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ARCH SOC ESP OFTALMOL 2008; 83: 325-327
SHORT COMMUNICATION
SPONTANEOUS CLOSURE OF FULL THICKNESS
TRAUMATIC MACULAR HOLES
CIERRE ESPONTÁNEO DE AGUJEROS MACULARES
TRAUMÁTICOS DE ESPESOR COMPLETO
BOSCH-VALERO J1, MATEO J1, LAVILLA-GARCÍA L1, NÚÑEZ-BENITO E1,
CRISTÓBAL JA2
ABSTRACT
RESUMEN
Case report: We present case reports of two young
patients suffering from full thickness traumatic
macular holes resulting in visual impairment of
more than 60%. Both showed anatomical and visual
improvement whilst waiting for surgical treatment.
Discussion: Spontaneous closure of a traumatic
macular hole is an unusual outcome. OCT and clinical follow up enabled monitoring of this resolution during a period of a few weeks. Complex surgery was thus avoided by a short observational
period (Arch Soc Esp Oftalmol 2008; 83: 325-327).
Caso clínico: Se presentan dos casos de pacientes
jóvenes que sufrieron sendos agujeros maculares
traumáticos de espesor completo con deterioro
visual de más de un 60%. Ambos mejoraron clínica
y anatómicamente mientras esperaban un tratamiento quirúrgico.
Discusión: El cierre espontáneo de agujeros maculares traumáticos es un hallazgo infrecuente. El
seguimiento clínico y mediante OCT permite apreciar la mejoría en las primeras semanas. Un período
corto de observación nos puede evitar una intervención quirúrgica compleja y laboriosa.
Key words: Macular hole, optical coherence tomography, retinal edema, retinal perforations, eye injuries.
INTRODUCTION
Ocular contusion traumatisms are associated
with numerous retinal complications such as Berlin
edema, peripheral fractures and retinal dialysis,
vitreal or sub retinal hemorrhages, choroidal ruptures and macular holes.
Received: Jan. 1, 2007. Accepted: April 14, 2008.
Lozano Blesa University Clinical Hospital. Zaragoza. Spain.
1 Graduate in Medicine.
Correspondence:
Jordi Bosch Valero
C/. La Pampa, 17
07003 Menorca (Baleares)
Spain
E-mail: [email protected]
Palabras clave: Agujero macular, tomografía de
coherencia óptica, edema retiniano, perforación
retiniana, lesión ocular.
Despite an increasing knowledge of the mechanisms that induce both the formation and the spontaneous resolution of the traumatic macular holes
(TMA) there is a scarcity of reliable data regarding
the prevalence and chronology of the process of
self-sealing. In the literature there are only short
series: Mizusawa et al highlight a prevalence of
BOSCH-VALERO J, et al.
10%, Tomii et al. of 66.6% and Yamashita et al of
44.4% but with very few samples (10, 6, and 18
patients respectively) (1). The time between diagnosis and anatomical resolution of TMA is also
variable, between 1 week and six months according
to publications.
The cases of two patients with TMA after ocular
concussion are presented, well documented by
means of Optical Coherence Tomography (OCT),
where a spontaneous closure in less than 6 weeks
with a significant visual improvement is produced.
CASE REPORT
Case 1
A 36 year old male who came to our service in
February 2006 six days after having suffered a contusion with a nail in the left eye (LE). He referred
immediate visual deterioration with central scotoma
of the same eye. On examination a visual acuity
(VA) in the RE of 0.4 was observed. By means of
the Amsler’s girdle a central alteration and metamorphosis in the RE was detected. With the biomicroscope a moderate iritis and in the back of the
eye, inferior hemovitreous, peripapillary hemorrhage and a full thickness macular hole could be seen
Fig. 2: OCT in which a full thickness macular hole is
observed.
