Management Modalities for Traumatic Macular Hole: A Systematic Review and Single-Arm Meta-Analysis

Pediatric and Adolescent Traumatic Macular Hole: A Systematic Review

PURPOSE

The optimal management of pediatric traumatic macular holes (TMH) is unclear from lack of prospective randomized trials. The literature is divided into early (≤1month post-trauma), delayed (>1 month) pars plana vitrectomy (PPV), and observation. Our aim is to find which group can achieve best-superior spectacle corrected visual acuity (VA), visual gain, and time for hole closure.

DESIGN

Systematic review.

METHODS

This systematic review was registered with PROSPERO (ID:CRD42022383134). The databases searched from inception until July 31, 2023, were MEDLINE OVID, Scopus, Web of Science, Embase, and Google Scholar. The articles were screened for title and abstract then for full text. Risk of bias was also assessed. Three outcome measures were analyzed: final VA, visual gain, and time to closure of macular hole (MH). MH size was divided into small (≤250 µm), medium (>250-500 µm), and large (>500 µm).

RESULTS

Ninety eight (98) studies with 234 patients in the PPV group and 87 patients in the observation group were included in the review. Final VA (logarithm of the minimum angle of resolution) and visual gain were respectively in PPV vs observation groups: (1) small MH 0.37 ± 0.52 vs 0.42 ± 0.56 (P = .484) and -0.96 ± 0.83 vs -0.49 ± 0.40 (P = .005); (2) medium MH 0.58 ± 0.39 vs 0.34 ± 0.34 (P = .06) and -0.36 ± 0.42 vs -0.74 ± 0.44 (P < .001); (3) large MH 0.62 ± 0.42 vs 0.59 ± 0.35 (P = .337) and -0.31 ± 0.48 vs -0.62 ± 0.37 (P = .11). Small TMH had comparable closure time: 3.21 ± 2.52 months vs 3.49 ± 4.43 (P = .954) in the PPV and observation groups. Early and late PPV yielded comparable final VA 0.67 ± 0.66 vs 0.54 ± 0.35 (P = .576) and visual gain -0.58 ± 0.69 vs -0.49 ± 0.48 (P = .242) in the PPV and observation groups.

CONCLUSIONS

PPV was very effective in closing TMH and VA gain in children throughout a wide range of hole size. Early and delayed PPV yielded similar anatomic and visual results. Observation and PPV yielded comparable final VA and closure time. Clinicians can choose either early PPV or delayed PPV when healing biomarkers are absent on periodic optical coherence tomography.

Etiologies and clinical characteristics of macular hole: An 8-year, single-center, retrospective study

To investigate the etiologies and clinical characteristics of full-thickness macular hole (FTMH) cases at Shanxi Eye Hospital in North China. Patients diagnosed with FTMH who underwent surgery from 2012 to 2020 were included, and the etiologies and clinical features of MH types were analyzed in an 8-year, cross-sectional, retrospective study. A total of 752 cases (776 eyes) were analyzed. The top 3 subtypes of MH were idiopathic (IMH, 64.4%), myopic (MMH, 21.1%) and traumatic (TMH, 3.7%) MH. Among these, there were significant differences in sex, age, and baseline best-corrected visual acuity (BCVA) distributions. Females predominated in the IMH and MMH groups, while males predominated in the TMH group. The IMH onset age was older than the MMH and TMH onset ages. Baseline BCVA in the IMH (Z = 8.9, P < .001) and the other group (Z = 4.0, P < .001) was significantly better than that in the MMH group. In the IMH group, females were younger, had a shorter axial length (AL), and had a worse baseline BCVA than males, while in the MMH group, there were no significant sex differences. Multivariate correlation analysis showed that a smaller hole diameter in IMH, no retinal detachment in MMH, and a younger age in TMH may result in better baseline BCVA. The most common MH etiologies were IMH, MMH and TMH, which contributed to differences in clinical features. Females predominated in the IMH and MMH groups, and the onset of MMH occurred 6.5 years earlier than the onset of IMH. Therefore, early fundus monitoring in females and high myopia patients is helpful for the early detection and treatment of MH.

Eccentric Fixation and Good Visual Acuity in a Child with Large Traumatic Macular Hole: A Case Report

A girl of 8 years old was referred to our clinic with a history of penetrating injury to her left eye 6 years ago with light perception vision and a large traumatic macular hole in her right eye. Her right eye's vision was 4/10 when she first visited our clinic. Considering the patient's one-eye status, her parents' reluctance to undergo surgery, and the possibility of spontaneous closure of traumatic macular holes, it was determined to observe the patient and evaluate her visual acuity and macular hole condition. In 2 years, the final best corrected visual acuity was 8/10 in the right eye, with infratemporal eccentric fixation in visuoscopy. In addition to evaluating and reporting this case as a traumatic macular hole, we will discuss the role of nonsurgical treatment and the possibility of good visual acuity with eccentric fixation in a child with large traumatic macular hole.

