Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

OCT Findings in Macular Hole Formation in Eyes With Complete Vitreofoveal Separation

Abelardo Targino, MD; Rogério A. Costa, MD, PhD; Daniela Calucci, COMT; José A. Cardillo, MD; Rodrigo Jorge, MD, PhD; Ingrid U. Scott, MD, MPH

Abstract

The current study describes the morphologic macular features in two eyes that developed full-thickness macular holes in the setting of documented vitreofoveal separation. Using third-generation optical coherence tomography, complete vitreofoveal separation associated with the disruption of the inner foveal retina was documented in both cases. Five months after presentation, decreased vision and epiretinal membrane formation associated with development of a full-thickness macular hole were observed in the first patient. In the second patient, a full-thickness macular hole was demonstrated by optical coherence tomography 6 weeks after presentation. These findings suggest that full-thickness macular holes may develop in eyes with vitreofoveal separation. Evidence of the disturbance of the inner foveal architecture on optical coherence tomography indicates the potential role of factors other than anteroposterior or oblique vitreoretinal tractional forces in the genesis of some full-thickness macular holes.

Abstract

The current study describes the morphologic macular features in two eyes that developed full-thickness macular holes in the setting of documented vitreofoveal separation. Using third-generation optical coherence tomography, complete vitreofoveal separation associated with the disruption of the inner foveal retina was documented in both cases. Five months after presentation, decreased vision and epiretinal membrane formation associated with development of a full-thickness macular hole were observed in the first patient. In the second patient, a full-thickness macular hole was demonstrated by optical coherence tomography 6 weeks after presentation. These findings suggest that full-thickness macular holes may develop in eyes with vitreofoveal separation. Evidence of the disturbance of the inner foveal architecture on optical coherence tomography indicates the potential role of factors other than anteroposterior or oblique vitreoretinal tractional forces in the genesis of some full-thickness macular holes.

OCT Findings in Macular Hole Formation in Eyes With Complete Vitreofoveal Separation

From the Centro Avancado de Retina e Catarata (AT), Fortaleza, CE, Brazil; U.D.A.T. – Retina Diagnostic & Treatment Division (RAC, DC, JAC), Hospital de Olhos de Araraquara, Araraquara; the Retina and Vitreous Section (RAC, RJ), Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and the Departments of Ophthalmology and Health Evaluation Sciences (IUS), Penn State College of Medicine, Hershey, Pennsylvania.

Supported in part by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP grant no: 98/14270–8).

Address correspondence to Rogério A. Costa, MD, U.D.A.T. – Hospital de Olhos de Araraquara, Rua Padre Duarte 989 apto 172, Araraquara-SP, 14801–310 Brazil.

Accepted: July 03, 2007

Introduction

Optical coherence tomography has repeatedly demonstrated the presence of “biconvex” perifoveal posterior vitreous detachment with persistent vitreofoveal attachment in the early course of macular hole formation.1–3 Depending on residual vitreofoveal adhesion and related tractional forces, an intrafoveal splitting (pseudocyst) may develop followed by a break in the roof of the pseudocyst, which may lead to lamellar or full-thickness macular hole formation after vitreofoveal separation.1 Furthermore, it has been reported that once vitreofoveal separation is established, macular holes rarely occur.4–6 Herein, two cases of full-thickness macular hole formation in eyes with well-documented vitreofoveal separation are described, with particular emphasis on the optical coherence tomography macular features before macular hole formation.

Case Reports

Case 1

A 57-year-old woman was referred for evaluation of progressive central vision loss in her right eye over the past 4 months. Visual acuity was 20/200−1 in the right eye and 20/20 in the left eye. A full-thickness macular hole was seen in the right eye and examination of the left eye was unremarkable. A Weiss ring was visible in both eyes by biomicroscopic examination. Optical coherence tomography on presentation confirmed the full-thickness macular hole in the right eye and revealed a complete vitreofoveal separation and minimal irregularities of the inner foveal retina in the left eye. Five months later, visual acuity dropped to 20/25−2 and the patient experienced metamorphopsia and visual deterioration in her left eye. Fundus examination of the left eye revealed a macular epiretinal membrane (grade 1) and optical coherence tomography of the left eye revealed a full-thickness macular hole (Fig. 1).

