Spontaneous resolution of a full thickness idiopathic macular hole: fundus autofluorescence and OCT imaging

Case Report: Spontaneous Closure of Idiopathic Full-thickness Macular Hole and Early Development of Lamellar Hole

SIGNIFICANCE

Spontaneous closure of an idiopathic full-thickness macular hole (FTMH) is a rare event. The underlying mechanisms are unclear because of the difficulty in detecting subtle structural changes even with serial imaging. Previous reports are largely optical coherence tomography (OCT) based, but multimodal imaging could highlight new information.

PURPOSE

This study aimed to report the spontaneous closure of an idiopathic FTMH (iFTMH) and its recurrence and late closure documented by serial OCT integrated with multimodal imaging modalities and microperimetry (MP).

CASE REPORT

A healthy 46-year-old man was referred to the Department of Ophthalmology of the University of Padova for an iFTMH in the right eye with preserved visual acuity. The patient was scheduled for monthly controls up to 12 months by an integrated assessment of OCT, angiography-OCT, short-wavelength fundus autofluorescence, and MP. Two months later, tracked OCT scans showed a closure of the hole with a residual lamellar macular hole. Sequential examinations revealed a discontinuation of photoreceptors (ellipsoid zone) and a recurrence of iFTMH, and 7 months later, iFTMH reclosed without any relevant changes up to 12 months. Foveal avascular zone area increased from the baseline reaching its maximum value when iFTMH recurred. Two hyper-fundus autofluorescence points were detected in the foveal area, one progressively decreased and one reached the most intense signal when iFTMH recurred. Retinal sensitivity decreased mostly in one hyper-fundus autofluorescence point when the ellipsoid zone line discontinued and reached the lowest value when iFTMH recurred, and increased mostly in the other points when iFTMH reclosed.

CONCLUSIONS

Spontaneous iFTMH closure, as well as its recurrence and reclosure, is a rare event. By monitoring with multiple imaging modalities, MP and their overlaying elaboration can add new biomarkers with diagnostic and prognostic value.

Non-Invasive Retinal Imaging Modalities for the Identification of Prognostic Factors in Vitreoretinal Surgery for Full-Thickness Macular Holes

In this review, we will focus on different non-invasive retinal imaging techniques that can be used to evaluate morphological and functional features in full-thickness macular holes with a prognostic purpose. Technological innovations and developments in recent years have increased the knowledge of vitreoretinal interface pathologies by identifying potential biomarkers useful for surgical outcomes prediction. Despite a successful surgery of full-thickness macular holes, the visual outcomes are often puzzling, so the study and the identification of prognostic factors is a current topic of interest. Our review aims to provide an overview of the current knowledge on prognostic biomarkers identified in full-thickness macular holes by means of different retinal imaging tools, such as optical coherence tomography, optical coherence tomography angiography, microperimetry, fundus autofluorescence, and adaptive optics.

Spontaneous Closure of an Idiopathic Full-Thickness Macular Hole: A Literature Review

Purpose:

This work reviews the literature regarding spontaneous closure of idiopathic full-thickness macular holes (FTMHs).

Methods:

Literature on patients with spontaneous idiopathic FTMH closure was reviewed via Ovid MEDLINE, EMBASE, and PubMed through July 16, 2020. A total of 27 of 66 identified articles were included.

Results:

A total of 68 eyes had spontaneous closure. Of the patients, 62.7% were women and the average age was 67.5 years. Visual acuity improved from Snellen 20/78 to 20/33 post closure. The average hole diameter was 176.8 μm; the largest was 350 μm. Most were stage 2 according to Gass and of small size according to International Vitreomacular Traction Study Group (IVTS) staging. The predominant classification system in recent literature is IVTS staging. The average optical coherence tomography–observed closure time was 4.5 months.

Conclusions:

On review, reported spontaneous closure rates of all idiopathic FTMH range from 3% to 15%, and no demographic subgroups are more likely to have closure. Holes ≤250 µm have higher closure rates (22.2%) than those in the range of >250 to 400 µm (13.3%) and ≥400 µm (0%). Closure is associated with favorable visual outcomes, and retinal bridging via glial cells is likely critical to closure. These determinations were based on limited numbers; prospective studies are needed to further ascertain rate, mechanism, and characteristics. IVTS staging provides reliable reporting and insight into whether FTMH can be observed before surgery.

Spontaneous closure of bilateral macular holes

Purpose

To present a case of a right eye spontaneous closure of a full thickness macular hole (FTMH), followed several years later by a left eye spontaneous closure of a FTMH, in an otherwise healthy woman.

Observations

We show the temporal changes and spontaneous resolution observed with Spectral-Domain Ocular Coherence Tomography (SD-OCT) of a FTMH in the right eye and a FTMH secondary to vitreomacular traction in the left eye of the same patient 5 years later, also with full spontaneous resolution. Following the resolution, SD-OCT demonstrated outer retinal layer disruption recovery and visual acuity improvement in both eyes.

