Traumatic macular hole (TMH)
Traumatic macular hole (TMH) is a full-thickness defect of neuroretina within the fovea, after a mechanic ocular blunt injury. It causes a major visual loss directly and associated with retinal edema and 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%. Patients are generally young between the second and third decades of life and, more often, male  Since it's usually related to sport, recreation, or work. It's the second most typical reason for the macular hole.
TMH is produced mainly by blunt ocular trauma. It appears immediately after the injury in most of the cases, nevertheless in other, it will occur weeks later. The hypotheses considered for the apparition of TMH are:
- Retinal stretching, from the deformation of the eye or the force of the impact on the posterior pole
- Cystic degeneration
- Detachment of the posterior vitreous
Including also different factors as:
- Necrosis and post-contusional cystoid degeneration
- Subfoveal hemorrhage caused by a choroidal rupture
- Anterior-posterior vitreous traction.
TMH presents with a vision between 20/80 and 20/400. The TMH has a size between 0.2 and 0.5 diameters, with irregular elliptical edges, in some cases with yellow deposits. The posterior vitreous is completely adhered to in 85% of the cases and partially adhered in 15%, a complete posterior vitreous detachment is rare. The finding of an epiretinal membrane is unusual, appearing later on.
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, or an epiretinal membrane.
Different presentations of TMH are:
|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|
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. The spontaneous closure has been described up to 40% of the cases, after 2 months or more of the trauma, and until 66.7% after 6 months.
Vitrectomy has excellent anatomic results, with closure between 92% and 96% of cases. using C3F8 or SF6 gas. The peeling of the inner limiting membrane and, therefore, the extraction of the epiretinal membrane improve the results. The large traumatic macular holes may benefit from inverted internal limiting peeling and retinal transplantation.
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. However, there is a high risk of para/peri macular pigmentary changes to develop due to RPE trauma that may limit visual recovery. The vision prognosis is the same with spontaneous closure or surgery. The measure from injury to surgery was statistically associated significantly with the extent of sight improvement. the various TMH presentations in OCT don't clearly correlate to the visual results..
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