CENTRIFUGAL ENLARGEMENT OF MACULAR HOLE AND MACULAR DETACHMENT IN A PATIENT WITH BILATERAL GIANT MACULAR HOLES Atsushi Takahashi, MD, Taiji Nagaoka, MD, PhD, Hiroyuki Kagokawa, MD, PhD, Satoshi Ishiko, MD, PhD, Akitoshi Yoshida, MD, PhD
Purpose: To report the detailed vitreomacular morphology of a case of progressive enlargement and macular detachment secondary to and several years after the development of bilateral giant macular holes using optical coherence tomography. Methods: Using optical coherence tomography, both eyes of a patient with bilateral giant macular holes were examined. Results: A 33-year-old woman had bilateral giant macular holes at the first visit. At the 5-year follow-up visit, the macular hole had enlarged centrifugally in the right eye, and a macular detachment developed beyond the arcade vessels in the left eye. Optical coherence tomography showed retinoschisis in the right eye around the edges of the hole and a macular detachment in the left eye with vitreoretinal adhesion temporal to both holes. Conclusion: These optical coherence tomography findings suggested that vitreomacular traction at the temporal edge of the hole may have resulted in progressive centrifugal enlargement of the hole in both eyes and then the macular detachment occurred in the left eye. RETINAL CASES & BRIEF REPORTS 5:184–188, 2011
From the Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Japan.
follow-up, we observed progressive enlargement of the macular hole in the right eye and a macular detachment in the left eye. We report the detailed vitreomacular morphology of this case of progressive enlargement and macular detachment secondary to and several years after the development of bilateral giant macular holes using optical coherence tomography (OCT).
C
hew et al reported that the diameters of idiopathic macular holes range from 250 mm to 640 mm, with most holes having diameters ranging from 351 mm to 640 mm even after 6 years of follow-up. Approximately 34% of idiopathic macular holes increase in size over time. However, no macular detachments developed in 122 patients during follow-up.1 We previously reported a patient with bilateral giant macular holes with diameters of 1,800 mm and 1,500 mm in the right and left eyes, respectively.2 After the 5-year
Case Report A 33-year-old woman with bilateral giant macular holes had a bilateral visual acuity of 20/40 with 25.0 diopters of myopia at the first visit in June 2000. She did not have a history of trauma. She had no personal or family history of ocular disease and did not use any medications. Fundus examination showed large bilateral macular holes. The retina partially bridged the hole in the right eye. No posterior vitreous detachment or operculum was found in either eye. Microperimetry images obtained by scanning laser ophthalmoscopy (Rodenstock, Munich, Germany) showed that the fixation points were at the upper edges of the holes in both eyes. Optical coherence tomography showed that the hole edges were swollen in both eyes. The vertical diameters were 1,800 mm and 1,500 mm in the right and left eyes, respectively. No macular
The authors have no proprietary or commercial interest in any materials discussed in this article. The authors have no conflicts of interest or sources of financial support. Reprint requests: Akitoshi Yoshida, MD, PhD, Department of Ophthalmology, Asahikawa Medical College, 2-1-1-1, MidorigaokaHigashi, Asahikawa, Hokkaido 078-8510, Japan; e-mail: pyoshida@ asahikawa-med.ac.jp
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VITREOMACULAR MORPHOLOGY IN BILATERAL GIANT MACULAR HOLES detachment, retinoschisis, staphyloma, or posterior hyaloid membrane were observed bilaterally. Surgery was not recommended because the anatomic success rates are low in cases of large macular holes. Five years after the initial visit, the patient reported acutely decreased visual acuity in the left eye. The best-corrected visual acuity remained 20/50 in the right eye but decreased to 20/400 in the left eye. The macular holes had enlarged in the right eye (Figure 1A). An extensive macular detachment developed beyond the arcade vessels in the left eye (Figure 1B). No posterior vitreous detachment or operculum was found in either eye. Optical