(fig. 1). The Watkze-Allen Test was positive. The
OCT confirmed the presence of a macular hole of
complete thickness (fig. 2) in the RE and surgery
was programmed (pars plana vitrectomy and the
extraction of internal limiting membrane) and the
treatment was with oral Prednisone at doses of 1
mg/kg/day in a descending guideline, along with
gastric protection. The day before surgery (35 days
after the traumatism) the patient was examined
again and an evident improvement of the visual
acuity of the RE was seen and a complete closure of
the lesion demonstrated by OCT (fig. 3).
Case 2
A 16 year old male that came to our ophthalmology service in April 2006 due to loss of visual
acuity and central scotoma after ocular impact in
LE with a football. The VA was finger counting at
2m in LE and of 1 in the contralateral eye. On examination of the eye fundus a Berlin’s edema of
suprafoveal predominance and image of full macular hole was detected (fig. 4) and later confirmed by
the OCT (fig. 5).The Amsler girdle and the WatzkeAllen test gave coherent results. The treatment was
Fig. 1: Retinography with green filter in which the
suprapapillar hemorrhage and the traumatic macular
hole can be seen.
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Fig. 3: OCT of the same patient 42 days later showing
the complete resolution of the lesion.
ARCH SOC ESP OFTALMOL 2008; 83: 325-327
Spontaneous closure of traumatic macular holes
Fig. 6: OCT of patient #2, 20 days later, where complete resolution is seen.
Fig. 4: Posterior pole edema and traumatic macular
hole of patient # 2.
identical to the case previously described. Two
weeks later the patient came for a check-up and an
improvement of LE was seen, with visual acuity of
0.3 and self-sealing of the lesion shown by OCT
(fig. 6).
DISCUSSION
The cases of self-sealing TMA published to date
agree on two points: firstly all the patients are younger than 20 years and, secondly in all the cases the
lesion is a consequence of a contuse traumatism.
One of our patients was a lot older at 36 years.
The deterioration of visual acuity can be both
immediate and delayed for which Yamashita proposed two formation mechanisms: the dehiscence of
the immediate fovea to the traumatism, and the persistence of a vitreous traction that originates the
macular hole days later (1). In our two patients the
Fig. 5: Full macular hole with thinning of the edges and
subretinal liquid.
clinical diagnosis was immediate and no vitreous
tractions were observed in the OCT.
The time elapsed from the traumatism to the
spontaneous closure is variable according to different publications. The case published by Yeshurun
et al. lasted 5 months (2), the three of Kusaka et al.
between 3 and 4 months (3), those of Yamada et al.
between 4 and 6 (4). In 2002, Yamashita et al. presented eight cases that took between 1 week and 4
months to close, citing Mizusawa (9 months), Tomii
(14 days to 5 months), Nunode (15 days), Murakami (3 months) and Parmar (2 months) (1). In 2006,
Lai et al. published the case of TMA with secondary retina detatchment that took three weeks to
self-seal (5).
In our two cases the closure was early (42 and 20
days respectively) while surgery was being considered. Despite the good results obtained by present
surgical techniques, we consider it important to
wait some weeks before indicating surgery in
young patients with traumatic MA because of the
possibility of spontaneous closure in this subgroup
of patients.
REFERENCES
1. Yamashita T, Uemara A, Uchino E, Doi N, Ohba N. Spontaneous closure of traumatic macular hole. Am J Ophthalmol 2002; 133: 230-235.
2. Yeshurun I, Guerrero-Naranjo JL, Quiroz-Mercado H.
Spontaneous closure of a large traumatic macular hole in
a young patient. Am J Ophthalmol 2002; 134: 602-603.
3. Kusaka S, Fujikado T, Ikeda T, Tano Y. Spontaneous
disappearance of traumatic macular holes in young
pacients. Am J Ophthalmol 1997; 123: 837-839.
4. Yamada H, Sakai A, Yamada E, Nishimura T, Matsumura
M. Spontaneous closure of traumatic macular hole. Am J
Ophthalmol 2002; 134: 340-347.
5. Lai MM, Joshi MM, Trese MT. Spontaneous resolution of
traumatic macular hole-related retinal detachment. Am J
Ophthalmol 2006; 141: 1148-1151.
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