SPONTANEOUS CLOSURE OF MYOPIC MACULAR HOLE TWICE WITHOUT POSTERIOR VITREOUS DETACHMENT

This case was a myopic macular hole that spontaneously closed but reopened later, and the hole finally closed again with the formation of a lamellar macular hole. The posterior hyaloid membrane remained broadly adherent throughout the course. Starting with the bridging tissue, the two hole closures showed different sealing results.

Abstract

Purpose:

To present a case of a myopic macular hole that spontaneously closed twice in the presence of a broadly adherent posterior hyaloid membrane.

Methods:

Case report.

Results:

A 49-year-old man with high myopia and pseudophakia had a full-thickness macular hole in the left eye. The hole spontaneously closed in all retinal layers before the elective surgery, but the macular hole recurred one month later. The hole started sealing again spontaneously after one month, leaving a defect in the outer retinal layers. Four months later, the outer layer defect sealed and a lamellar macular hole developed. Throughout the course, the posterior hyaloid membrane remained parallel to the macular surface. The macular morphology and the patient's vision remained stationary at the 2-year follow-up.

Conclusion:

This case demonstrated that myopic macular holes can form and seal repeatedly with a broadly adherent posterior hyaloid membrane. Although bridging phenomenon was the common sign indicating the initiation of the two hole closures, different patterns of tissue regeneration ensued.

Myopic macular holes are believed to differ from idiopathic macular holes in several aspects, including pathogenesis, clinical presentation, and both anatomical and visual outcomes. Although the occurrence of spontaneous closure is uncommon in an idiopathic macular hole, it is even rarer in a myopic macular hole. Among the observational studies of idiopathic macular holes, Yuzawa, Watanabe, and Takahashi et al found that 6 eyes (6.2%) in 97 eyes experienced apparent hole disappearance.¹ Moreover, Sugiyama, Imasawa, and Chiba et al reported that the spontaneous closure rate in idiopathic macular holes was 3.5% (5 eyes in 142 eyes).² Regarding the spontaneous closure of myopic macular holes, there were only few case reports.^3–8 The pathogenesis remains unclear, and the surgical criteria may need to be refined individually in myopic macular holes. Here, we present a case of a myopic macular hole that closed spontaneously twice in the absence of posterior hyaloid membrane detachment.

Case Report

A 49-year-old man was diagnosed with high myopia with −10.0 diopters in both eyes before a cataract operation 3 years ago. The axial lengths were 26.47 mm and 27.74 mm in each eye. He presented with complaints of blurred vision and metamorphopsia in the left eye for several days. His visual acuity was 20/66, and spectral domain optical coherence tomography raster scans revealed a small full-thickness macular hole with elevated edges and intraretinal cysts (Figure 1, A-1). There was no accompanying retinal detachment. Notably, a broadly adherent, smoothly curved posterior hyaloid membrane was identified across the peripapillary atrophy and macula (Figures 1, A-2).

Fig. 1.

Optical coherence tomography images: (A-1) the first macular hole formation with the “bridging” phenomenon; (A-2) the broadly adherent posterior hyaloid membrane (arrows), which was more clearly identified in the paracenter scan; (B) the first hole sealing; (C) the second hole formation; and (D) the second hole sealing. Notably, bridging tissue within the outer nuclear layer and the external limiting membrane was evident; (E) the lamellar macular hole formation; (F-1) the lamellar hole at the final visit; and (F-2) the broadly adherent posterior hyaloid membrane in the paracenter scan.

Fig. 2.

Optical coherence tomography image of the peripapillary region at the final visit. The posterior hyaloid membrane was identified across the peripapillary atrophy and adherent to the disc margin (arrow).

An operation was planned; however, the patient reported improvement in symptoms during the presurgical evaluation. The optical coherence tomography scan demonstrated a sealed macular hole which showed retinal layers regeneration with slightly elevated outer layers (Figure 1B), and the visual acuity improved to 20/33.

One month later, his metamorphopsia increased again and his vision declined to 20/40. An optical coherence tomography scan revealed reopening of the macular hole (Figure 1C). After one month of observation, the hole showed signs of sealing spontaneously again, leaving a defect in the outer retinal layers (Figure 1D). Four months later, the subfoveal defect resolved completely with an intact ellipsoid zone and a lamellar hole was formed (Figure 1E). The lamellar macular hole persisted over the following 2 years (Figure 1, F-1), and the patient's visual acuity was maintained at 20/25 with no significant metamorphopsia. The posterior hyaloid membrane remained parallel to the macular surface and the peripapillary area with adhesion to the optic disc margin throughout the observation period (Figures 1, F-2 and 2).

Discussion

Unlike an idiopathic macular hole, which is usually caused by an aberrant process of posterior vitreous detachment, the current case of a myopic macular hole showed no clear evidence of posterior vitreous detachment. The factors contributing to the formation of myopic macular holes without the involvement of vitreomacular traction may include 1) the tissue imbalance between the retina and the stretching posterior staphyloma and 2) the complex vectors of traction exerted from the internal limiting membrane, the adherent posterior vitreous membrane/cortex, and vitreoschisis to the macula in pathologic myopia.

There have been few case reports of spontaneous resolution of myopic macular holes with associated retinal detachment.^3–6 The formation of foveoschisis and a lamellar macular hole was proposed to be a relatively stable form to compensate for the shortening of the retina in the posterior staphyloma.³ This was similar to our case, where the patient finally developed a lamellar macular hole and remained stable for 2 years. The release of vitreomacular traction, a small hole size, and the easily movable property of the detached retina were considered as possible factors related to spontaneous hole closure.⁴ However, in our case, the posterior hyaloid membrane remained broadly adherent to the macular surface, and there was no associated retinal detachment.

There have been two previous case reports regarding spontaneous closure of myopic macular holes without retinal detachment.^7,8 Bruè, Rossiello, and Guidotti et al presented a case of a stage IV myopic macular hole that spontaneously sealed four years later.⁷ Golen and Barak presented a 75-year-old woman with a third-time spontaneous closure of the myopic macular hole.⁸ The proliferative property of glial cells was considered to be the major factor responsible for hole remodeling. In these two cases, there was no vitreous membrane identified by optical coherence tomography imaging both before and after hole sealing, suggesting that the release of vitreomacular adhesion may not be the main contributor to the closure process. To the best of our knowledge, the present case is the first to demonstrate spontaneous closure of a myopic macular hole twice in the presence of a broadly adherent posterior hyaloid membrane. The size of the first hole was small with the presence of a “bridging” phenomenon which may have the propensity of sealing.⁹ The second hole was flat open. Again, bridging tissue was noted, and the hole was initially sealed in the inner layers and finally in the outer layers with the formation of a lamellar macular hole. The different patterns of compensation could further demonstrate the reparative ability of glial cells in the evolution of myopic macular holes.