coherence tomography 3 (Stratus OCT; Carl Zeiss Meditec, Inc, Dublin, CA) showed a small retinoschisis in the right eye, macular hole enlargement to 3,440 mm horizontally and 3,480 mm vertically (Figure 2, A and B), and a macular detachment in the left eye (Figure 2, C and D). OCT also showed a partially detached posterior hyaloid with vitreoretinal adherence at the temporal edge of both holes (Figure 2, A and C). Although microperimetry images obtained by scanning laser ophthalmoscopy showed that the fixation point remained at the upper edge of the hole in the right eye (Figure 3A), the fixation point in the left eye moved to the superonasal edge of the macular detachment (Figure 3B). We performed a standard pars plana vitrectomy to reattach the macula in the left eye. A posterior vitreous detachment was induced using a vitreous hook and suction with the vitrectomy probe overlying the optic nerve head; we then tamponaded the vitreous cavity with 20% sulfur hexafluoride gas. Intraoperatively, the posterior vitreous was firmly attached to the retinal surface on the edge of the hole. We tried to remove the internal limiting membrane by peeling around the hole using 0.25% indocyanine green, but the internal limiting membrane could barely be removed because of the strong adhesion. Therefore, we applied photocoagulation to the inferior edge of the hole to prevent retinal
Fig. 1. Color fundus photographs. A, Five years after the initial visit, the hole has enlarged in the right eye. B, Five years after the initial visit, an extensive macular detachment has developed beyond the arcade vessels with the giant macular hole in the left eye. C, Nine years after the initial visit, the hole has enlarged further in the right eye. D, Nine years after the initial visit, the hole has not closed, but the macular retina has reattached postoperatively in the left eye.
redetachment. The patient was instructed to remain facedown for 1 week postoperatively. The hole did not close predictably, but the macular retina reattached postoperatively. The fixation point in the left eye returned to the upper edge of the hole, and the bestcorrected visual acuity increased to 20/100 (Figure 3C). Nine years after the initial visit, the best-corrected visual acuity remained 20/50 and 20/100 in the right and left eyes, respectively. Spectral-domain OCT (Spectralis; Heidelberg Engineering, Heidelberg, Germany) clearly showed that the macular hole had enlarged further to 4,000 mm vertically and 4,107 mm horizontally in the right eye. The macular retinoschisis with vitreoretinal adherence and a taut posterior hyaloid membrane were seen at the temporal edge of the hole in the right eye (Figures 1C, 4A–D). The macula remained attached postoperatively in the left eye (Figure 1D).
Discussion In a randomized clinical trial of 236 eyes, which compared vitrectomy to observation for idiopathic macular holes, the average hole size was 552 mm (range, 215–950 mm).3 In the current report, we described an unusual case in which a macular hole progressively enlarged from 1,800 mm to 3,480 mm vertically 5 years after the initial visit and to 4,000 mm 9 years after the initial visit in the right eye and a macular detachment developed beyond the arcade vessels in the left eye 5 years after the initial visit in a relatively young patient with bilateral giant macular holes without high myopia. Optical coherence
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Fig. 2. Vertical and horizontal tomographic images were obtained using OCT 3. A, (horizontal) B, (vertical) Five years after the initial visit, the hole has enlarged to 3,440 mm horizontally and 3,480 mm vertically. A retinoschisis (arrow) and a partially detached posterior hyaloid (arrowhead) with vitreoretinal adherence temporal to the giant macular hole are seen in the horizontal scan of the right eye. The edges of the macular hole are swollen inferiorly and superiorly in the right eye. C, (horizontal) D, (vertical) Five years after the initial visit, OCT shows a macular detachment with the macular hole in the left eye. OCT also showed a partially detached posterior hyaloid (arrowheads) with vitreoretinal adherence (arrow) at the temporal edge of the hole in the horizontal scan of the left eye.
