SEQUENTIAL SURGICAL REPAIR OF A MACULAR HOLE–RELATED RETINAL DETACHMENT IN A HYPEROPIC PATIENT Imran J. Khan, MRCOphth, Ibrahim Elaraoud, MB BCh, Usman Mahmood, FRCS
Purpose: To report a case of macular hole–related retinal detachment in a hyperopic patient and a sequential surgical approach to repair. Methods: Case report. Patients: A single patient with acute macular hole–related retinal detachment. Conclusion: Retinal detachment secondary to macular hole typically occurs in highly myopic patients and is rare in patients with hypermetropia. Surgical repair may involve a combined or sequential approach to close the macular hole. RETINAL CASES & BRIEF REPORTS 7:347–349, 2013
revealed a large amount of subretinal fluid, a macular hole, and associated vitreous traction (Figure 2). We performed a combined procedure of phacoemulsification, intraocular lens implant, and pars plana vitrectomy. The subretinal fluid was drained with a 23-gauge silicone cannula held just above the macular hole to avoid enlarging the hole and to minimize trauma to the hole’s edges. Tamponade was with 20% hexaflouoroethane (C2F6), and the patient was postured face down postoperatively for 24 hours. Three weeks postoperatively, the visual acuity in the right eye was 20/200. Optical coherence tomography confirmed that the retina was attached although the
From the Department of Ophthalmology, University Hospital of North Staffordshire, Royal Infirmary, Staffordshire, United Kingdom
R
etinal detachment occurring as a result of a macular hole (macular hole retinal detachment) is a sightthreatening condition that typically occurs in high myopes with posterior staphyloma.1,2 The pathogenesis is considered to be the result of tangential traction from an epiretinal membrane or the inverse traction of the retina unable to expand with the posterior staphyloma.1,2 We present a case of macular hole retinal detachment occurring in a hyperopic patient and our sequential surgical approach to the repair. An 85-year-old white woman presented with a 1-day sudden loss of vision in her right eye. Her refractive error was +2.25/−1.75 · 80 in the right eye and +2.25/−1.25 · 99 in the left eye. The visual acuity was reduced to hand movements in the right eye and was 20/30 in the left eye. Full ocular examination showed a circumscribed retinal detachment at the posterior pole in the right eye (Figure 1). Optical coherence tomography
None of the authors have any financial/conflicting interests to disclose. Reprint requests: Imran J. Khan, MRCOphth, Department of Ophthalmology, University Hospital of North Staffordshire, Royal Infirmary, Princes Road, Stoke on Trent, Staffordshire ST4 7LN, United Kingdom; e-mail: [email protected]
Fig. 1. Color fundus photograph of the right eye at presentation showing a well-circumscribed retinal detachment at the posterior pole.
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Fig. 2. Spectral-domain optical coherence tomography images (Spectralis OCT; Heidelberg Engineering, Heidelberg, Germany): preoperative appearance of the retinal detachment, macular hole, and associated vitreous traction.
Fig. 3. Spectral-domain optical coherence tomography images (Spectralis OCT; Heidelberg Engineering): initial postoperative optical coherence tomography demonstrating a flat retina with persistent macular hole.
macular hole persisted (Figure 3). A second procedure of pars plana vitrectomy, internal limiting membrane (ILM) peel with 20% C2F6 tamponade, was performed. Two weeks postoperatively, the vision had improved to 20/120, with optical coherence tomography showing closure of the macular hole and some residual cystic spaces in the retina (Figure 4). In the case we described, an ILM peel was not attempted during the first procedure because it was believed that this may pose an increased risk of damage to the detached retina and also because the vitrectomy and release of the posterior hyaloid face may have resulted in closure of the hole without having to resort to an ILM peel. Various strategies for surgical management of macular hole retinal detachment have been described from the initial pars plana vitrectomy and gas tamponade3 to various adjunctive procedures, including epiretinal membrane peeling,4,5 ILM peel,6,7 and silicone oil tamponade.8 The optimum surgical approach is not
Fig. 4. Spectral-domain optical coherence tomography images (Spectralis OCT; Heidelberg Engineering): postoperative appearance after the second operation, with closure of the macular hole.
yet known, and the only identified prognostic factor for initial reattachment is axial length in cases of high myopia.9 In a comparative interventional case series of 12 patients, Singh10 described the outcome of surgery on eyes with rhegmatogenous retinal detachment with coexisting macular holes divided in to a combined approach, with ILM peel performed during the initial surgery and a sequential approach with the ILM peel being performed later as a second procedure. Similar visual outcomes were found in both groups. The author cites that a combined procedure can be technically more demanding although more convenient for the patient and more cost-effective than two operations. It should be noted, however, that a proportion of macular holes can resolve spontaneously after resolution of the detachment without resorting to an ILM peel. In summary, we present an unusual case of macular hole retinal detachment in a hyperopic patient who underwent a successful repair with sequential surgery.
