabetic retinopathy. In the second case, the macular hole did not change even without treatment, although the retina had already been severely dam aged. In cases of macular hole in diabetic maculopathy without subjective ocular signs and with more than 0.1 of visual acuity, no treatment is needed. In cases of macular hole in diabetic maculopathy with subjec tive ocular symptoms and less than 0.1 of visual acuity, photocoagulation is recom mended. In addition, progressive maculo pathy is expected to improve with photo coagulation.
Summary Three patients with diabetic maculopathy had macular holes. It is suggested that shrinkage or traction of the fibrous proliferation on the ede matous and exudative macula led to the forma tion of these macular holes. Photocoagulation is recommended in patients with macular holes with progressive diabetic retinopathy and visual acuity of less than 0.1.
Zusammenfassung Drei Patienten mit Makulaloch litten an einer diabetischen Makulopathie. Es wird vorgeschla gen. die Schrumpfung oder den Zug der fibrinö sen Wucherung auf der ödematösen und exsuda tiven Makula als Ursache des Makulalochs auf zufassen. Die Lichtkoagulation wird empfohlen
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
hemorrhage, exudate or degeneration due to vascular diseases, senile degeneration, trau ma, inflammation or hereditary disposition [1,5,7,9,13], In diabetic retinopathy, es pecially diabetic maculopathy, with proli ferative changes, macular holes should de velop easily. However, they have not been reported yet in the literature. Maculopathy with proliferative changes and a history of more than 10 years of dia betes were present in the 3 cases reported here. In the first case there was fibrous proli feration contiguous to the optic disk follow ing vitreous hemorrhage, and this prolifera tion extended to the temporal part of the optic disk. The traction of the fibrous proli feration on the edematous macula may have caused the macular hole. In the second case, a proliferative lesion contiguous to the optic disk was scarified by photocoagulation. The shrinkage of this scar may have led to trac tion on the macular area which resulted in the development of a macular hole. Al though the details of the clinical course of the third case were not known, the presence of severe fibrous proliferation around the optic disk and total retinal detachment sug gests traction of fibrous proliferation on the macular area. These facts suggest that shrinkage or traction of the fibrous proli feration on the edematous and exudative macula plays an important role in the for mation of macular holes. The fibrous proli feration develops around the macula in 93% of cases with diabetic retinopathy and is connected with the optic disk [3], The fi brous proliferation shrinks and results in secondary retinal detachment [3], There fore, it is apparent that shrinkage or trac tion of the fibrous proliferation leads to ma cular holes. In spite of this, macular holes in diabetic maculopathy have almost never
Macular Hole in Diabetic Maculopathy
Résumé Trois patients souffrant de maculopathie dia bétique présentaient des trous maculaires. Les au teurs pensent que la formation de ces trous ma culaires est due à la contraction ou à la traction de la prolifération fibreuse sur la macula œdéma teuse et exsudative. Ils recommandent la photo coagulation chez les patients présentant des trous maculaires avec rétinopathie diabétique progres sive et une acuité visuelle inférieure à 0,1.
5
6
7
8
9
References 10 1 Bangerter, A.: Zur Diagnose, Differentialdiagnose und Therapie des cystoiden Maculaodems (Maculacysten). Ophthalmologica, Basel 109: 102-122 (1945). 2 Cheng, H.; Blach, R. K.; Hamilton, A. M., and Kohner, E. M.: Diabetic maculopathy. A preli minary report. Trans, ophthal. Soc. U.K. 92: 407-411 (1972). 3 Fukuda, M.; Tamura, T.; Abe, T„ and Kasahara, T.: Clinical study of proliferative dia betic retinopathy (in Japanese with English summary). Acta Soc. ophthal. jap. 80: 1514— 1525 (1976). 4 Gass, J. D. M.: A fluorescein angiographic study of macular dysfunction secondary to re tinal vascular disease. IV. Diabetic retinal
11
12
13
angiopathy. Archs Ophthal., Chicago 80: 583591 (1968). Kiisel: Beitrag zur Genese der Retinitis atro phicans centralis (Kuhnt). Klin. Mbl. Augen heil k. 44: 464-469 (1906). Merin, S.; Yanko, L„ and Ivry, M.: Treatment of diabetic maculopathy by argon-laser. Br. J. Ophthal. 58: 85-91 (1974). Norn, M. S.: Central retinoschisis. A case de veloped after central vein thrombosis. Acta ophthal. 39: 817-823 (1961). Patz, A.; Schatz, H.: Berkow, J. W.; Gittelsohn, A. M.. and Ticho, U.: Macular edema. An over looked complication of diabetic retinopathy. Trans. Am. Acad. Ophthal. Oto-lar. 77; 34-42 (1973). Reis, W.: Zur Ätiologie und Genese der Loch bildung in der Macula lutea [Retinitis atrophi cans centralis (Kuhnt)]. Z. Augcnheilk. 15: 3751 (1906). Rubinstein, K. and Myska, V.: Treatment of diabetic maculopathy. Br. J. Ophthal. 56: 1-5 (1972). Spalter, H. F.: Photocoagulation of circinate maculopathy in diabetic retinopathy. Am. J. Ophthal. 71: 242-250 (1971). Schatz, H. and Patz, A.: Cystoid maculopathy in diabetics. Archs Ophthal., Chicago 94: 761768 (1976). Zentmayer: Hole at the macula. Ophthal. Rec. 18: 198-200 (1909).
Tsugio Amemiya, MD, Department of Ophthalmology. Faculty of Medicine, Kyoto University, Sakyo-ku, Kyoto-shi 606 (Japan)
Downloaded by: King's College London 137.73.144.138 - 3/7/2018 3:37:39 AM
in Fällen von Makulaloch mit progressiver diabe tischer Retinopathie und einem Visus schlechter als 0.1.
191
