Large subfoveal pigment epithelial detachment causing macular hole formation: Surgical approach

Abstract

Subfoveal pigment epithelial detachments (PEDs) have been reported to develop full-thickness macular hole (FTMH). The response to treatment has been varied in different reports, with most cases having persistent PED even after successful surgical closure of the macular hole. Here, we report an unusual case of nonneovascular age-related macular degeneration, having a large subfoveal serous PED, leading to the formation of a large FTMH, which showed complete flattening of the PED with a successful closure of the macular hole with the surgical approach.

Introduction

Subfoveal pigment epithelial detachments (PEDs) have been reported to develop full-thickness macular hole (FTMH) in previous reports.[1,2,3,4,5,6] Most of these cases developed FTMH following intravitreal antivascular endothelial growth factors (VEGFs) injections for a subfoveal fibrovascular PED. The response to treatment has been varied in different reports, with most cases having persistent PED even after successful surgical closure of the macular hole.

Here, we report an unusual case of a large subfoveal serous PED that developed a large FTMH, without a history of intravitreal injections, and showed a successful closure of the macular hole with a simultaneous complete flattening of the PED after surgical intervention.

Case Report

An 82-year-old female, a known diabetic and hypertensive for the past 20 years, and a known case of nonneovascular age-related macular degeneration (AMD) for the past 3 years, presented with progressive diminution of visual acuity in her left eye. On examination, she had a best-corrected visual acuity of 6/9 in the right eye and counting fingers at 2 m in the left eye. She was pseudophakic in both eyes. Fundus evaluation of both eyes revealed numerous soft drusen in the macula, suggestive of dry AMD, while the left eye revealed a large subfoveal PED, approximately one-disc area in size, with an overlying FTMH [Figure 1]. Optical coherence tomography (OCT) confirmed the presence of a large serous PED with a hyporeflective interior and an overlying macular hole with partial posterior vitreous detachment [Figure 2a]. The minimum linear diameter of the macular hole was 698 μm, and the maximum height of the underlying PED was 504 μm. Fluorescein angiography and indocyanine green angiography did not reveal retinal or choroidal neovascularization. The patient was managed with pars plana vitrectomy, internal limiting membrane (ILM) peeling with inverted flap technique, and tamponade with 20% sulfur hexafluoride. The ILM was peeled in a centripetal fashion, starting from outside the edges of PED and peeling toward the center of the macular hole. During the following 6 weeks, the macular hole was found to be closed, and the PED showed progressive flattening till it had completely flattened [Figure 2b-f]. The visual acuity in the left eye improved to 6/60 at the end of 6 weeks.

Figure 1.

(a) Color fundus photograph of the left eye showing a large serous pigment epithelial detachment (PED), an overlying macular hole (arrow), and soft drusen in macula (arrowhead); (b) fundus autofluorescence (FAF) image showing a well-circumscribed hypoautofluorescent area at the site of subfoveal PED (arrow); (c) postoperative closed macular hole, with underlying retinal pigment epithelial atrophy (arrow); (d) postoperative FAF image a showing hypoautofluorescent area (arrow)

Figure 2.

Serial optical coherence tomograms of the left eye showing (a) partial posterior vitreous detachment, a large serous pigment epithelial detachment (PED) (arrow), overlying which, is a full thickness macular hole (arrowhead); (b) Closure of macular hole one week after pars plana vitrectomy with inverse internal limiting membrane peeling with gas tamponade; (c) progressive flattening of the PED at 2 weeks; (d) Further flattening of PED 3 weeks (arrow); (e) Completely flattened PED at 4 weeks; (f) Flat PED and closed macular hole at six months

Discussion

The current report highlights an unusual presentation of an FTMH overlying a large subfoveal serous PED and a good outcome with the surgical intervention.

Cazabon S has hypothesized that the elevation and stretching of the fovea due to an underlying PED makes it more vulnerable to vitreofoveal traction, thereby creating an FTMH.[1] Previous reports have shown the development of a macular hole after treating a subfoveal PED with anti-VEGF injections.[2,3,4,5] Our case differs from previously reported cases as it was a case of serous PED with no evidence of neovascularization. Hence, there was no history of intravitreal anti-VEGF injection in the past.

The response of an FTMH and the underlying PED to various treatment strategies has been varied in previous reports. Reiji VR et al. have reported a case with a large subfoveal serous PED that developed an FTMH after intravitreal anti-VEGF injection given for a suspected choroidal neovascular membrane (CNVM).[2] The case showed closure of the macular hole after surgery, but continued to have the PED. Clemens CR et al. reported a case of FTMH that developed after three anti-VEGF injections for a serous PED with CNVM.[3] The macular hole closed after vitrectomy, but the PED persisted. Mukherjee C et al. have presented a case series of five patients who developed FTMH after intravitreal ranibizumab injections for treatment of wet AMD.[4] Of these, two had vascularized PEDs, both of which flattened with ant-VEGF injections. The macular hole surgery was performed only in the first case and was successful. PS Meyer et al. have reported closure of macular hole, but a persistent PED, after vitrectomy and gas tamponade, in a case of subfoveal PED that developed a macular hole after receiving 19 intravitreal anti-VEGF injections.[5]

Azuma K et al. have reported an FTMH over a large drusenoid PED.[6] The macular hole closed after a second surgery, but the PED persisted. Inoue M et al. have reported two cases with FTMH overlying a serous PED.[7] The first case showed flattening of PED after photodynamic therapy (PDT) and multiple anti-VEGF injections, after which the macular hole closure was attained with vitrectomy and gas tamponade. In the second case, anti-VEGF and PDT did not flatten the PED, and the FTMH also failed to close with surgery. Later, the PED collapsed spontaneously, but the FTMH was persistent.

Contrary to previous reports, our case showed a complete flattening of the PED and simultaneous closure of the FTMH with vitrectomy, ILM peeling with inverse ILM flap, and gas tamponade.

The macular hole in our case possibly developed because of the transverse stretch on the fovea due to the large subfoveal PED. However, the contributory role of vitreomacular traction (VMT) cannot be ruled out, as we also saw a partial PVD with an operculum on the OCT. Our case, to the best of our knowledge is the only case to be reported that simultaneously showed complete flattening of the PED as well as closure of the macular hole, after vitrectomy with inverse ILM flap and gas tamponade.

To conclude, a large subfoveal PED can lead to the formation of macular hole, especially in the case of coexistent VMT. Pars plana vitrectomy with gas tamponade needs to be explored as a viable option to flatten large subfoveal PEDs when a macular hole is present or is impending, provided neovascularization has been ruled out.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.