Third Generation Optical Coherence Tomography Scan of the Left Eye of a 57-Year-Old Woman with Idiopathic Age-Related Macular Hole in the Right Eye (case 1). (A) at Presentation, an Epiretinal Membrane (grade 2) and a Full-Thickness Macular Hole (Gaudric Stage 3) Were Seen in the Patient’s Right Eye (data not Shown). a Horizontal (6 mm in Length) Scan of the Left Eye Revealed Complete Detachment of the Posterior Hyaloid in the Macular Region with Hyperreflective Signals in the Plane of the Detached Posterior Hyaloid over the Foveal Region (arrow). (B, C) Oblique (4 mm in Length) Scans Revealed the Extent of Disruption of the Inner Foveal Retina (arrows). (D) Five Months Later, an Epiretinal Membrane (grade 1) Associated with the Development of a Full-Thickness Macular Hole Was Seen in the Left Eye. (E, F) Oblique (4 mm in Length) Scans Revealed Complete Interruption of the Foveal Retina of Approximately 99 μm Associated with Perifoveal Intraretinal Fluid Accumulation and Attenuation of the Inner Hyperreflective Layer Corresponding to the Junction of the Inner and Outer Photoreceptor Segments, Suggesting Edema of the Outer Perifoveal Neural Retina.

Figure 1. Third Generation Optical Coherence Tomography Scan of the Left Eye of a 57-Year-Old Woman with Idiopathic Age-Related Macular Hole in the Right Eye (case 1). (A) at Presentation, an Epiretinal Membrane (grade 2) and a Full-Thickness Macular Hole (Gaudric Stage 3) Were Seen in the Patient’s Right Eye (data not Shown). a Horizontal (6 mm in Length) Scan of the Left Eye Revealed Complete Detachment of the Posterior Hyaloid in the Macular Region with Hyperreflective Signals in the Plane of the Detached Posterior Hyaloid over the Foveal Region (arrow). (B, C) Oblique (4 mm in Length) Scans Revealed the Extent of Disruption of the Inner Foveal Retina (arrows). (D) Five Months Later, an Epiretinal Membrane (grade 1) Associated with the Development of a Full-Thickness Macular Hole Was Seen in the Left Eye. (E, F) Oblique (4 mm in Length) Scans Revealed Complete Interruption of the Foveal Retina of Approximately 99 μm Associated with Perifoveal Intraretinal Fluid Accumulation and Attenuation of the Inner Hyperreflective Layer Corresponding to the Junction of the Inner and Outer Photoreceptor Segments, Suggesting Edema of the Outer Perifoveal Neural Retina.

Case 2

A 27-year-old man was referred for evaluation of acute vision loss in his right eye after direct ocular trauma with a soccer ball 72 hours prior to presentation. Visual acuity was 20/40+2 in the right eye and 20/20−1 in the left eye. Fundus examination revealed a reddish dot in the center of the right macula and was unremarkable in the left eye. A Weiss ring was visualized by biomicroscopic examination in the right eye. Optical coherence tomography of the right eye demonstrated complete vitreomacular separation and a tiny inner lamellar hole with relative maintenance of the foveal contour. Six weeks later, the patient experienced a further decrease in the visual acuity of his right eye (20/63−1) and optical coherence tomography revealed a full-thickness macular hole (Fig. 2).

Third Generation Optical Coherence Tomography Scans of the Right Eye of a 27-Year-Old Man with Traumatic Lamellar Macular Hole (case 2). (A, B) at Presentation, a Horizontal (6 mm in Length) Scan Revealed Complete Detachment of the Posterior Hyaloid in the Macular Region. a Hyperreflective Structure Corresponding to the Pseudo-Operculum Was Seen in the Plane of the Detached Posterior Hyaloid over the Foveal Region (arrow). a Tiny Break Within the Inner Retina with Abnormal Reflective Signals from the Underlyingphotoreceptor Layerat the Center of the Fovea and Preserved Reflectivity from Perifoveal Retinal Layers Was Seen. (C) Six Weeks Later, a Scan Revealed a Full-Thickness Macular Hole (arrow) with Perifoveal Cystic Spaces at the Level of the Outer Plexiform Layer and Focal Attenuation of the Outer Highly Reflective Layer Corresponding to the Junction of the Inner and Outer Photoreceptor Segments. Subsequent Scans Performed (D) 10 Weeks and (E) 16 Weeks After Presentation Showed Some Decrease in Perifoveal Fluid Accumulation and Outer Retina Edema and Persistence of a Full-Thickness Macular Hole of Approximately 261 μm.

