Traumatic macular hole (TMH)

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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%.[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] Since it's usually related to sport, recreation, or work. It's the second most typical reason for the macular hole.

Pathophysiology

TMH is produced mainly by blunt ocular traumatism, originated by balls, or blows with kicks or fists.[10] 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:

  1. Retinal stretching, from the deformation of the eye or the force of the impact on the posterior pole[8]
  2. Cystic degeneration
  3. Detachment of the posterior vitreous


Including also different factors as:[11]

  1. Necrosis and post-contusional cystoid degeneration
  2. Subfoveal hemorrhage caused by a choroidal rupture
  3. Anterior-posterior vitreous traction.

Clinical presentation

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.[10] The posterior vitreous is completely adhered to 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, appearing later on.[12]

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:[13]

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

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][14][15][16] The spontaneous closure has been described up to 40% of the cases, after 2 months or more of the trauma,[1][14][15][16][17][18] and until 66.7% after 6 months.[19]

Vitrectomy has excellent anatomic results, with closure between 92% and 96% of cases.[3][4][6][7][14] using C3F8 or SF6 gas.[3][4][6] The peeling of the inner limiting membrane and, therefore, the extraction of the epiretinal membrane improve the results.[1][6][7] The large traumatic macular holes may benefit from inverted internal limiting peeling and retinal transplantation.[20][21]

Prognosis

The prognosis is good, with vision improvement of two or more lines of vision between 69% and 93% of cases, obtaining almost 50% of patients 20/40 or better.[3][4][5][6][7] The vision prognosis is the same with spontaneous closure or surgery.[18][22] The measure from injury to surgery was statistically associated significantly with the extent of sight improvement.[18][22] the various TMH presentations in OCT don't clearly correlate to the visual results.[19][13].

References

  1. 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.
  2. Aaberg TM. Macular holes: A review. Surveill Ophthalmol 1970;15:139-62.
  3. 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. 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. 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. 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. 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. 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.
  9. 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. 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. Gass JD. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4thed., Vol. 2. St. Louis: Mosby; 1997. p. 744.
  12. Gill M, Lou P, Ray S, Jakobiec F. Ocular trauma: Traumatic macular holes. Int Ophthalmol Clin 2002;3:97-106.
  13. 13.0 13.1 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.
  14. 14.0 14.1 14.2 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.
  15. 15.0 15.1 Mitamura Y, Wataru S, Masahiro I, Yamamoto S, Takeuchi S. Spontaneous closure of traumatic macular hole. Retina 2001;21:385-9.
  16. 16.0 16.1 Yamada H, Sakai A, Yamada E, Nishimura T, Matsumura M. Spontaneous closure of traumatic macular hole. Am J Ophthalmol 2002;134:340-7.
  17. Kusaka S, Fujikado T, Ikeda T, Tano Y. Spontaneous disappearance of traumatic macular holes in young patients. Am J Ophthalmol 1997;123:837-9.
  18. 18.0 18.1 18.2 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.
  19. 19.0 19.1 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.
  20. Özkan B, Karabas VL. Surgical closure of giant traumatic macular hole with retinal graft. Eur J Ophthalmol 2019;29:NP14-7.
  21. Singh SR, Narayanan R. Functional and morphological evaluation of autologous retinal graft in large traumatic macular hole. Indian J Ophthalmol 2019;67:1760-2.
  22. 22.0 22.1 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.
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