tomography showed a partially detached posterior hyaloid with vitreoretinal adhesion around the temporal edges of both holes. Two cases with comparable large bilateral macular holes have been reported previously. The first case had a bilateral giant macular hole measuring 3,580 mm in the right eye and 2,910 mm in the left eye with high myopia.4 The second case had a bilateral giant macular hole measuring 3,800 mm in the right eye and 3,600 mm in the left eye.5 The large diameters of the holes in the current case resemble those cases. However, our patient may be the first observational case of development of
bilateral giant macular holes after long-term follow-up. Development of a macular detachment (extending at least 1 disk diameter from the center of the hole) is an unusual variation of idiopathic macular holes. Although similar OCT images from two patients with vitreous attachment adjacent to a small macular hole and extensive subretinal fluid on OCT 3 can be observed in the article of Kitchens et al,6 to the best of our knowledge, the development of a macular detachment beyond the arcade vessels secondary to and several years after the progressive development of the giant macular hole has not been reported previously.
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hypothetically to anteroposterior vitreofoveal traction of a posterior hyaloid face.8–10 The current OCT findings suggested that vitreomacular traction with vitreoretinal adherence at the temporal edge of the hole may have resulted in progressive centrifugal enlargement of the hole in both eyes and the macular detachment then developed in the left eye. Our case showed that OCT may facilitate a better understanding of the vitreoretinal relationship involved with progression and enlargement of giant macular holes. Therefore, OCT may provide important information for predicting the progressive risk of giant macular holes. Key words: macular hole, macular detachment, optical coherence tomography.
References
Fig. 3. Microperimetry obtained by scanning laser ophthalmoscopy. A, Five years after the initial visit, the fixation point (white cross) remain at the upper edge of the macular hole in the right eye. B, Five years after the initial visit, the fixation point (white cross) in the left eye has moved to the superonasal edge of the macular detachment. C, The fixation point (white cross) in the left eye has returned to the upper edge of the macular hole postoperatively.
Gass7 hypothesized that contraction of the prefoveal vitreous cortex causes focal tangential vitreous traction leading to the formation of idiopathic macular holes. Because OCT became available, idiopathic macular hole formation has been attributed
1. Chew EY, Sperduto RD, Hiller R, et al. Clinical course of macular holes: the eye disease case-control study. Arch Ophthalmol 1999;117:242–246. 2. Takahashi A, Takeda M, Kitaya N, et al. Bilateral giant macular holes with excellent visual function. Arch Ophthalmol 2002; 120:661–663. 3. Freeman WR, Azen SP, Kim JW, el-Haig W, Mishell DR 3rd, Bailey I. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group. Arch Ophthalmol 1997;115:11–21. 4. Kusaka S, Hosotani H, Hayashi A, Ohji M, Fujikado T, Tano Y. Bilateral giant macular hole. Arch Ophthalmol 2000;118: 1453–1455. 5. Ozdek SC, Pehlivanli Z, Sari A, Hasanreisoglu B. Bilateral giant macular hole in a patient with chronic renal failure. Ophthalmic Surg Lasers Imaging 2003;34:480–482. 6. Kitchens JW, Flynn HW Jr, Moshfeghi AA, Puliafito CA. Idiopathic macular hole with extensive subretinal fluid: clinical and optical coherence tomography features before and after surgery. Am J Ophthalmol 2005;139:383–386. 7. Gass JDM. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629–639. 8. Gaudric A, Haouchine B, Massin P, Paques M, Blain P, Erginay A. Macular hole formation: new data provided by optical coherence tomography. Arch Ophthalmol 1999;117: 744–751. 9. 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. 10. Kishi S, Takahashi H. Three-dimensional observations of developing macular holes. Am J Ophthalmol 2000;130: 65–75.
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Fig. 4. Vertical and horizontal tomographic images were obtained using Spectraldomain OCT. A, (horizontal) B, (vertical) Nine years after the first visit, Spectral-domain OCT scans through the center of the hole show that the hole has enlarged further to 4,107 mm horizontally and 4,000 mm vertically in the right eye. C, A taut posterior hyaloid membrane (arrowheads) at the temporal edge of the macular hole in the right eye. D, Macular retinoschisis (arrow) expands with vitreoretinal adherence (arrowhead).