MACULAR HOLE RETINAL DETACHMENT IN A HYPEROPE
This problem is more commonly encountered in high myopes and the best approach to surgical management has yet to be agreed upon. Key words: detachment, hyperope, macular, retinal. References 1. Morita H, Ideta H, Ito K, et al. Causative factors of retinal detachment in macular holes. Retina 1991;11:281–284. 2. Yoshinori O, Kazuyuki E. Incidence of fellow eye retinal detachment resulting from macular hole. Am J Ophthalmol 2007;143:203–205. 3. Gonvers M, Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthalmol 1982;94:468–472. 4. Stirpe M, Michels RG. Retinal detachment in highly myopic eyes due to macular holes and epiretinal traction. Retina 1990;10:113–114.
349 5. Seike C, Kusaka S, Sakagami K, Ohashi Y. Reopening of macular holes in highly myopic eyes with retinal detachments. Retina 1997;17:2–6. 6. Kadonosono K, Yazama F, Itoh N, et al. Treatment of retinal detachment resulting from myopic macular hole with internal limiting membrane removal. Am J Ophthalmol 2001;131:203–207. 7. Uemoto R, Yamamoto S, Tsukahara I, Takeuchi S. Efficacy of internal limiting membrane removal for retinal detachments resulting from a myopic macular hole. Retina 2004;24:560–566. 8. Wolfensberger TJ, Gonvers M. Long-term follow-up of retinal detachment due to macular hole in myopic eyes treated by temporary silicone oil tamponade and laser photocoagulation. Ophthalmology 1999;106:1786–1791. 9. Nakanishi H, Kuriyama S, Saito I, et al. Am J Ophthalmol 2008;146:198–204. 10. Singh AJ. Combined or sequential surgery for management of rhegmatogenous retinal detachment with macular holes. Retina 2009;29:1102–1110.
Purpose: To report a case of macular hole–related retinal detachment in a hyperopic patient and a sequential surgical approach to repair. Methods: Case report. Patients: A single patient with acute macular hole–related retinal detachment. Conclusion: Retinal detachment secondary to macular hole typically occurs in highly myopic patients and is rare in patients with hypermetropia. Surgical repair may involve a combined or sequential approach to close the macular hole. RETINAL CASES & BRIEF REPORTS 7:347–349, 2013
revealed a large amount of subretinal fluid, a macular hole, and associated vitreous traction (Figure 2). We performed a combined procedure of phacoemulsification, intraocular lens implant, and pars plana vitrectomy. The subretinal fluid was drained with a 23-gauge silicone cannula held just above the macular hole to avoid enlarging the hole and to minimize trauma to the hole’s edges. Tamponade was with 20% hexaflouoroethane (C2F6), and the patient was postured face down postoperatively for 24 hours. Three weeks postoperatively, the visual acuity in the right eye was 20/200. Optical coherence tomography confirmed that the retina was attached although the
From the Department of Ophthalmology, University Hospital of North Staffordshire, Royal Infirmary, Staffordshire, United Kingdom
R
etinal detachment occurring as a result of a macular hole (macular hole retinal detachment) is a sightthreatening condition that typically occurs in high myopes with posterior staphyloma.1,2 The pathogenesis is considered to be the result of tangential traction from an epiretinal membrane or the inverse traction of the retina unable to expand with the posterior staphyloma.1,2 We present a case of macular hole retinal detachment occurring in a hyperopic patient and our sequential surgical approach to the repair. An 85-year-old white woman presented with a 1-day sudden loss of vision in her right eye. Her refractive error was +2.25/−1.75 · 80 in the right eye and +2.25/−1.25 · 99 in the left eye. The visual acuity was reduced to hand movements in the right eye and was 20/30 in the left eye. Full ocular examination showed a circumscribed retinal detachment at the posterior pole in the right eye (Figure 1). Optical coherence tomography
None of the authors have any financial/conflicting interests to disclose. Reprint requests: Imran J. Khan, MRCOphth, Department of Ophthalmology, University Hospital of North Staffordshire, Royal Infirmary, Princes Road, Stoke on Trent, Staffordshire ST4 7LN, United Kingdom; e-mail: [email protected]
Fig. 1. Color fundus photograph of the right eye at presentation showing a well-circumscribed retinal detachment at the posterior pole.
