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Clinicopathologic Reports, Case Reports, and Small Case Series |

Repair of Impending Macular Hole in the Early Postoperative Period as Evaluated by Optical Coherence Tomography FREE

Akinori Uemura, MD; Eisuke Uchino, MD; Norihito Doi, MD; Norio Ohba, MD
Arch Ophthalmol. 2002;120(3):398-400. doi:.
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High-resolution cross-sectional imaging provided by optical coherence tomography (OCT) facilitates assessment of the postoperative as well as preoperative vitreoretinal state of idiopathic macular holes. Although the hole is considered to be closed in the first few postoperative days by studies using gas or silicone oil tamponade,1,2 the detailed postoperative change in the fovea in the early postoperative period is unknown because of the poor quality of the image due to the use of gas or silicone oil. Impending macular hole may resolve either from spontaneous vitreous detachment or with vitrectomy with separation of the vitreous cortex from the retina. Herein we describe 2 patients with impending macular hole who underwent vitrectomy without gas tamponade and from whom we were able to obtain a series of good-quality OCT images from before and after surgery, and discuss the repair process of impending macular hole.

Case 1

A 65-year-old woman had a 1-week history of blurred vision in the left eye, with best-corrected visual acuity of 20/60. Contact lens biomicroscopy disclosed foveal changes typical of idiopathic impending macular hole, with a loss of foveal depression and a yellow ring in the fovea. No posterior vitreous detachment was identified on biomicroscopy. Horizontal and vertical cross-sectional images provided by OCT revealed loss of the foveal pit associated with a bridgelike inner retina and hyporeflective cystic formation apparently due to disruption of the outer retinal layer extending to the retinal pigment epithelium. The posterior hyaloid was adherent to the foveal center with perifoveal posterior hyaloid separation (Figure 1). The fellow eye was normal on biomicroscopy and OCT.

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figure

Case 1. Preoperative and postoperative optical coherence tomographic (OCT) images of a 65-year-old woman with impending macular hole. Preoperative OCT shows intrafoveal cyst with disruption of the outer retinal layer and a partially detached posterior hyaloid adherent to the roof of the cyst. On the first postoperative day, both a horizontal and a vertical OCT section showed the roof of the cyst slightly depressed, increasing its thickness. During subsequent days, the foveal depression recovered with reapproximation of the edge of the disrupted outer retinal layer. One week postoperatively, a small residual clear space was identified in the fovea. One month after surgery, the image shows normal foveal configuration.

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Case 2

A 75-year-old woman noted distorted vision in the left eye 2 weeks before being examined. Her best-corrected visual acuity in this eye was 20/60 due to impending macular hole, the biomicroscopic and OCT findings of which were similar to those in case 1. The fellow eye had developed a full-thickness macular hole (stage 3) and had undergone successful vitrectomy and gas tamponade with hole closure 10 months previously.

The 2 patients were informed of the known natural course of idiopathic impending macular hole and its surgical intervention. Each patient consented to vitrectomy with careful peeling of the posterior hyaloid from the center of the fovea. The postoperative course was uncomplicated, and the ocular media remained clear enough to allow a series of sequential OCT evaluations as early as the first postoperative day. Figure 1 shows preoperative and postoperative cross-sectional OCT images through the fovea in case 1, demonstrating a restoration of foveal configuration. On the first postoperative day, a pronounced decrease of cystic spaces was found with early depression of the central fovea with disappearance of vitreous adhesion to the fovea. Subsequent daily OCT evaluations revealed a further recovery of foveal contour in such a manner that the inner retina appeared slightly thickened and depressed while the underlying cysts regressed and appeared to be replaced by outer retinal tissue. By 1 to 2 weeks after surgery, the fovea had a distinct pit with minimal optical clear space under it. The foveal configuration appeared normal 1 month after surgery and remained unchanged when examined at 6-month follow-up. Case 2 also had a foveal restoration with a similar time course. In concert with the anatomical recovery, best-corrected visual acuity in both patients improved to 20/40 at 1 week after surgery and to 20/25 at 6 months.

The preoperative OCT images of these cases are consistent with impending macular hole characterized by an intrafoveal cyst that has raised the foveal floor and disrupted the outer retina probably due to perifoveal posterior vitreous detachment with residual adhesion to the fovea. The natural course of impending macular hole is variable among patients, but surgical intervention may be beneficial to prevent a possible progression to full-thickness macular hole. The patients described herein underwent successful vitrectomy with peeling of the posterior hyaloid without gas injection. With no gas in the eyes, it was possible to obtain good-quality OCT images in the early postoperative period. The findings indicate that impending macular hole begins to resolve as early as the first postoperative day and that an anatomical restoration of the fovea is achieved by about 1 month after surgery.

