Eccentric Macular Hole after Pars Plana Vitrectomy for Idiopathic Macular Hole: A Case Report

Time course of eccentric macular hole formation after pars plana vitrectomy for epiretinal membrane detected by optical coherence tomography

Purpose

This case report aims to describe the detailed time course of eccentric macular hole (MH) formation following pars plana vitrectomy (PPV) for epiretinal membrane (ERM) treatment, using optical coherence tomography (OCT) images.

Observations

A 60-year-old male patient presented to our hospital with complaints of blurred vision and distortion in his left eye. He was diagnosed with an ERM in the affected eye and subsequently underwent PPV with internal limiting membrane peeling. The patient's initial postoperative course was unremarkable; however, one month later, macular edema worsened, as evidenced by OCT findings. Initially, the edema was observed in both nasal and temporal to the fovea. However, four months postoperatively, the retina fluid in the area nasal to the fovea resolved, and the resolution was delayed in the area temporal to the fovea. At 18 months postoperatively, an eccentric macular hole was detected in the temporal to the fovea. The patient remained asymptomatic, and at the two-year follow-up, the eccentric macular hole demonstrated no signs of enlargement.

Conclusions and Importance

This case demonstrates the progression of an unusual asymptomatic parafoveal full-thickness retinal hole after PPV for ERM treatment. Since the development of this condition may occur over a more extended postoperative period than previously reported, long-term patient monitoring is essential following ERM or MH surgery.

Development of an Eccentric Macular Hole Followed by Reopening of the Original Macular Hole as a Long-term Sequelae of Internal Limiting Membrane Peeling and Focal Laser Photocoagulation: A Case Report

A macular hole (MH) is a widely known disease among ophthalmologists. Vitrectomy with internal limiting membrane (ILM) peeling is a standard technique for full-thickness MHs. However, the recurrence of MHs is sometimes seen. In addition, an eccentric MH is known to rarely occur after vitrectomy. An eccentric MH has been considered to require no therapeutic intervention because of its lack of increase in size. This study reports a case of two MHs (a recurrent MH and an enlarged eccentric MH) developed after laser photocoagulation around the injured retina caused by ILM peeling at the initial surgery. A 56-year-old woman presented with an idiopathic MH in her left eye and best-corrected visual acuity (BCVA) was decreased to 20/80. She underwent phacoemulsification and vitrectomy combined with posterior hyaloid removal, ILM peeling, and 20% sulfur hexafluoride gas tamponade.  During the ILM peeling, we performed laser photocoagulation around the injured retina within the arcade. The MH was successfully closed and her BCVA was improved to 20/20 one month after surgery. Eight months after surgery, an eccentric MH occurred next to the photocoagulation spots. However, her BCVA remained 20/20; thus, we just followed up on her eye. Six years after surgery, her BCVA was decreased to 20/200. The eccentric MH increased in size and the original MH re-opened. The second vitrectomy was performed, but ILM had been already peeled within the arcade during the previous surgery and a usable sufficient size of ILM which could be auto-transplanted to the holes was not obtained. Thus, free flaps of the posterior lens capsule were harvested and placed within each hole. Two holes were successfully closed and her BCVA improved to 10/20 at three months after the surgery. Laser photocoagulation around the injured retina derived from ILM peeling may be a risk for recurrent MHs. .

Multiple extrafoveal macular holes following internal limiting membrane peeling

Objective

Internal limiting membrane (ILM) peeling has been the standard of treatment for macular holes. Besides, causing retinal nerve fiber layer surface abnormality, postoperative extrafoveal multiple retinal holes is a rare phenomenon following ILM peeling. We report an unusual complication of eight extrafoveal macular holes occurring following ILM peeling.

Case presentation

A 60-year-old male presented with complaints of decreased and distorted vision in the right eye. He was diagnosed as having epiretinal membrane with lamellar macular hole. He underwent 23G pars plana vitrectomy, brilliant blue assisted ILM peeling and fluid gas exchange. Intraoperatively, ILM was found to be adherent to the underlying neurosensory retina. One month after cataract surgery, he underwent YAG capsulotomy in the right eye. He complained of visual distortion. His fundus evaluation in the right eye showed multiple (eight) extrafoveal retinal holes temporal to the macula clustered together.

Conclusion

This case demonstrated that peeling of ILM, especially when it is adherent to the underlying neurosensory retina, may cause unwanted mechanical trauma to the inner retina. Glial apoptosis and neuronal degeneration may presumably play a role in delayed appearance of multiple (eight) extrafoveal macular holes, which has not been reported earlier.

Eccentric Macular Hole after Pars Plana Vitrectomy for Epiretinal Membrane Without Internal Limiting Membrane Peeling: A Case Report

Introduction

Postoperative eccentric macular hole formation is an uncommon complication after pars plana vitrectomy (PPV) without internal limiting membrane (ILM) peeling for the treatment of epiretinal membrane (ERM). We present a case of eccentric macular hole formation after PPV for ERM without ILM peeling.

Case report

A 68-year-old male patient presented with ERM and visual acuity of 6/24 in his left eye. He underwent 23-gauge PPV without ILM peeling for treatment of ERM. One week postoperatively the retina was attached and the epiretinal membrane was successfully removed, while visual acuity was 6/9. One month after PPV, a single eccentric retinal hole below the macula was detected using fundoscopy and subsequently confirmed by optical coherence tomography. At this time the visual acuity was 6/9 and the patient reported no symptoms. No further intervention was attempted and at the 9-month follow-up, the visual acuity and the size of the eccentric macular hole remained stable.

Conclusion

Eccentric macular holes can be developed after PPV even without ILM peeling and are usually managed conservatively by observation.