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Fig. 2. Spectral-domain optical coherence tomography images (Spectralis OCT; Heidelberg Engineering, Heidelberg, Germany): preoperative appearance of the retinal detachment, macular hole, and associated vitreous traction.
Fig. 3. Spectral-domain optical coherence tomography images (Spectralis OCT; Heidelberg Engineering): initial postoperative optical coherence tomography demonstrating a flat retina with persistent macular hole.
macular hole persisted (Figure 3). A second procedure of pars plana vitrectomy, internal limiting membrane (ILM) peel with 20% C2F6 tamponade, was performed. Two weeks postoperatively, the vision had improved to 20/120, with optical coherence tomography showing closure of the macular hole and some residual cystic spaces in the retina (Figure 4). In the case we described, an ILM peel was not attempted during the first procedure because it was believed that this may pose an increased risk of damage to the detached retina and also because the vitrectomy and release of the posterior hyaloid face may have resulted in closure of the hole without having to resort to an ILM peel. Various strategies for surgical management of macular hole retinal detachment have been described from the initial pars plana vitrectomy and gas tamponade3 to various adjunctive procedures, including epiretinal membrane peeling,4,5 ILM peel,6,7 and silicone oil tamponade.8 The optimum surgical approach is not
Fig. 4. Spectral-domain optical coherence tomography images (Spectralis OCT; Heidelberg Engineering): postoperative appearance after the second operation, with closure of the macular hole.
yet known, and the only identified prognostic factor for initial reattachment is axial length in cases of high myopia.9 In a comparative interventional case series of 12 patients, Singh10 described the outcome of surgery on eyes with rhegmatogenous retinal detachment with coexisting macular holes divided in to a combined approach, with ILM peel performed during the initial surgery and a sequential approach with the ILM peel being performed later as a second procedure. Similar visual outcomes were found in both groups. The author cites that a combined procedure can be technically more demanding although more convenient for the patient and more cost-effective than two operations. It should be noted, however, that a proportion of macular holes can resolve spontaneously after resolution of the detachment without resorting to an ILM peel. In summary, we present an unusual case of macular hole retinal detachment in a hyperopic patient who underwent a successful repair with sequential surgery.
MACULAR HOLE RETINAL DETACHMENT IN A HYPEROPE
This problem is more commonly encountered in high myopes and the best approach to surgical management has yet to be agreed upon. Key words: detachment, hyperope, macular, retinal. References 1. Morita H, Ideta H, Ito K, et al. Causative factors of retinal detachment in macular holes. Retina 1991;11:281–284. 2. Yoshinori O, Kazuyuki E. Incidence of fellow eye retinal detachment resulting from macular hole. Am J Ophthalmol 2007;143:203–205. 3. Gonvers M, Machemer R. A new approach to treating retinal detachment with macular hole. Am J Ophthalmol 1982;94:468–472. 4. Stirpe M, Michels RG. Retinal detachment in highly myopic eyes due to macular holes and epiretinal traction. Retina 1990;10:113–114.
349 5. Seike C, Kusaka S, Sakagami K, Ohashi Y. Reopening of macular holes in highly myopic eyes with retinal detachments. Retina 1997;17:2–6. 6. Kadonosono K, Yazama F, Itoh N, et al. Treatment of retinal detachment resulting from myopic macular hole with internal limiting membrane removal. Am J Ophthalmol 2001;131:203–207. 7. Uemoto R, Yamamoto S, Tsukahara I, Takeuchi S. Efficacy of internal limiting membrane removal for retinal detachments resulting from a myopic macular hole. Retina 2004;24:560–566. 8. Wolfensberger TJ, Gonvers M. Long-term follow-up of retinal detachment due to macular hole in myopic eyes treated by temporary silicone oil tamponade and laser photocoagulation. Ophthalmology 1999;106:1786–1791. 9. Nakanishi H, Kuriyama S, Saito I, et al. Am J Ophthalmol 2008;146:198–204. 10. Singh AJ. Combined or sequential surgery for management of rhegmatogenous retinal detachment with macular holes. Retina 2009;29:1102–1110.