Recently the natural history of an impending macular hole has been clarified using OCT.3 According to that report, foveal pseudocysts are the first step in full-thickness macular hole formation, which is the result of incomplete vitreous detachment in the perifoveal area. After the occurrence of a split in the foveal tissue, the outer retinal layer is disrupted in some eyes, and the unroofing of a foveal pseudocyst results in the full-thickness macular hole. Disruption of the outer retinal layer is thought to occur because of the particular anatomy of the central foveal Müller cells.3,4

The OCT images described herein provide additional information for understanding the repair process of idiopathic macular holes. We found 2 anatomical changes occurring in the fovea. First, the roof of the cyst gradually increased in thickness and its separation from the underlying layer diminished (vertical change). The second was reapproximation of the edge of the disrupted outer retinal layers (horizontal change). We measured the thickness of the roof and vertical and horizontal diameter of the cyst in case 1 to see how the fovea changes. The thickness of the roof before the surgery and at postoperative days 1 and 4 measured 60 µm, 88 µm, and 108 µm, respectively. The horizontal diameter of the cyst measured 250 µm, 240 µm, and 180 µm, respectively. These facts indicate that disrupted outer retinal layers begin to reapproach as well as the gradual depression of the roof of the cyst, increasing its thickness following the release of vitreous traction.

In conclusion, detailed observations of impending macular hole after pars plana vitrectomy using OCT have revealed 2 factors: depression of the inner part of the cyst with an increase in thickness and reapproximation of the disrupted outer retinal layer. These changes are associated with resolution of the impending macular hole.

The authors have no proprietary interests in any of the materials used in this study.

Corresponding author: Akinori Uemura, MD, Department of Ophthalmology, Kagoshima City Hospital, 20-17 Kajiya-cho, Kagoshima-shi 892-8580, Japan (e-mail: akiu@ml.kch.kagoshima.kagoshima.jp).

Jumper  JMGallemore  RPMcCuen  BWToth  CA Features of macular hole closure in the early postoperative period using optical coherence tomography. Retina. 2000;20232- 237
Link to Article
Kasuga  YArai  JAkimoto  NYoshimura  N Optical coherence tomography to confirm early closure of macular hole. Am J Ophthalmol. 2000;130675- 676
Link to Article
Haouchine  BMassin  PGaudric  A Foveal pseudocyst as the first step in macular hole formation: a prospective study by optical coherence tomography. Ophthalmology. 2001;10815- 22
Link to Article
Spaide  RF Closure of an outer lamellar macular hole by vitrectomy: hypothesis for one mechanism of macular hole formation. Retina. 2000;20587- 590
Link to Article

Figures

Place holder to copy figure label and caption
figure

Case 1. Preoperative and postoperative optical coherence tomographic (OCT) images of a 65-year-old woman with impending macular hole. Preoperative OCT shows intrafoveal cyst with disruption of the outer retinal layer and a partially detached posterior hyaloid adherent to the roof of the cyst. On the first postoperative day, both a horizontal and a vertical OCT section showed the roof of the cyst slightly depressed, increasing its thickness. During subsequent days, the foveal depression recovered with reapproximation of the edge of the disrupted outer retinal layer. One week postoperatively, a small residual clear space was identified in the fovea. One month after surgery, the image shows normal foveal configuration.

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Tables

References

Jumper  JMGallemore  RPMcCuen  BWToth  CA Features of macular hole closure in the early postoperative period using optical coherence tomography. Retina. 2000;20232- 237
Link to Article
Kasuga  YArai  JAkimoto  NYoshimura  N Optical coherence tomography to confirm early closure of macular hole. Am J Ophthalmol. 2000;130675- 676
Link to Article
Haouchine  BMassin  PGaudric  A Foveal pseudocyst as the first step in macular hole formation: a prospective study by optical coherence tomography. Ophthalmology. 2001;10815- 22
Link to Article
Spaide  RF Closure of an outer lamellar macular hole by vitrectomy: hypothesis for one mechanism of macular hole formation. Retina. 2000;20587- 590
Link to Article

Correspondence

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