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Repair of Impending Macular Hole in the Early Postoperative Period as Evaluated by Optical Coherence Tomography
Arch Ophthalmol. 2002;120:398-400.
High-resolution cross-sectional imaging provided by optical coherence
tomography (OCT) facilitates assessment of the postoperative as well as preoperative
vitreoretinal state of idiopathic macular holes. Although the hole is considered
to be closed in the first few postoperative days by studies using gas or silicone
oil tamponade,1-2 the detailed
postoperative change in the fovea in the early postoperative period is unknown
because of the poor quality of the image due to the use of gas or silicone
oil. Impending macular hole may resolve either from spontaneous vitreous detachment
or with vitrectomy with separation of the vitreous cortex from the retina.
Herein we describe 2 patients with impending macular hole who underwent vitrectomy
without gas tamponade and from whom we were able to obtain a series of good-quality
OCT images from before and after surgery, and discuss the repair process of
impending macular hole.
Report of Cases
Case 1
A 65-year-old woman had a 1-week history of blurred vision in the left
eye, with best-corrected visual acuity of 20/60. Contact lens biomicroscopy
disclosed foveal changes typical of idiopathic impending macular hole, with
a loss of foveal depression and a yellow ring in the fovea. No posterior vitreous
detachment was identified on biomicroscopy. Horizontal and vertical cross-sectional
images provided by OCT revealed loss of the foveal pit associated with a bridgelike
inner retina and hyporeflective cystic formation apparently due to disruption
of the outer retinal layer extending to the retinal pigment epithelium. The
posterior hyaloid was adherent to the foveal center with perifoveal posterior
hyaloid separation (Figure 1). The
fellow eye was normal on biomicroscopy and OCT.
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Case 1. Preoperative and postoperative optical coherence tomographic
(OCT) images of a 65-year-old woman with impending macular hole. Preoperative
OCT shows intrafoveal cyst with disruption of the outer retinal layer and
a partially detached posterior hyaloid adherent to the roof of the cyst. On
the first postoperative day, both a horizontal and a vertical OCT section
showed the roof of the cyst slightly depressed, increasing its thickness.
During subsequent days, the foveal depression recovered with reapproximation
of the edge of the disrupted outer retinal layer. One week postoperatively,
a small residual clear space was identified in the fovea. One month after
surgery, the image shows normal foveal configuration.
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Case 2
A 75-year-old woman noted distorted vision in the left eye 2 weeks before
being examined. Her best-corrected visual acuity in this eye was 20/60 due
to impending macular hole, the biomicroscopic and OCT findings of which were
similar to those in case 1. The fellow eye had developed a full-thickness
macular hole (stage 3) and had undergone successful vitrectomy and gas tamponade
with hole closure 10 months previously.
Results
The 2 patients were informed of the known natural course of idiopathic
impending macular hole and its surgical intervention. Each patient consented
to vitrectomy with careful peeling of the posterior hyaloid from the center
of the fovea. The postoperative course was uncomplicated, and the ocular media
remained clear enough to allow a series of sequential OCT evaluations as early
as the first postoperative day. Figure 1
shows preoperative and postoperative cross-sectional OCT images through the
fovea in case 1, demonstrating a restoration of foveal configuration. On the
first postoperative day, a pronounced decrease of cystic spaces was found
with early depression of the central fovea with disappearance of vitreous
adhesion to the fovea. Subsequent daily OCT evaluations revealed a further
recovery of foveal contour in such a manner that the inner retina appeared
slightly thickened and depressed while the underlying cysts regressed and
appeared to be replaced by outer retinal tissue. By 1 to 2 weeks after surgery,
the fovea had a distinct pit with minimal optical clear space under it. The
foveal configuration appeared normal 1 month after surgery and remained unchanged
when examined at 6-month follow-up. Case 2 also had a foveal restoration with
a similar time course. In concert with the anatomical recovery, best-corrected
visual acuity in both patients improved to 20/40 at 1 week after surgery and
to 20/25 at 6 months.
Comment
The preoperative OCT images of these cases are consistent with impending
macular hole characterized by an intrafoveal cyst that has raised the foveal
floor and disrupted the outer retina probably due to perifoveal posterior
vitreous detachment with residual adhesion to the fovea. The natural course
of impending macular hole is variable among patients, but surgical intervention
may be beneficial to prevent a possible progression to full-thickness macular
hole. The patients described herein underwent successful vitrectomy with peeling
of the posterior hyaloid without gas injection. With no gas in the eyes, it
was possible to obtain good-quality OCT images in the early postoperative
period. The findings indicate that impending macular hole begins to resolve
as early as the first postoperative day and that an anatomical restoration
of the fovea is achieved by about 1 month after surgery.
Recently the natural history of an impending macular hole has been clarified
using OCT.3 According to that report, foveal
pseudocysts are the first step in full-thickness macular hole formation, which
is the result of incomplete vitreous detachment in the perifoveal area. After
the occurrence of a split in the foveal tissue, the outer retinal layer is
disrupted in some eyes, and the unroofing of a foveal pseudocyst results in
the full-thickness macular hole. Disruption of the outer retinal layer is
thought to occur because of the particular anatomy of the central foveal Müller
cells.3-4
The OCT images described herein provide additional information for understanding
the repair process of idiopathic macular holes. We found 2 anatomical changes
occurring in the fovea. First, the roof of the cyst gradually increased in
thickness and its separation from the underlying layer diminished (vertical
change). The second was reapproximation of the edge of the disrupted outer
retinal layers (horizontal change). We measured the thickness of the roof
and vertical and horizontal diameter of the cyst in case 1 to see how the
fovea changes. The thickness of the roof before the surgery and at postoperative
days 1 and 4 measured 60 µm, 88 µm, and 108 µm, respectively.
The horizontal diameter of the cyst measured 250 µm, 240 µm, and
180 µm, respectively. These facts indicate that disrupted outer retinal
layers begin to reapproach as well as the gradual depression of the roof of
the cyst, increasing its thickness following the release of vitreous traction.
In conclusion, detailed observations of impending macular hole after
pars plana vitrectomy using OCT have revealed 2 factors: depression of the
inner part of the cyst with an increase in thickness and reapproximation of
the disrupted outer retinal layer. These changes are associated with resolution
of the impending macular hole.
AUTHOR INFORMATION
The authors have no proprietary interests in any of the materials used
in this study.
Akinori Uemura, MD;
Eisuke Uchino, MD;
Norihito Doi, MD;
Norio Ohba, MD
Kagoshima-shi, Japan
Corresponding author: Akinori Uemura, MD, Department of Ophthalmology,
Kagoshima City Hospital, 20-17 Kajiya-cho, Kagoshima-shi 892-8580, Japan (e-mail: akiu{at}ml.kch.kagoshima.kagoshima.jp).
REFERENCES
1. Jumper JM, Gallemore RP, McCuen BW, Toth CA. Features of macular hole closure in the early postoperative period
using optical coherence tomography. Retina. 2000;20:232-237.
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2. Kasuga Y, Arai J, Akimoto N, Yoshimura N. Optical coherence tomography to confirm early closure of macular hole. Am J Ophthalmol. 2000;130:675-676.
PUBMED
3. Haouchine B, Massin P, Gaudric A. Foveal pseudocyst as the first step in macular hole formation: a prospective
study by optical coherence tomography. Ophthalmology. 2001;108:15-22.
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4. Spaide RF. Closure of an outer lamellar macular hole by vitrectomy: hypothesis
for one mechanism of macular hole formation. Retina. 2000;20:587-590.
PUBMED
SECTION EDITOR: W. RICHARD GREEN, MD
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ABSTRACT
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