Purpose: To report the detailed vitreomacular morphology of a case of progressive enlargement and macular detachment secondary to and several years after the development of bilateral giant macular holes using optical coherence tomography. Methods: Using optical coherence tomography, both eyes of a patient with bilateral giant macular holes were examined. Results: A 33-year-old woman had bilateral giant macular holes at the first visit. At the 5-year follow-up visit, the macular hole had enlarged centrifugally in the right eye, and a macular detachment developed beyond the arcade vessels in the left eye. Optical coherence tomography showed retinoschisis in the right eye around the edges of the hole and a macular detachment in the left eye with vitreoretinal adhesion temporal to both holes. Conclusion: These optical coherence tomography findings suggested that vitreomacular traction at the temporal edge of the hole may have resulted in progressive centrifugal enlargement of the hole in both eyes and then the macular detachment occurred in the left eye. RETINAL CASES & BRIEF REPORTS 5:184–188, 2011
From the Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Japan.
follow-up, we observed progressive enlargement of the macular hole in the right eye and a macular detachment in the left eye. We report the detailed vitreomacular morphology of this case of progressive enlargement and macular detachment secondary to and several years after the development of bilateral giant macular holes using optical coherence tomography (OCT).
C
hew et al reported that the diameters of idiopathic macular holes range from 250 mm to 640 mm, with most holes having diameters ranging from 351 mm to 640 mm even after 6 years of follow-up. Approximately 34% of idiopathic macular holes increase in size over time. However, no macular detachments developed in 122 patients during follow-up.1 We previously reported a patient with bilateral giant macular holes with diameters of 1,800 mm and 1,500 mm in the right and left eyes, respectively.2 After the 5-year
Case Report A 33-year-old woman with bilateral giant macular holes had a bilateral visual acuity of 20/40 with 25.0 diopters of myopia at the first visit in June 2000. She did not have a history of trauma. She had no personal or family history of ocular disease and did not use any medications. Fundus examination showed large bilateral macular holes. The retina partially bridged the hole in the right eye. No posterior vitreous detachment or operculum was found in either eye. Microperimetry images obtained by scanning laser ophthalmoscopy (Rodenstock, Munich, Germany) showed that the fixation points were at the upper edges of the holes in both eyes. Optical coherence tomography showed that the hole edges were swollen in both eyes. The vertical diameters were 1,800 mm and 1,500 mm in the right and left eyes, respectively. No macular
The authors have no proprietary or commercial interest in any materials discussed in this article. The authors have no conflicts of interest or sources of financial support. Reprint requests: Akitoshi Yoshida, MD, PhD, Department of Ophthalmology, Asahikawa Medical College, 2-1-1-1, MidorigaokaHigashi, Asahikawa, Hokkaido 078-8510, Japan; e-mail: pyoshida@ asahikawa-med.ac.jp
184
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VITREOMACULAR MORPHOLOGY IN BILATERAL GIANT MACULAR HOLES detachment, retinoschisis, staphyloma, or posterior hyaloid membrane were observed bilaterally. Surgery was not recommended because the anatomic success rates are low in cases of large macular holes. Five years after the initial visit, the patient reported acutely decreased visual acuity in the left eye. The best-corrected visual acuity remained 20/50 in the right eye but decreased to 20/400 in the left eye. The macular holes had enlarged in the right eye (Figure 1A). An extensive macular detachment developed beyond the arcade vessels in the left eye (Figure 1B). No posterior vitreous detachment or operculum was found in either eye. Optical coherence tomography 3 (Stratus OCT; Carl Zeiss Meditec, Inc, Dublin, CA) showed a small retinoschisis in the right