SPONTANEOUS RESOLUTION OF A STAGE 3 MACULAR HOLE Long-Term Follow-up With Optical Coherence Tomography Jennifer Chen, BAPPSC(OPTOM)(HONS), PHD,*† Lawrence Lee, MB, BS, FRANZCO, FRACS,*‡ Stephni Vorster, BAPPSC(OPTOM)†
Background: While spontaneous resolution of idiopathic macular holes is well documented for early macular holes, spontaneous closure of full-thickness macular holes has been less frequently reported. Methods: We followed a case of an idiopathic full-thickness stage III macular hole and its course of spontaneous closure using optical coherence tomography (OCT 3, Carl Zeiss Meditec, CA) over a 2-year period. Results: OCT scans demonstrated evidence of spontaneous closure of the macular hole over the 2-year follow-up period. Bridging of glial tissue over the macular hole area appeared to occur first with successive scans showing a decrease in the size of the hole. To our knowledge, this is the longest follow-up with OCT in a case of spontaneous resolution of macular holes that has been reported. Conclusion: Recognition of the likelihood of spontaneous closure of macular holes has important clinical values. The advent of OCT technology has provided significant capabilities in the diagnosis and monitoring of macular holes; it has also contributed to the greater understanding of the potential mechanisms involved in spontaneous macular hole closure. RETINAL CASES & BRIEF REPORTS 2:225–227, 2008
From *City Eye Centre, †Department of Ophthalmology, University of Queensland, Royal Brisbane Hospital, Brisbane, Queensland, Australia, and ‡School of Optometry and Institute of Health and Biomedical Innovation, Queensland University of Technology.
Case Report A 71-year-old man presented with blurred vision in the left eye of 3 months’ duration. Visual acuity was 20/20 in the right eye and 20/50 in the left eye. Optical coherence tomography (OCT [OCT 3, Carl Zeiss Meditec, CA]) at presentation revealed a full-thickness retinal defect at the fovea in the left eye, consistent with a stage III macular hole classification. The inner retinal diameter measured 926 m, while the base diameter was measured at 524 m (Fig. 1). Definition of full-thickness stage III macular holes outlined by Gass8 suggests a diameter of ⬎400 m. The posterior vitreous could be seen shallowly detached from the retina as a thin linear line, with a detached operculum on the hyaloid interface. The edges of the holes were slightly thickened with nonreflective perifoveal intraretinal fluid accumulation. The patient did not consider surgery at this stage because decreased vision in the left eye was not impairing his overall vision. At the 2-month follow-up, OCT showed bridging of the protruding retinal tissues, although there was no improvement in visual acuity (Fig. 2B). The detached posterior hyaloid was evident, and a thick pseudooperculum was visible at the level of the hyaloids. Visual acuity remained unchanged over the subsequent 12-month period, while the extent of the macular hole gradually decreased (Fig. 2,
S
pontaneous resolution of idiopathic macular hole has been well documented for early (stages I and II) macular holes,1 while closure of full-thickness (stages III and IV) macular holes is known to occur less frequently.2–5 Full-thickness macular holes usually are associated with poor visual prognosis without surgical intervention, particularly in long-standing cases.6 However, in rare instances, spontaneous resolution of a full-thickness macular hole has been reported to be associated with good visual outcome.7 Reprint requests: Associate Professor Lawrence Lee, City Eye Centre, 10/135 Wickham Terrace, Brisbane, Queensland 4000, Australia; e-mail: [email protected]
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Fig. 1. Optical coherence tomography at initial presentation revealed a full-thickness retinal defect consistent with a stage III classification. The inner retinal diameter and the base diameter of the hole were measured at 926 m and 524 m, respectively.
C–E). As there was OCT evidence of macular hole closure and no further visual decrease, we elected to observe rather than proceed with surgical intervention. At the 27-month follow-up, visual acuity improved to 20/15 in the left eye, and the macular hole was completely closed (Fig. 2F).
Discussion Recent OCT technology provides enhanced visualization of the vitreoretinal interface and morphologic changes of early macular holes; it also facilitates a more definitive diagnosis and contributes to a greater understanding of the mechanisms involved in macular hole pathogenesis and closure.5,9,10 Spontaneous closure of full-thickness macular holes is thought to occur by means of an inward protrusion and subsequent bridging of the surrounding retinal tissues over the macular hole.3,5 One other possible mechanism may occur through relief of vitreofoveal traction, which is supported by the OCT findings in our report. The hole closes from the innermost layer of the fovea, leaving a small defect in the outer retinal layers that may persist for some time, as demonstrated in our case (Fig. 2, B–E). Although spontaneous resolution of full-thickness macular holes occurs infrequently, our report illustrates that recognizing the possibility of spontaneous macular hole closure before recommending surgery may be of clinical value. It is perhaps reasonable to suggest that these holes can be observed initially for a short period, particularly if there are signs of proliferation of retinal tissue bridging taking place over the macular hole area by OCT. Other factors that may influence spontaneous stage III macular hole closure may include good initial visual acuity, protruding convex-shaped internal edges of the hole, and a small base diameter–to–inner retinal diameter ratio. Surgical intervention of macular holes is indicated if there are no signs of resolution within a period of 3 months, and
Fig. 2. Serial optical coherence tomography (OCT) scans over a 27-month follow-up period. A full-thickness stage III macular hole at initial presentation (A). Spontaneous resolution via bridging of the surrounding retinal tissues over the macular hole occurred at the 2-month follow-up (B). The size of the macular hole gradually decreased at the 6-month (C), 9-month (D), and 12-month (E) follow-ups. The hole was observed to be closed at the 18-month follow-up with OCT findings remaining unchanged at 27 months (F).