Figure 2. Third Generation Optical Coherence Tomography Scans of the Right Eye of a 27-Year-Old Man with Traumatic Lamellar Macular Hole (case 2). (A, B) at Presentation, a Horizontal (6 mm in Length) Scan Revealed Complete Detachment of the Posterior Hyaloid in the Macular Region. a Hyperreflective Structure Corresponding to the Pseudo-Operculum Was Seen in the Plane of the Detached Posterior Hyaloid over the Foveal Region (arrow). a Tiny Break Within the Inner Retina with Abnormal Reflective Signals from the Underlyingphotoreceptor Layerat the Center of the Fovea and Preserved Reflectivity from Perifoveal Retinal Layers Was Seen. (C) Six Weeks Later, a Scan Revealed a Full-Thickness Macular Hole (arrow) with Perifoveal Cystic Spaces at the Level of the Outer Plexiform Layer and Focal Attenuation of the Outer Highly Reflective Layer Corresponding to the Junction of the Inner and Outer Photoreceptor Segments. Subsequent Scans Performed (D) 10 Weeks and (E) 16 Weeks After Presentation Showed Some Decrease in Perifoveal Fluid Accumulation and Outer Retina Edema and Persistence of a Full-Thickness Macular Hole of Approximately 261 μm.

Discussion

Both of our patients shared similar tomographic features at presentation: vitreofoveal separation with avulsion of part of the inner foveal retina and a later development of a full-thickness macular hole. According to Gass, the presence of vitreofoveal separation most likely reduces the risk of macular hole formation to 1% or less and may be explained by either a subclinical full-thickness microhole caused by traction during posterior vitreous detachment or a tear in the posterior hyaloid at the time of posterior vitreous detachment, which leaves the vitreous cortex attached around the foveal area and the subsequent contraction mechanically causes a full-thickness hole in the macula.4

The latter could have explained the macular hole formation in our first case; however, macular holes produced by this mechanism are typically oval or irregular in shape, simulating a pseudo-macular hole. Furthermore, it is impossible to determine whether the macular hole occurred before the development of the epiretinal membrane or developed as a complication of the membrane because mild degrees of crinkled cellophane maculopathy often accompany a full-thickness macular hole.4

The recently proposed “hydration theory” suggests that a defect in the inner retina with secondary accumulation of fluid vitreous into the middle and outer retinal tissue may be responsible for macular hole formation.7 If one considers the peculiar foveal anatomy and assumes that retinal “hydration” may depend particularly on the level (possibly the outer nuclear layer) of disruption of the foveal retina during vitreofoveal separation (forming “true-” or “pseudo-opercula”8), this theory may explain the full-thickness macular hole formation in our cases. Moreover, it is important to recognize that theories based exclusively on vitreoretinal tractional forces cannot explain why some foveal pseudocysts lead to the formation of lamellar holes as opposed to full-thickness macular holes1 and also cannot explain the “closure” of Gass’ stage 2 macular holes after intravitreal gas injection and face-down positioning without vitrectomy.9,10

To our knowledge and based on a literature search of the MEDLINE database, this is the first report to document the development of a full-thickness macular hole in the setting of preexisting complete vitreofoveal separation using optical coherence tomography. Although the advent of optical coherence tomography has enabled new theories about the mechanisms of macular hole formation,1–3,7 several issues about the mechanism of macular hole formation remain unclear. The findings in the current report are useful because they indicate the potential role of factors other than anteroposterior or oblique vitreoretinal tractional forces in the genesis of some full-thickness macular holes.

References

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  8. : Ezra E, Munro PM, Charteris DG, Aylward WG, Luthert PJ, Gregor ZJMacular hole opercula: ultrastructural features and clinicopathological correlation. Arch Ophthalmol. 1997;115:1381–1387.
  9. : Chan CK, Wessels IF, Friedrichsen EJTreatment of idiopathic macular holes by induced posterior vitreous detachment. Ophthalmology. 1995;102:757–767.
  10. : Costa RA, Cardillo JA, Morales PH, Jorge R, Uno F, Farah MEOptical coherence tomography evaluation of idiopathic macular hole treatment by gas-assisted posterior vitreous detachment. Am J Ophthalmol. 2001; 132:264–266. doi:10.1016/S0002-9394(00)00903-X [CrossRef]
Authors

From the Centro Avancado de Retina e Catarata (AT), Fortaleza, CE, Brazil; U.D.A.T. – Retina Diagnostic & Treatment Division (RAC, DC, JAC), Hospital de Olhos de Araraquara, Araraquara; the Retina and Vitreous Section (RAC, RJ), Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and the Departments of Ophthalmology and Health Evaluation Sciences (IUS), Penn State College of Medicine, Hershey, Pennsylvania.

Address correspondence to Rogério A. Costa, MD, U.D.A.T. – Hospital de Olhos de Araraquara, Rua Padre Duarte 989 apto 172, Araraquara-SP, 14801–310 Brazil.

10.3928/15428877-20080101-17

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