Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Macular Hole Formation Secondary to Rhegmatogenous Retinal Detachment Demonstrated With Optical Coherence Tomography

Yi-Ting Hsieh, MD, PhD

Abstract

The author presents two cases of macular hole (MH) retinal detachment in non-myopic eyes for which optical coherence tomography demonstrated a detached macula and a nearly full-thickness MH with only the elongated outer segments connecting at the fovea. Such images have rarely been observed in cases of MH retinal detachment in highly myopic eyes or secondary to vitreomacular traction. This implies that MH may form secondary to a macula-off rhegmatogenous retinal detachment, as it may result from the pushing forces of the subretinal fluid involving the macula.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e193–e195.]

Abstract

The author presents two cases of macular hole (MH) retinal detachment in non-myopic eyes for which optical coherence tomography demonstrated a detached macula and a nearly full-thickness MH with only the elongated outer segments connecting at the fovea. Such images have rarely been observed in cases of MH retinal detachment in highly myopic eyes or secondary to vitreomacular traction. This implies that MH may form secondary to a macula-off rhegmatogenous retinal detachment, as it may result from the pushing forces of the subretinal fluid involving the macula.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e193–e195.]

Introduction

Macular hole (MH) retinal detachment is commonly seen in highly myopic eyes.1 In such cases, the lamellar MH or full-thickness MH (FTMH) usually existed long before the onset of retinal detachment. Occasionally, some non-myopic patients may also present with concurrent MH and retinal detachment. However, these patients usually had normal vision without metamorphopsia before the abrupt onset of blurred vision. Herein, two cases of MH retinal detachment in non-myopic eyes with specific characteristics in optical coherence tomography (OCT) are presented.

Case Reports

The first case is a 53-year-old man who complained of progressing blurred vision in his left eye for 1 week. On examination, a total retinal detachment was noted, with a flap tear the at 3-o'clock area and a MH (Figure 1A). OCT demonstrated a bullous macular detachment and a nearly FTMH with only the elongated outer segments connecting at the fovea; no vitreomacular traction was noted (Figure 1B). The second case is a 54-year-old-woman who complained of sudden onset of floaters with progressing blurred vision in her right eye for 1 week. With indirect ophthalmoscopy, a macula-off retinal detachment extending to periphery from the 9-o'clock to 2-o'clock area was noted, with a flap tear at the 11-o'clock area and a MH (Figure 2A). OCT also demonstrated a detached macula and a nearly FTMH with only the elongated outer segments connecting at the fovea, and there was also no vitreomacular traction (Figure 2B). Their axial lengths were 24.75 mm and 25.61 mm, respectively. Both cases then received pars plana vitrectomy with inverted internal limiting membrane (ILM) flap coverage over the MH. After operation, the retina was well attached, and the MH was sealed successfully in both cases (Figures 1C and 2C).

(A) Color fundus photography showed a detached macula and a macular hole (MH). (B) Preoperative optical coherence tomography (OCT) demonstrated a bullous macular detachment and a nearly full-thickness MH with only the elongated outer segments connecting at the fovea; no vitreomacular traction was noted. (C) Postoperative OCT showed that the MH was sealed; the internal limiting membrane flap could be seen on the retinal surface.

Figure 1.

(A) Color fundus photography showed a detached macula and a macular hole (MH). (B) Preoperative optical coherence tomography (OCT) demonstrated a bullous macular detachment and a nearly full-thickness MH with only the elongated outer segments connecting at the fovea; no vitreomacular traction was noted. (C) Postoperative OCT showed that the MH was sealed; the internal limiting membrane flap could be seen on the retinal surface.

(A) Color fundus photography showed retinal detachment involving the superior macula and a macular hole (MH). (B) Preoperative optical coherence tomography (OCT) demonstrated subretinal fluid (SRF) and retinal folding involving superior macula, and a nearly full-thickness MH with the elongated outer segments connecting at the fovea; no vitreomacular traction was noted. (C) Postoperative OCT showed that the MH was sealed with a residual SRF pocket at the fovea.

Figure 2.

(A) Color fundus photography showed retinal detachment involving the superior macula and a macular hole (MH). (B) Preoperative optical coherence tomography (OCT) demonstrated subretinal fluid (SRF) and retinal folding involving superior macula, and a nearly full-thickness MH with the elongated outer segments connecting at the fovea; no vitreomacular traction was noted. (C) Postoperative OCT showed that the MH was sealed with a residual SRF pocket at the fovea.

Discussion

In the present study, two cases of MH retinal detachment in non-myopic eyes are presented. Both cases were nearly emmetropic with normal visual acuity and no metamorphopsia noted prior to the onset of retinal detachment. For MH retinal detachment in non-myopic eyes, one or more peripheral breaks usually can be detected with indirect ophthalmoscopy, and the regions of retinal detachment usually follow Lincoff's rules.2 Therefore, it is hypothesized that in these cases, such a MH may develop concurrently with the rhegmatogenous retinal detachment after posterior vitreous detachment. In this scenario, vitreomacular traction should have existed previously.

Another hypothesis is that the MH may develop secondary to the retinal detachment due to the pushing forces of the subretinal fluid (SRF). In the present study, a detached macula and a nearly FTMH was found, with only the elongated outer segments connecting at the fovea in both cases using OCT. Such images have rarely been observed in cases of MH retinal detachment in highly myopic eyes or secondary to vitreomacular traction. Because the outer segment layer was still continuous, it is impossible for the fluid in the vitreous cavity to go into the subretinal space through the MH. This finding supports the hypothesis that a MH may form secondary to a macula-off rhegmatogenous retinal detachment. It may result from the pushing forces of the SRF involving the macula.

For MH retinal detachment in highly myopic eyes, inverted ILM insertion has been proposed to increase the closure rate of MH.3 However, such a procedure may not be suitable for the cases in the present study, because it might disrupt the continuous layer of outer segments. ILM flap coverage provided good surgical results in both cases presented here. Therefore, it is suggested that preoperative OCT examination should be performed in cases of MH retinal detachment without high myopia or metamorphopsia prior to the onset.

References

  1. Ikuno Y. Overview of the complications of high myopia. Retina. 2017;37(12):2347–2351. doi:10.1097/IAE.0000000000001489 [CrossRef]
  2. Lincoff H, Gieser R. Finding the hole. Arch Ophthalmol. 1971;85(5):565–569. doi:10.1001/archopht.1971.00990050567007 [CrossRef]
  3. Chen SN, Yang CM. Inverted internal limiting membrane insertion for macular hole-associated retinal detachment in high myopia. Am J Ophthalmol. 2016;162:99–106. doi:10.1016/j.ajo.2015.11.013 [CrossRef]
Authors

From the Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan.

The author reports no relevant financial disclosures.

Address correspondence to Yi-Ting Hsieh, MD, PhD, Department of Ophthalmology, National Taiwan University Hospital, 7 Zhongshan S. Road, Zhongzheng District, Taipei, Taiwan 10002; email: ythyth@gmail.com.

Received: August 19, 2018
Accepted: November 06, 2018

10.3928/23258160-20190605-16

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