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surgery should be performed within the first year of onset for more favorable surgical prognosis. Key words: full thickness, macular hole, optical coherence tomography, spontaneous resolution.
spontaneously closed macular hole. Am J Ophthalmol 2002; 133:280–282. Freund KB, Ciardella AP, Shah V, et al. Optical coherence tomography documentation of spontaneous macular hole closure without posterior vitreous detachment. Retina 2002;22:506–509. Guyer DR, de Bustros S, Diener-West M, Fine SL. Observations on patients with idiopathic macular holes and cysts. Arch Ophthalmol 1992;110:1264–1268. de Cruz L, Constable IJ, Barry CJ. Spontaneous resolution of a full-thickness macular hole with good visual acuity. Arch Ophthalmol 1997;115:130–131. Gass JDM. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752–759. Glacet-Bernard A, Jourdani A, Perrenoud F, et al. Stage 3 macular hole: role of optical coherence tomography and of B-scan ultrasonography. Am J Ophthalmol 2005;139:814–819. Lo WR, Hubbard GB. Macular hole formation, spontaneous closure, and recurrence in a previously vitrectomized eye. Am J Ophthalmol 2006;141:962–964.
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References 1.
2.
3.
4.
Ansari H, Rodriguez-Coleman H, Langton K, Chang S. Spontaneous resolution of bilateral stage 1 macular holes documented by optical coherence tomography. Am J Ophthalmol 2002;134:447–449. Yuzawa M, Watanabe A, Takahashi Y, Matsui M. Observation of idiopathic full-thickness macular holes. Arch Ophthalmol 1994;112:1051–1056. Takahashi H, Kishi S. Optical coherence tomography images of spontaneous macular hole closure. Am J Ophthalmol 1999; 128:519–520. Kokame GT, McCauley MB. Spontaneous reopening of a
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Background: While spontaneous resolution of idiopathic macular holes is well documented for early macular holes, spontaneous closure of full-thickness macular holes has been less frequently reported. Methods: We followed a case of an idiopathic full-thickness stage III macular hole and its course of spontaneous closure using optical coherence tomography (OCT 3, Carl Zeiss Meditec, CA) over a 2-year period. Results: OCT scans demonstrated evidence of spontaneous closure of the macular hole over the 2-year follow-up period. Bridging of glial tissue over the macular hole area appeared to occur first with successive scans showing a decrease in the size of the hole. To our knowledge, this is the longest follow-up with OCT in a case of spontaneous resolution of macular holes that has been reported. Conclusion: Recognition of the likelihood of spontaneous closure of macular holes has important clinical values. The advent of OCT technology has provided significant capabilities in the diagnosis and monitoring of macular holes; it has also contributed to the greater understanding of the potential mechanisms involved in spontaneous macular hole closure. RETINAL CASES & BRIEF REPORTS 2:225–227, 2008
From *City Eye Centre, †Department of Ophthalmology, University of Queensland, Royal Brisbane Hospital, Brisbane, Queensland, Australia, and ‡School of Optometry and Institute of Health and Biomedical Innovation, Queensland University of Technology.