eye, macular hole enlargement to 3,440 mm horizontally and 3,480 mm vertically (Figure 2, A and B), and a macular detachment in the left eye (Figure 2, C and D). OCT also showed a partially detached posterior hyaloid with vitreoretinal adherence at the temporal edge of both holes (Figure 2, A and C). Although microperimetry images obtained by scanning laser ophthalmoscopy showed that the fixation point remained at the upper edge of the hole in the right eye (Figure 3A), the fixation point in the left eye moved to the superonasal edge of the macular detachment (Figure 3B). We performed a standard pars plana vitrectomy to reattach the macula in the left eye. A posterior vitreous detachment was induced using a vitreous hook and suction with the vitrectomy probe overlying the optic nerve head; we then tamponaded the vitreous cavity with 20% sulfur hexafluoride gas. Intraoperatively, the posterior vitreous was firmly attached to the retinal surface on the edge of the hole. We tried to remove the internal limiting membrane by peeling around the hole using 0.25% indocyanine green, but the internal limiting membrane could barely be removed because of the strong adhesion. Therefore, we applied photocoagulation to the inferior edge of the hole to prevent retinal
Fig. 1. Color fundus photographs. A, Five years after the initial visit, the hole has enlarged in the right eye. B, Five years after the initial visit, an extensive macular detachment has developed beyond the arcade vessels with the giant macular hole in the left eye. C, Nine years after the initial visit, the hole has enlarged further in the right eye. D, Nine years after the initial visit, the hole has not closed, but the macular retina has reattached postoperatively in the left eye.
redetachment. The patient was instructed to remain facedown for 1 week postoperatively. The hole did not close predictably, but the macular retina reattached postoperatively. The fixation point in the left eye returned to the upper edge of the hole, and the bestcorrected visual acuity increased to 20/100 (Figure 3C). Nine years after the initial visit, the best-corrected visual acuity remained 20/50 and 20/100 in the right and left eyes, respectively. Spectral-domain OCT (Spectralis; Heidelberg Engineering, Heidelberg, Germany) clearly showed that the macular hole had enlarged further to 4,000 mm vertically and 4,107 mm horizontally in the right eye. The macular retinoschisis with vitreoretinal adherence and a taut posterior hyaloid membrane were seen at the temporal edge of the hole in the right eye (Figures 1C, 4A–D). The macula remained attached postoperatively in the left eye (Figure 1D).
Discussion In a randomized clinical trial of 236 eyes, which compared vitrectomy to observation for idiopathic macular holes, the average hole size was 552 mm (range, 215–950 mm).3 In the current report, we described an unusual case in which a macular hole progressively enlarged from 1,800 mm to 3,480 mm vertically 5 years after the initial visit and to 4,000 mm 9 years after the initial visit in the right eye and a macular detachment developed beyond the arcade vessels in the left eye 5 years after the initial visit in a relatively young patient with bilateral giant macular holes without high myopia. Optical coherence
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Fig. 2. Vertical and horizontal tomographic images were obtained using OCT 3. A, (horizontal) B, (vertical) Five years after the initial visit, the hole has enlarged to 3,440 mm horizontally and 3,480 mm vertically. A retinoschisis (arrow) and a partially detached posterior hyaloid (arrowhead) with vitreoretinal adherence temporal to the giant macular hole are seen in the horizontal scan of the right eye. The edges of the macular hole are swollen inferiorly and superiorly in the right eye. C, (horizontal) D, (vertical) Five years after the initial visit, OCT shows a macular detachment with the macular hole in the left eye. OCT also showed a partially detached posterior hyaloid (arrowheads) with vitreoretinal adherence (arrow) at the temporal edge of the hole in the horizontal scan of the left eye.
