Case of the Month

Edited by Robert N. Johnson, MD

Case #114, December, 2018

Presented by:

Michelle Peng, MD

A 14-year-old Caucasian boy with sudden monocular vision loss following soccer injury

Figure 1: Wide-field color photo of the left eye. Note the area of retinal whitening extending from the macula to the periphery as well as scattered areas of retinal and vitreous hemorrhage. The inset detail shows the whitening in the superior part of the macula and hemorrhage in the fovea.

Case History

A 14-year-old healthy Caucasian boy presented with sudden onset vision loss in the left eye after he was hit in the face with a soccer ball.

On examination, visual acuity was 20/16 in the right eye and 1/200 in the left eye.  The right eye was unremarkable. His left eyelid was mildly swollen. Fundus examination showed temporal vitreous hemorrhage, a macular hole with intraretinal hemorrhage, as well as superotemporal peripheral retinal whitening (Figure 1). Ocular coherence tomography displayed a full thickness macular hole with a focal macular detachment (Figure 2). Fluorescein angiography revealed focal leakage in the area of superior retinal whitening (Figure 3). Fundus autofluoresence displayed hyperautofluorescence in the region of retinal whitening  (Figure 4).

Figure 2: Spectral domain OCT of the left eye. Note the full-thickness macular hole and the overlying area of vitreous opacities. The hyaloid still appears to be attached centrally.

Figure 3: Wide-field fluorescein angiogram of the left eye. Note the prominent area of fluorescein leakage in the posterior pole.

Figure 4: Wide-field autoflourescence scan of the left eye. Note the areas of increased autofluorescence superior to the macula.

What is your Diagnosis?

Differential Diagnosis

Lamellar macular hole, cystoid macular edema with central cyst, choroidal neovascularization, central serous retinopathy,

 

Additional History and Diagnosis

The patient was observed for two months with improvement in his vision to 20/80 but persistence of the macular hole (Figure 5. Note the open macular hole and the retinal pigment epithelial atrophy and clumping superiorly).

Surgical repair was recommended at this time, but the boy’s parents were reluctant to proceed. The macular hole remains five months after initial injury.

 

Discussion

Traumatic macular holes occur due to blunt injury to the eye and are the second most common cause of a macular hole. They are observed more often in the younger population as they relate to recreation, work, and transportation. There is often associated retinal pathology such as commotio retinae, vitreous hemorrhage, retinal tear, photoreceptor and/or retinal pigment epithelial (RPE) damage, or choroidal rupture.1

The mechanism for formation of traumatic macular holes remains uncertain and numerous theories have been postulated. The foveola is a thin structure and may rupture from the blunt force transmitted.2 Some feel that it is due to sudden vitreous separation though a posterior vitreous detachment is not always observed3. Another theory that has been proposed is that the force of injury results in a cystoid change that then ruptures and leaves a defect.2,4

Ocular coherence tomography allows for detailed assessment of the macula. Fluorescein angiography may be useful to evaluate the extent of retinal pigment epithelial damage. The areas with commotio that leak acutely (as demonstrated in our patient) may have more limited visual recovery. Later once the commotio resolves, RPE atrophy and pigment clumping occur.5

A number of reports have documented spontaneous closure of traumatic macular holes has been well documented, with varying closure rates.4 Characteristics which have been postulated to predict successful closure include younger age, male gender, smaller holes, and absence of intraretinal cysts.6-9 It is reasonable to defer surgery for a few months to give the macular hole an opportunity to resolve. For persistent macular holes, pars plana vitrectomy, removal of the posterior hyaloid, and air fluid exchange has been shown to demonstrate successful anatomic closure of the macular hole.5,10,11

Take Home Points

  • Traumatic macular holes are a cause of visual loss from blunt ocular injury
  • Fluorescein angiography may be used acutely to assess for extent of retinal pigment epithelial damage and visual prognosis
  • Spontaneous closure of traumatic macular holes has been observed

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References

  1. F. Kuhn, R. Morris, C. D. Witherspoon, and L. Mann, “Epidemiology of blinding trauma in the United States Eye Injury Registry,” Ophthalmic Epidemiology 2006;13(3): 209–16.
  2. Yanagiya N, Akiba J, Takahashi M, et al. Clinical characteristics of traumatic macular holes. Jpn J Ophthalmol 1996;40: 544–7.
  3. Yokotsuka K, Kishi S, Tobe K, Kamei Y. Clinical features of traumatic macular hole [in Japanese]. Rinsho Ganka 1991;45: 1121–4.
  4. Agarwal A. Posttraumatic Macular Hole and Foveolar Pit. In: Agarwal, A. Gass’ Atlas of Macular Diseases. Fifth ed. Elsevier:722.
  5. Horn EP, McDonald RM, Johnson RNJ, et al. Soccer Ball-Related Retinal Injuries: A Report of 13 Cases. Retina 2000; 20(6):604–9.
  6. Mitamura Y, Saito W, Ishida M, et al. Spontaneous closure of traumatic macular hole. Retina 2001;21:385–9.
  7. Yamada H, Sakai A, Yamada E, et al. Spontaneous closure of traumatic macular hole. Am J Ophthalmol 2002;134:340–7.
  8. Yeshurun I, Guerrero-Naranjo JL, Quiroz-Mercado H. Spontaneous closure of a large traumatic macular hole in a young patient. Am J Ophthalmol 2002;134:602–3.
  9. Chen H., Chen W., Zheng K., Peng K., Xia H., Zhu L. Prediction of spontaneous closure of traumatic macular hole with spectral domain optical coherence tomography. Scientific Reports. 2015;5, article 12343doi: 10.1038/srep12343.
  10. Johnson RN, McDonald RM, Lewis H, et al. Traumatic Macular Hole. Ophthalmology 2001;108(5): 853-857.
  11. Amari F, Ogino N, Matsumura M, et al. Vitreous surgery for traumatic macular holes. Retina 1999;19:410–3.

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