Bilateral macular hole secondary to remote lightning strike

We report a case of a 16-year-old girl, who was struck by lightning, and experienced blurred vision in the right eye (RE) immediately following the episode. She reported for ophthalmic evaluation two months later. Examination revealed relative afferent pupillary defect in the RE. Posterior subcapsular cataract was noted in both eyes. Fundus examination revealed macular holes and multiple areas of RPE hyperpigmentation in the periphery in both eyes. Fundus fluorescein angiography showed increased choroidal transmission with early fluorescence and late fading in the foveal region and retinal pigment epithelium (RPE) stippling in the periphery in both eyes. This is the first case report of such nature in India to the best of our knowledge.     

Vitreous surgery combined with internal limiting membrane peeling for traumatic macular hole with severe retinal folds

PURPOSE: To report a case of a traumatic macular hole with severe retinal folds in which vitreous surgery combined with internal limiting membrane (ILM) peeling was beneficial. To demonstrate that the area from which the ILM was peeled can be clearly differentiated by scanning laser ophthalmoscopy. METHODS: A posterior hyaloid detachment was created during vitreous surgery on a 34 year old man with a traumatic macular hole. The remaining vitreous was resected and the ILM was peeled. The fundus was examined through a scanning laser ophthalmoscope before and after the surgery. RESULTS: The retinal folds disappeared concurrently with the detachment of the ILM, resulting in closure of the macular hole. The area from which the ILM was peeled was clearly observed through the scanning laser ophthalmoscope. CONCLUSION: In this patient, it was helpful to perform not only posterior hyaloid detachment but also ILM peeling. The scanning laser ophthalmoscope was highly useful for observing the area from which the ILM was peeled.     

Complications of macular hole surgery

Macular hole is a serious vision-threatening disease for which, until the early 1990s, no effective treatment was available. However, with advanced techniques in microsurgical vitrectomy surgery, effective and successful closure of macular holes now can be obtained. Many complications can occur after any ocular surgery. Some of the specific complications associated with macular hole surgery are RPE alterations, retinal detachments, CME, subretinal neovascular membrane, endophthalmitis, hypopyon, late re-opening of macular holes, increased intraocular pressure, visual field defects, and cataract formation. Because macular hole surgery is a relatively recent operation devised in the last 8 years, data on complications still are being compiled and studied to understand and minimize the rates of complications after such surgery. We hope that, in the future, the rate of complications after macular hole surgery will be no higher than that for any other ophthalmic procedure.     

Vitrectomy and internal limiting membrane peeling of a traumatic macular hole with retinal folds

An 8-year-old active boy suffered a penetrating injury to his right eye. A temporal retinal perforation with an adherent blood clot about 4-disc diameter from the fovea was noted. Six weeks after the initial primary repair, a macular hole (MH) and retinal folds radiating from the penetrating site of the retina were found. Two months after the injury, the patient underwent a standard pars plana vitrectomy. Intraoperatively, the retinal folds still existed after creating a posterior hyaloid detachment and disappeared concurrently within the area of the internal limiting membrane peeling. Occlusion therapy was carried out after absorption of the intraocular gas. One year after the vitrectomy surgery, the MH remained closed with a visual acuity improving from 20/60 to 20/25 in his right eye. Our results suggest that vitrectomy with internal limiting membrane peeling and sequential occlusion therapy can achieve both anatomical and functional improvement in a child suffering a penetrating injury with a MH and retinal folds.     

