Traumatic Macular Hole (TMH)
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Traumatic macular hole (TMH) is a full-thickness defect of neuroretina at the fovea, after a mechanical ocular blunt injury. The spontaneous closure rates are reported between 10 and 50%. Functional prognosis even with spontaneous closure depends on the extent of direct injury to the macula; associated pathology may include retinal edema, commotio retinae, retinal hemorrhage, vitreous hemorrhage, choroidal rupture, photoreceptor and RPE damage, retinal tears and dialysis, or retinal detachment.
The incidence of the traumatic macular hole varies between 1% and 9%.[1][2] Patients are generally young between the second and third decades of life and, more often, male [3][4][5][6][7][8][9] .
Disease Entity
Pathophysiology
TMH is produced mainly by blunt ocular trauma due to antero-posterior compression with equatorial expansion of the globe causing tangential traction.[8][10][11][12] It appears immediately after the injury in most of the cases, nevertheless, in others, it can occur weeks later.
Diagnosis
Clinical presentation
TMH presents with a vision between 20/30 and 20/400. It has a size between 0.2 and 0.5 diameters, with irregular elliptical edges, in some cases with yellow deposits.[10] A round or ellipsoid full-thickness defect of the neurosensory retina with a rim of subretinal fluid is seen located centrally or eccentrically in the macula. [11] Associated retinal edema and subretinal hemorrhage can be noted if examined immediately after trauma. Posterior vitreous detachment is absent in most cases. Usually, the traumatic MHs involve the foveal center, but they can have an eccentric location, particularly if they arise from surgical trauma The posterior vitreous is completely adhered to the macula in 85% of the cases and partially adhered in 15%, a complete posterior vitreous detachment is rare.[8] The finding of an epiretinal membrane is unusual, and appears later on with time.[13]
The retinal fluorescein angiography shows a central hyper fluorescence by window defect in the macular hole, with hyper fluorescence around the hole.
The OCT shows complete retinal thickness loss with other changes as the presence of operculum, cystic retinal changes.
Different presentations of TMH are:[14]
| Type | Description |
|---|---|
| I | Cystic edema of the neurosensory retina on both margins of the hole |
| II | Cystic edema of the neurosensory retina on only one margin of the hole |
| III | Without cystic edema or detachment of the margins |
| IV | Localized detachment of the neurosensory retina at the margin without cystic edema |
| V | Thinning of the neurosensory retina |
Management
Treatment
Observation is an option to discuss because there's an opportunity of spontaneous closure, especially in cases with small diameters (0.1–0.2 diameters of the optic disc), without detachment of the posterior vitreous, or presence of the epiretinal membrane.[1][15][16][17] The spontaneous closure has been described up to 40% of the cases, after 2 months or more of the trauma,[1][15][16][17][18][19] and upto 50-65% after 6-9 months.[20]
Vitrectomy can be considered for traumatic MHs that do not close spontaneously. These types of holes are observed usually for 3-6 months for spontaneous closure, and vitrectomy is considered if no closure is seen. One should have an in depth discussion with the patient and the family since anatomic closure may still not improve visual acuity. Improvement of vision depends on the status of the fovea and peri-foveal layers. Traumatic MHs of more than 1 year duration are unlikely to close spontaneously.[21]
Vitrectomy has excellent anatomic results, with closure between 92% and 96% of cases.[3][4][6][7][15] using C3F8 or SF6 gas.[3][4][6] The peeling of the inner limiting membrane may improve the results.[1][6][7] The large traumatic macular holes may benefit from inverted internal limiting peeling and retinal transplantation.[22][23]
The prognosis is fair, with vision improvement of two or more lines of vision between 69% and 93% of cases; almost 50% of patients may attain 20/40 or better.[3][4][5][6][7] However, there is a high risk of developing para/peri macular pigmentary changes due to RPE trauma that may limit visual recovery. The vision prognosis is the same with spontaneous closure or surgery.[19][24] Various phenotypic TMH presentations in OCT do not clearly correlate with the visual results.[20][14].
References
- ↑ 1.0 1.1 1.2 1.3 Margheria RR, Schepens CL. Macular breaks. 1. Diagnosis, etiology, and observations. Am J Ophthalmol 1972;74:219-32.
- ↑ Aaberg TM. Macular holes: A review. Surveill Ophthalmol 1970;15:139-62.
- ↑ 3.0 3.1 3.2 3.3 Amari F, Ogino N, Matsumura M, Negi A, Yoshimura N. Vitreous surgery for traumatic macular holes. Retina 1999;19:410-3.