Case Report A 71-year-old man presented with blurred vision in the left eye of 3 months’ duration. Visual acuity was 20/20 in the right eye and 20/50 in the left eye. Optical coherence tomography (OCT [OCT 3, Carl Zeiss Meditec, CA]) at presentation revealed a full-thickness retinal defect at the fovea in the left eye, consistent with a stage III macular hole classification. The inner retinal diameter measured 926 m, while the base diameter was measured at 524 m (Fig. 1). Definition of full-thickness stage III macular holes outlined by Gass8 suggests a diameter of ⬎400 m. The posterior vitreous could be seen shallowly detached from the retina as a thin linear line, with a detached operculum on the hyaloid interface. The edges of the holes were slightly thickened with nonreflective perifoveal intraretinal fluid accumulation. The patient did not consider surgery at this stage because decreased vision in the left eye was not impairing his overall vision. At the 2-month follow-up, OCT showed bridging of the protruding retinal tissues, although there was no improvement in visual acuity (Fig. 2B). The detached posterior hyaloid was evident, and a thick pseudooperculum was visible at the level of the hyaloids. Visual acuity remained unchanged over the subsequent 12-month period, while the extent of the macular hole gradually decreased (Fig. 2,
S
pontaneous resolution of idiopathic macular hole has been well documented for early (stages I and II) macular holes,1 while closure of full-thickness (stages III and IV) macular holes is known to occur less frequently.2–5 Full-thickness macular holes usually are associated with poor visual prognosis without surgical intervention, particularly in long-standing cases.6 However, in rare instances, spontaneous resolution of a full-thickness macular hole has been reported to be associated with good visual outcome.7 Reprint requests: Associate Professor Lawrence Lee, City Eye Centre, 10/135 Wickham Terrace, Brisbane, Queensland 4000, Australia; e-mail: [email protected]
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Fig. 1. Optical coherence tomography at initial presentation revealed a full-thickness retinal defect consistent with a stage III classification. The inner retinal diameter and the base diameter of the hole were measured at 926 m and 524 m, respectively.
C–E). As there was OCT evidence of macular hole closure and no further visual decrease, we elected to observe rather than proceed with surgical intervention. At the 27-month follow-up, visual acuity improved to 20/15 in the left eye, and the macular hole was completely closed (Fig. 2F).
Discussion Recent OCT technology provides enhanced visualization of the vitreoretinal interface and morphologic changes of early macular holes; it also facilitates a more definitive diagnosis and contributes to a greater understanding of the mechanisms involved in macular hole pathogenesis and closure.5,9,10 Spontaneous closure of full-thickness macular holes is thought to occur by means of an inward protrusion and subsequent bridging of the surrounding retinal tissues over the macular hole.3,5 One other possible mechanism may occur through relief of vitreofoveal traction, which is supported by the OCT findings in our report. The hole closes from the innermost layer of the fovea, leaving a small defect in the outer retinal layers that may persist for some time, as demonstrated in our case (Fig. 2, B–E). Although spontaneous resolution of full-thickness macular holes occurs infrequently, our report illustrates that recognizing the possibility of spontaneous macular hole closure before recommending surgery may be of clinical value. It is perhaps reasonable to suggest that these holes can be observed initially for a short period, particularly if there are signs of proliferation of retinal tissue bridging taking place over the macular hole area by OCT. Other factors that may influence spontaneous stage III macular hole closure may include good initial visual acuity, protruding convex-shaped internal edges of the hole, and a small base diameter–to–inner retinal diameter ratio. Surgical intervention of macular holes is indicated if there are no signs of resolution within a period of 3 months, and
Fig. 2. Serial optical coherence tomography (OCT) scans over a 27-month follow-up period. A full-thickness stage III macular hole at initial presentation (A). Spontaneous resolution via bridging of the surrounding retinal tissues over the macular hole occurred at the 2-month follow-up (B). The size of the macular hole gradually decreased at the 6-month (C), 9-month (D), and 12-month (E) follow-ups. The hole was observed to be closed at the 18-month follow-up with OCT findings remaining unchanged at 27 months (F).
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227
surgery should be performed within the first year of onset for more favorable surgical prognosis. Key words: full thickness, macular hole, optical coherence tomography, spontaneous resolution.
spontaneously closed macular hole. Am J Ophthalmol 2002; 133:280–282. Freund KB, Ciardella AP, Shah V, et al. Optical coherence tomography documentation of spontaneous macular hole closure without posterior vitreous detachment. Retina 2002;22:506–509. Guyer DR, de Bustros S, Diener-West M, Fine SL. Observations on patients with idiopathic macular holes and cysts. Arch Ophthalmol 1992;110:1264–1268. de Cruz L, Constable IJ, Barry CJ. Spontaneous resolution of a full-thickness macular hole with good visual acuity. Arch Ophthalmol 1997;115:130–131. Gass JDM. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752–759. Glacet-Bernard A, Jourdani A, Perrenoud F, et al. Stage 3 macular hole: role of optical coherence tomography and of B-scan ultrasonography. Am J Ophthalmol 2005;139:814–819. Lo WR, Hubbard GB. Macular hole formation, spontaneous closure, and recurrence in a previously vitrectomized eye. Am J Ophthalmol 2006;141:962–964.
5.
6.
References 1.
2.
3.
4.
Ansari H, Rodriguez-Coleman H, Langton K, Chang S. Spontaneous resolution of bilateral stage 1 macular holes documented by optical coherence tomography. Am J Ophthalmol 2002;134:447–449. Yuzawa M, Watanabe A, Takahashi Y, Matsui M. Observation of idiopathic full-thickness macular holes. Arch Ophthalmol 1994;112:1051–1056. Takahashi H, Kishi S. Optical coherence tomography images of spontaneous macular hole closure. Am J Ophthalmol 1999; 128:519–520. Kokame GT, McCauley MB. Spontaneous reopening of a
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