Conclusions and importance

Spontaneous closure of macular holes is an uncommon event, with most descriptions in the literature being of single cases or very small series, including several reports in patients who have undergone vitrectomy for other causes, or in highly myopic eyes. Bilateral spontaneous closure of macular holes in the same patient is an even more uncommon event, described only once in one patient previously in the literature to our knowledge.

Characteristics and Risk Factors for Spontaneous Closure of Idiopathic Full-Thickness Macular Hole

Idiopathic full-thickness macular hole is a severe visual impairment disease. Pars plana vitrectomy remains the primary treatment option for idiopathic full-thickness macular holes, and over 90% idiopathic full-thickness macular holes are closed by vitrectomy surgery. However, the full-thickness macular hole may close spontaneously, with a good visual acuity progress. Since recent studies are small-sample studies and case reports, the characteristics for spontaneous closure of idiopathic full-thickness macular holes are not fully understood. Here, we review the articles in PubMed database from 1999 to 2018 and discuss the characteristic and the risk factors, especially OCT structure features, for spontaneous closure of idiopathic full-thickness macular holes.

Correlation between Postoperative Area of High Autofluorescence in Macula and Visual Acuity after Macular Hole Closure

PURPOSE

To determine the correlation between the preoperative basal diameter of macular hole, the postoperative area of high autofluorescence (AF) in macula, and visual acuity in full-thickness macular hole.

METHODS

Forty-nine patients with full-thickness macular hole who underwent vitrectomy and C₃F₈ filling were reviewed. The preoperative diameter of macular hole, the 6 months postoperative area of high AF in macula if it existed, the length of inner segment/outer segment (IS/OS) defect, and visual acuity were obtained. The correlation between them was determined.

RESULTS

At postoperative 6 months, the rate of high AF in macula was 63.3%. There were statistical differences between with and without high AF groups in postoperative best-corrected visual acuity (BCVA) (t = -2.751, p = 0.008), preoperative basal diameter of macular hole (t = -4.946, p = 0.00001), and postoperative length of IS/OS defect (t = -8.351, p<0.00001). Simple linear regression analysis showed high positive correlations between preoperative basal diameter of macular hole and area of high AF (p<0.00001, r = 0.893), postoperative length of IS/OS defect and area of high fundus AF (FAF) (p<0.00001, r = 0.779), and negative correlations between area of high AF and postoperative BCVA (p = 0.037, r = 0.375). There was low correlation between diameter of macular hole and postoperative BCVA (p = 0.112).

CONCLUSIONS

The preoperative basal diameter of macular hole and postoperative length of IS/OS defect decides the postoperative area of high AF in macula to some degree, and the postoperative area of high AF in macula can be an evaluating indicator for poor macular function recovery.

Late Closure of a Stage III Idiopathic Macular Hole after Pars Plana Vitrectomy

A 57-year-old female presented to our hospital with decreased vision in her right eye. Detailed ocular examination was performed, and a macular hole was detected in the right eye. The presence of a full-thickness stage III macular hole was confirmed with optical coherence tomography (OCT) imaging. Pars plana vitrectomy followed by long-acting gas tamponade (C3F8) was performed as treatment. One month after surgery, clinical examination revealed a persistent macular hole, confirmed by an OCT scan. Although the patient was scheduled for reoperation, the surgery was postponed due to personal reasons of the patient. Surprisingly, after five months, a closure pattern with accompanying epiretinal membrane was observed in the macular hole area. The closure of the macular hole was completed without any further intervention 8 months post-surgery. In cases of unclosed macular hole after the first surgery, if a second surgery cannot be performed, follow-up with OCT recommended due to the possibility of spontaneous closure. However, spontaneous closure of a persistent macular hole following PPV is rare, so early diagnosis and surgical repair of unclosed macular holes must remain the primary goal.

Spontaneous closure of stage IV idiopathic full-thickness macular hole and late reopening as a lamellar macular hole: a case report

Introduction

Spontaneous closure of traumatic macular holes is described as a common event in the peer-reviewed literature. However, the spontaneous closure of stage III and IV full-thickness idiopathic macular holes has been reported in less than 15 cases in the literature, this being an extremely rare event, with their reopening being even more infrequent. We report a case of a spontaneous closure of stage IV idiopathic full-thickness macular hole and late reopening as a lamellar macular hole.

Case presentation

A 67-year-old Spanish man was referred to our hospital with a complaint of decreased vision in his right eye and metamorphopsia for approximately 11 months. He did not report any trauma. Diagnosis was based on fundoscopic and optical coherence tomography. They revealed a stage IV full-thickness idiopathic macular hole and a small epiretinal membrane. Three months later the hole spontaneously closed, and two years later we appreciated its reopening as a lamellar macular hole.