- ↑ 4.0 4.1 4.2 4.3 Johnson RN, McDonald HR, Lewis H, Grand MG, Murray TG, Mieler WF, et al. Traumatic macular hole: Observations, pathogenesis, and results of vitrectomy surgery. Ophthalmology 2001;108:853-7.
- ↑ 5.0 5.1 Yamashita T, Uemara A, Uchino E, Doi N, Ohba N. Spontaneous closure of traumatic macular hole. Am J Ophthalmol 2002;133:230-5.
- ↑ 6.0 6.1 6.2 6.3 6.4 Chow DR, Williams GA, Trese MT, Margherio RR, Ruby AJ, Ferrone PJ. Successful closure of traumatic macular holes. Retina 1999;19:405-9.
- ↑ 7.0 7.1 7.2 7.3 García-Arumí J, Corcostegui B, Cavero L, Sararols L. The role of vitreoretinal surgery in the treatment of posttraumatic macular hole. Retina 1997;17:372-7.
- ↑ 8.0 8.1 8.2 Yanagiya N, Akiba J, Takahashi M, Shimizu A, Kakehashi A, Kado M, et al. Clinical characteristics of traumatic macular holes. Jpn J Ophthalmol 1996;40:544-7.
- ↑ Chen YP, Chen TL, Chao AN, Wu WC, Lai CC. Surgical management of traumatic macular hole-related retinal detachment. Am J Ophthalmol 2005;140:331-3.
- ↑ 10.0 10.1 Yokotsuka K, Kishi S, Tobe K, Kamei Y. Clinical features of traumatic macular hole. Jpn J Clin Ophthalmol Rinsho Ganka 1991;45:1121-4.
- ↑ 11.0 11.1 Budoff G, Bhagat N, Zarbin MA. Traumatic Macular Hole: Diagnosis, Natural History, and Management. J Ophthalmol. 2019 Mar 19;2019:5837832. doi: 10.1155/2019/5837832. PMID: 31016038;
- ↑ Gass JD. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4thed., Vol. 2. St. Louis: Mosby; 1997. p. 744.
- ↑ Gill M, Lou P, Ray S, Jakobiec F. Ocular trauma: Traumatic macular holes. Int Ophthalmol Clin 2002;3:97-106.
- ↑ 14.0 14.1 Huang J, Liu X, Wu Z, Lin X, Li M, Dustin L, et al. Classification of full-thickness traumatic macular holes by optical coherence tomography. Retina 2009;29:340-8.
- ↑ 15.0 15.1 15.2 Rubin JS, Glaser BM, Thompson JT, Sjaarda RN, Pappas SS, Murphy RP. Vitrectomy, fluid-gas exchange and transforming growth factor--beta-2 for the treatment of traumatic macular holes. Ophthalmology 1995;102:1840-5.
- ↑ 16.0 16.1 Mitamura Y, Wataru S, Masahiro I, Yamamoto S, Takeuchi S. Spontaneous closure of traumatic macular hole. Retina 2001;21:385-9.
- ↑ 17.0 17.1 Yamada H, Sakai A, Yamada E, Nishimura T, Matsumura M. Spontaneous closure of traumatic macular hole. Am J Ophthalmol 2002;134:340-7.
- ↑ Kusaka S, Fujikado T, Ikeda T, Tano Y. Spontaneous disappearance of traumatic macular holes in young patients. Am J Ophthalmol 1997;123:837-9.
- ↑ 19.0 19.1 Gao M, Liu K, Lin Q, Liu H. Management modalities for traumatic macular hole: A systematic review and single-arm meta-analysis. Curr Eye Res 2017;42:287-96.
- ↑ 20.0 20.1 Chen HJ, Jin Y, Shen LJ, Wang Y, Li ZY, Fang XY, et al. Traumatic macular hole study: A multicenter comparative study between immediate vitrectomy and six-month observation for spontaneous closure. Ann Transl Med 2019;7:726.
- ↑ Miller JB, Yonekawa Y, Eliott D, Kim IK, Kim LA, Loewenstein JI, Sobrin L, Young LH, Mukai S, Vavvas DG. Long-term follow-up and outcomes in traumatic macular holes. Am J Ophthalmol. 2016;166:206–207.
- ↑ Özkan B, Karabas VL. Surgical closure of giant traumatic macular hole with retinal graft. Eur J Ophthalmol 2019;29:NP14-7.
- ↑ Singh SR, Narayanan R. Functional and morphological evaluation of autologous retinal graft in large traumatic macular hole. Indian J Ophthalmol 2019;67:1760-2.
- ↑ Miller JB, Yonekawa Y, Eliott D, Kim IK, Kim LA, Loewenstein JI, et al. Long-term follow-up and outcomes in traumatic macular holes. Am J Ophthalmol 2015;160:1255-80.