Macular hole size as a prognostic factor in macular hole surgery

BACKGROUND/AIM: In 1991 there was a series of successful closures of a macular hole after vitrectomy and membrane peeling. Today this technique has become a standard procedure. The aim of this study was to evaluate the role of optical coherence tomography in diagnosing and staging, as well as in predicting, the functional and anatomical outcome after macular hole surgery. METHOD: In a prospective study 94 consecutive patients (20 male, 74 female) with a mean age of 67.6 (SD 6.0) years and a macular hole stage II (n = 8), III (n = 72), and IV (n = 14) according to the classification by Gass were examined with optical coherence tomography (OCT) before pars plana vitrectomy. Macular hole diameters were determined at the level of the retinal pigment epithelium (base diameter) and at the minimal extent of the hole (minimum diameter). Calculated hole form factor (HFF) was correlated with the postoperative anatomical success rate and best corrected visual acuity. The duration of symptoms was correlated with base and minimum diameter of the macular hole. RESULTS: In eyes without anatomical closure of the macular hole after one surgical approach (13/94) the base diameter (p1) and the minimum diameter (p2) were significantly larger than in cases with immediate postsurgical closure (p1 = 0.003; p2 = 0.028). There was a significant negative correlation between both the base and the minimum diameter of the hole and the postoperative visual function (p1 = 0.016; p2 = 0.002). In all patients with HFF >0.9 the macular hole was closed following one surgical procedure, whereas in eyes with HFF <0.5 anatomical success rate was 67%. Better postoperative visual outcome correlated with higher HFF (p = 0.050). There was no significant correlation between the duration of symptoms and base or minimum diameters (p1 = 0.053; p2 = 0.164), respectively. CONCLUSION: Preoperative measurement of macular hole size with OCT can provide a prognostic factor for postoperative visual outcome and anatomical success rate of macular hole surgery. The duration of symptoms did not correlate with the diameters measured. Base and minimum diameters especially seem to be of predictive value in macular hole surgery.     

A traumatic macular hole secondary to a high-energy Nd:YAG laser

A case is reported of a traumatic macular hole caused by a high-energy Nd:YAG laser. The initial ocular examination revealed an explosive, crater-shaped, full-thickness macular hole surrounded by local edema and detachment. By the 12th day after the injury, the hole had shrunk progressively and was covered by a thin fibrin-like membrane. A thick epiretinal membrane covered the injured area 1 month after the injury. Nine months after the injury, the macular hole closed spontaneously with a partially detached epiretinal membrane. This case demonstrates one of the natural healing processes of a traumatic macular hole. Although the hole finally closed, the patient did not regain his vision because of the severe damage to the photoreceptors, retinal pigment epithelium, and choroid.     

Posturing after macular hole surgery: a review

Since the first reports on surgical repair of macular holes, postoperative face-down posturing (FDP) has been part of the management regime. However, prone positioning is unpleasant for patients, and has adverse effects. Over the last decade some vitreoretinal surgeons have reduced the duration of FDP, or even abandoned it altogether. There have been few non-randomised, and even fewer randomised trials addressing this controversy. With high success rates for macular hole surgery and multiple different surgical strategies such as internal limiting membrane peeling, combining macular hole and cataract surgery, and different durations of gas tamponade, analysing the effects of individual factors is difficult. This paper discusses the mechanisms of surgical repair as well as the role of postoperative FDP, and reviews the studies that have attempted to determine its effect on the success of macular hole surgery.     

Stereo acuity in patients with unilateral macular hole and after unilateral macular hole surgery

PURPOSE: To investigate stereo acuity levels in patients with unilateral idiopathic macular hole and after surgical intervention. METHODS: In 31 consecutive patients with a unilateral macular hole and 46 consecutive patients who underwent successful unilateral macular hole surgery, complete ocular examinations, including orthoptic examinations and microperimetry using the scanning laser ophthalmoscope, were performed. RESULTS: A significantly positive correlation was found between VA and stereo acuity (r = 0.87, P < 0.01). After successful surgery, stereo acuity also correlated with the presence or absence of absolute and/or relative scotoma, and was best in eyes without scotomata. Patients with unilateral idiopathic macular hole, suppression, and symptom duration of 24 months or longer had no stereoscopic vision. CONCLUSIONS: The results indicated that in patients with unilateral idiopathic macular hole and after surgery, stereo acuity correlated with VA. Patients with unilateral macular hole should be operated upon as early as possible, resulting in better VA and better stereo acuity.     

Tomographic features of a lamellar macular hole formation and a lamellar hole that progressed to a full-thickness macular hole

PURPOSE: To report optical coherence tomography of a lamellar macular hole and a lamellar macular hole that progressed to a full-thickness macular hole. METHODS: Case Reports. RESULTS: Case 1. In the right eye of a 66-year old man, a lenticular-shaped split was present in the inner neurosensory retina corresponding to the fovea. Three months later, an operculum formed anterior to the fovea where the retina was attenuated. Case 2. In the left eye of a 58-year old woman, a foveal cyst was seen in the inner neurosensory retina and the inner wall of the cyst was elevated, where a slightly detached posterior vitreous cortex was attached. One month later, the inner wall was operculated, leaving a thin foveal bottom. Four months later, the hole progressed to a full-thickness macular hole. CONCLUSION: Lamellar macular hole appears to form when the inner wall of a split or cyst in the neurosensory retina at the fovea is avulsed by vitreous traction.