tomography showed a partially detached posterior hyaloid with vitreoretinal adhesion around the temporal edges of both holes. Two cases with comparable large bilateral macular holes have been reported previously. The first case had a bilateral giant macular hole measuring 3,580 mm in the right eye and 2,910 mm in the left eye with high myopia.4 The second case had a bilateral giant macular hole measuring 3,800 mm in the right eye and 3,600 mm in the left eye.5 The large diameters of the holes in the current case resemble those cases. However, our patient may be the first observational case of development of
bilateral giant macular holes after long-term follow-up. Development of a macular detachment (extending at least 1 disk diameter from the center of the hole) is an unusual variation of idiopathic macular holes. Although similar OCT images from two patients with vitreous attachment adjacent to a small macular hole and extensive subretinal fluid on OCT 3 can be observed in the article of Kitchens et al,6 to the best of our knowledge, the development of a macular detachment beyond the arcade vessels secondary to and several years after the progressive development of the giant macular hole has not been reported previously.
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hypothetically to anteroposterior vitreofoveal traction of a posterior hyaloid face.8–10 The current OCT findings suggested that vitreomacular traction with vitreoretinal adherence at the temporal edge of the hole may have resulted in progressive centrifugal enlargement of the hole in both eyes and the macular detachment then developed in the left eye. Our case showed that OCT may facilitate a better understanding of the vitreoretinal relationship involved with progression and enlargement of giant macular holes. Therefore, OCT may provide important information for predicting the progressive risk of giant macular holes. Key words: macular hole, macular detachment, optical coherence tomography.
References
Fig. 3. Microperimetry obtained by scanning laser ophthalmoscopy. A, Five years after the initial visit, the fixation point (white cross) remain at the upper edge of the macular hole in the right eye. B, Five years after the initial visit, the fixation point (white cross) in the left eye has moved to the superonasal edge of the macular detachment. C, The fixation point (white cross) in the left eye has returned to the upper edge of the macular hole postoperatively.
Gass7 hypothesized that contraction of the prefoveal vitreous cortex causes focal tangential vitreous traction leading to the formation of idiopathic macular holes. Because OCT became available, idiopathic macular hole formation has been attributed
1. Chew EY, Sperduto RD, Hiller R, et al. Clinical course of macular holes: the eye disease case-control study. Arch Ophthalmol 1999;117:242–246. 2. Takahashi A, Takeda M, Kitaya N, et al. Bilateral giant macular holes with excellent visual function. Arch Ophthalmol 2002; 120:661–663. 3. Freeman WR, Azen SP, Kim JW, el-Haig W, Mishell DR 3rd, Bailey I. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group. Arch Ophthalmol 1997;115:11–21. 4. Kusaka S, Hosotani H, Hayashi A, Ohji M, Fujikado T, Tano Y. Bilateral giant macular hole. Arch Ophthalmol 2000;118: 1453–1455. 5. Ozdek SC, Pehlivanli Z, Sari A, Hasanreisoglu B. Bilateral giant macular hole in a patient with chronic renal failure. Ophthalmic Surg Lasers Imaging 2003;34:480–482. 6. Kitchens JW, Flynn HW Jr, Moshfeghi AA, Puliafito CA. Idiopathic macular hole with extensive subretinal fluid: clinical and optical coherence tomography features before and after surgery. Am J Ophthalmol 2005;139:383–386. 7. Gass JDM. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629–639. 8. Gaudric A, Haouchine B, Massin P, Paques M, Blain P, Erginay A. Macular hole formation: new data provided by optical coherence tomography. Arch Ophthalmol 1999;117: 744–751. 9. 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. 10. Kishi S, Takahashi H. Three-dimensional observations of developing macular holes. Am J Ophthalmol 2000;130: 65–75.
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Fig. 4. Vertical and horizontal tomographic images were obtained using Spectraldomain OCT. A, (horizontal) B, (vertical) Nine years after the first visit, Spectral-domain OCT scans through the center of the hole show that the hole has enlarged further to 4,107 mm horizontally and 4,000 mm vertically in the right eye. C, A taut posterior hyaloid membrane (arrowheads) at the temporal edge of the macular hole in the right eye. D, Macular retinoschisis (arrow) expands with vitreoretinal adherence (arrowhead).
