Case Study: The Whole Shebang

Patel Moshfeghi
Presenter: Luv Patel, MD Discussant: Andrew Moshfeghi, MD, MBA
 

History

  • 21-year-old man with no past medical or ocular history was punched on the right side of his face three days prior. He was seen at an outside hospital ER, where a CT scan was performed without evidence of open globe or orbital fracture. Now presenting for ophthalmological follow-up.
  • States he has blurry vision in the right eye.

Exam Findings (POD3)

  • Pupils RR OU; no RAPD
  • Visual Acuity
    • pH 20/400 OD; pH 20/20 OS
  • IOP 19 OD, 19 OS
  • Gross exam notable for periorbital ecchymosis, subconjunctival hemorrhage on the right side
  • Slit lamp exam otherwise unremarkable
  • Right side fundus exam
Figure 1
Figure 1: Right side fundus exam showing disrupted foveal contour, macular hole. Otherwise fundus exam OD unremarkable, exam OS unremarkable

 

Differential Diagnosis

  • Traumatic macular hole

Additional Investigations

  • OCT macula of the right eye
Figure 2
Figure 2: OCT macula of the right eye at level of the fovea showing macular hole with no evidence of posterior vitreous detachment or traction. A cuff of subretinal fluid is present without intraretinal cysts

 

Diagnosis

  • Traumatic macular hole

Pathophysiology

  • A traumatic macular hole (TMH) has a different pathophysiology than an idiopathic macular hole (IMH). IMH is a disease of vitreomacular traction caused by pulling of the vitreous on the inner retina. However, studies have shown that TMH infrequently have vitreous detachments or traction. Instead, TMH are thought to occur from blunt trauma that results in a flattening of the globe in the anterior-posterior direction causing a stretching on the perpendicular plane. This physical stretching from a significant impact force causes a development of a hole in the retina (see Figure 3).
Figure 3
Figure 3: IMH most often occurs in older patients (due to vitreous syneresis and traction). TMH tends to occur in younger male patients, the demographic most likely to undergo blunt facial trauma

 

Treatment

  • There is evidence that some traumatic macular holes can be initially observed and may close spontaneously (see Figure 4).
  • Surgical treatment requires a pars plana vitrectomy and gas tamponade. Prone positioning is required as well.
  • This patient was observed for two months; however spontaneous closure did not occur. He subsequently underwent pars plana vitrectomy, membrane peel, air-fluid exchange and instillation of SF6 gas. At one month follow-up the retinal hole was closed, with best corrected visual acuity of 20/100.
Figure 4
Figure 4: OCT Macula right eye at level of fovea POM1. Macular hole is closed. There is disrupted foveal contour with significant central outer nuclear, ellipsoid zone and RPE loss

 

Prognosis and Future Directions

  • Recent studies have shown that TMH may close spontaneously, which often occurs within the first two to three months; if not, surgical closure is required. Large TMH were less likely to close spontaneously and more often required surgical closure. However, studies have been limited by small sample sizes and do not show statistical significance.

References

  • Huang J et al. Comparison of full-thickness traumatic macular holes and idiopathic macular holes by optical coherence tomography. Graefes Arch Clin Exp Ophthalmol. 2010 Aug;248(8):1071–5.
  • Miller JB et al. Long-term Follow-up and Outcomes in Traumatic Macular Holes. Am J Ophthalmol. 2016 June;166:206–207.
  • Chen H et al. Prediction of spontaneous closure of traumatic macular hole with spectral domain optical coherence tomography. Sci Rep. 2015 Jul 21;5:12343.

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Section Editors

 

Produced by: Monica Chavez, John Daniel, Mellissa Linton and Dr. Vivek Patel