Conclusions

The contraction of the epiretinal membrane could have contributed to cystic spaces and their fusion, subsequently, to the formation of a lamellar macular hole. To the best of our knowledge this is the first report in the literature of a spontaneously closed full-thickness idiopathic macular hole with reopening as a partial thickness macular defect.

Correlation of microperimetry with fundus autofluorescence and spectral-domain optical coherence tomography in repaired macular holes

PURPOSE

To investigate the correlation of microperimetry with fundus autofluorescence (FAF), spectral-domain optical coherence tomography (SD-OCT), and visual acuity (VA) in order to better characterize visual outcomes after successful macular hole (MH) surgery.

DESIGN

Cross-sectional case series.

METHODS

Postoperative VA, microperimetry, FAF, and SD-OCT images from 23 eyes of 23 patients who underwent successful MH surgery were obtained. FAF images were examined using the Heidelberg retina angiograph 2, and foveal structure and macular sensitivity were evaluated with SD-OCT and microperimetry. The mean retinal sensitivities within the central 9 degrees (microperimetry, mean), the retinal sensitivity of the foveal center (microperimetry, center), and the difference between the values obtained for the foveal center or mean of study and fellow eyes (microperimetry, centerdiff and microperimetry, meandiff, respectively) were measured with microperimetry.

RESULTS

Microperimetry (mean) was well correlated with microperimetry (center) in both study and fellow eyes. Poor postoperative VA was correlated with large microperimetry (meandiff). Following successful MH surgery, FAF of all eyes decreased markedly. There was a positive correlation between microperimetry (centerdiff) and degree of FAF of study eyes. However, a decrease in FAF after MH surgery was not correlated well with either degree of defect in the junction between photoreceptor inner and outer segment (IS/OS) or central retinal thickness on SD-OCT.

CONCLUSIONS

The amount of remaining FAF is related to macular sensitivity as measured by microperimetry after successful MH surgery. Function of photoreceptors and retinal pigment epithelium as well as integrity can be estimated by measuring the decrease in FAF after successful MH surgery. Moreover, functional correlation with microperimetry provides both morphologic and functional information on repaired MHs.

Posturing time after macular hole surgery modified by optical coherence tomography images: a pilot study

PURPOSE

To see the early postoperative stage of macular hole (MH) surgery and to distinguish eyes needing prolonged posturing from those that do not use Fourier-domain optical coherence tomography (FD-OCT).

DESIGN

Interventional case series.

METHODS

Sixteen eyes of 15 patients with MH underwent the protocol at Kagoshima University Hospital. After the pars plana vitrectomy with 16% SF(6) gas tamponade followed by posturing, the eyes were examined by FD OCT from 3 hours to the day after surgery. After MH closure was confirmed, posturing was stopped. Follow-up was performed for 4 months or longer. The main outcome measures included time and OCT finding of MH closure after surgery.

RESULTS

On the day after surgery, the macula could be examined by FD-OCT in 13 of 16 eyes; 10 eyes had a closed MH and 3 had an unclosed MH. At day 2, 2 of the 3 eyes with unclosed MHs on day 1 demonstrated a closed MH. Posturing continued for 8 days in 4 eyes whose MH closure was not confirmed. The MH was closed in all eyes within 1 month. FD-OCT showed bridge formation of the neural retina in 9 eyes and simple closure in 3 eyes within 7 days. At 1 month, 12 eyes showed simple closure and 4 eyes showed bridge formation. Among 9 eyes with bridge formation within 7 days, 6 eyes had changed to simple closure at 1 month.

CONCLUSIONS

FD-OCT enabled confirmation of MH closure the day after surgery even in gas-filled eyes. This imaging method may be a good indicator to determine when to stop posturing for each patient.

Spontaneous macular hole closure in bilateral macular holes

The natural course of full thickness macular hole is progression in size and stage. There have been reports of spontaneous closure of unilateral idiopathic full thickness macular holes, but we report the first case of spontaneous closure of a full thickness macular hole in one eye in a patient with bilateral idiopathic full thickness macular holes. After macular hole surgery in the left eye of the patient, spontaneous closure of the macular hole in the right eye was observed during the follow-up period.

Spontaneous closure of stage III and IV idiopathic full-thickness macular holes—a two-case report

BACKGROUND

To document and study the spontaneous closure of stage III and IV idiopathic full-thickness macular holes by using both optical coherence tomography (Stratus OCT) and spectral optical coherence tomography (SOCT).

METHODS

A two-center, two-case, observational study of stage III and IV macular holes is presented. OCT and SOCT were performed.

RESULTS

Macular holes spontaneously resolved after 4 to 12 weeks of observation.

CONCLUSION

The spontaneous closure of large idiopathic full-thickness stage III and IV macular holes is possible. We suggest that, as long as no smooth oval shape of the macular hole edges appears on the cross-sectional OCT and SOCT scans, there is still a chance for its spontaneous closure.