A case of Nd:YAG laser-induced traumatic macular hole with good visual prognosis after vitrectomy with inverted internal limiting membrane technique

Purpose

To report an accidental case of traumatic macular hole caused by Nd:YAG laser in a dermatology clinic.

Observations

A 24-year-old woman sustained a laser injury to her right eye while practicing a dermatologic treatment using a Nd:YAG laser without wearing protective goggles. She noticed sudden-onset and progressing visual loss in her right eye and consulted an ophthalmologist 2 days after injury. The best-corrected visual acuity (BCVA) of her right eye decreased to 20/133. Fundus examination showed white parafoveal flecks with a central retinal hemorrhage and underlying serous retinal detachment. The retinal sensitivity in this lesion deteriorated. Two weeks later, a full-thickness macular hole (FTMH) developed in the affected eye. She was referred to Nagoya City University Hospital where the laser damage described was observed. The BCVA was 20/67. She underwent pars plana vitrectomy performed using the inverted internal limiting membrane (ILM) flap technique and gas tamponade. One week postoperatively, the FTMH closed, the BCVA in her right eye improved to 20/50, and the retinal sensitivity in the macular area mostly improved. The BCVA gradually improved and reached 20/25 9 months after the injury.

Conclusions and importance

Protective goggles must be worn when using an Nd:YAG laser in the laboratory or clinical setting. In the unfortunate event of a FTMH, early vitrectomy with an inverted ILM flap technique can be helpful to achieve a good visual prognosis.

Vitrectomy vs. Spontaneous Closure for Traumatic Macular Hole: A Systematic Review and Meta-Analysis

Objective: This systematic review and meta-analysis aimed to determine the traumatic macular hole (TMH) closure rate and visual acuity (VA) improvement rate by comparing two treatment methods for TMH: vitrectomy and observation for spontaneous closure. Methods: PubMed, Cochrane, Web of Science Library, Embase, CNKI, Wanfang, VIP, and Sino Med were systematically searched from their inception to June 10, 2021. Studies in the surgery group (n = 32) and studies in the observation group (n = 12) were meta-analyzed. The primary outcomes were the TMH closure and VA improvement rates in the surgery and observation groups. The secondary outcomes were best-corrected visual acuity (BCVA) improvement in the surgery group. Stata software (version 15.1) was used for the analyses. Results: Thirty-six studies that included 1,009 eyes were selected for this meta-analysis, among which 33 were retrospective studies and 3 were prospective studies. The meta-analysis showed that the random-model pooled event rate for TMH closure was 0.37 (95% confidence interval [CI], 0.26-0.48) in the observation group, while it was 0.9 (95% CI, 0.85-0.94) in the surgery group. The fixed-model pooled event rate for VA improvement was 0.39 (95% CI, 0.33-0.45) in the observation group, while the random-model pooled event rate of VA improvement for the surgery group was 0.72 (95% CI, 0.63-0.80). The pooled event rate for BCVA improvement in the surgery group was 0.39 (95% CI, 0.33-0.46). Conclusions: This meta-analysis suggests that TMH hole closure and VA improvement rates in the surgery group were significantly higher than those in the observation group. Vitrectomy is an effective method for treating TMH. However, further randomized controlled trials (RCTs) are required to evaluate the efficacy and safety of surgery and observation for TMH treatment. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021276684.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

Cell composition at the vitreomacular interface in traumatic macular holes

Purpose

To describe characteristics of the vitreomacular interface (VMI) in traumatic macular holes (TMH) compared to idiopathic macular holes (IMH) using immunofluorescence and electron microscopy, and to correlate with clinical data.

Methods

For immunocytochemical and ultrastructural analyses, premacular tissue with internal limiting membrane (ILM) and epiretinal membrane (ERM) was harvested during vitrectomy from 5 eyes with TMH and 5 eyes with IMH. All specimens were processed as flat mounts for phase-contrast microscopy, interference and fluorescence microscopy, and transmission electron microscopy (TEM). Primary antibodies were used against microglial and macroglial cells. Clinical data was retrospectively evaluated.

Results

Surgically excised premacular tissue of eyes with TMH showed a less pronounced positive immunoreactivity for anti-glutamine synthetase, anti-vimentin and anti-IBA1 compared to eyes with IMH. Cell nuclei staining of the flat-mounted specimens as well as TEM presented a lower cell count in eyes with TMH compared to IMH. All detected cells were found on the vitreal side of the ILM. No collagen fibrils were seen in specimens of TMH. According to patients’ age, intraoperative data as well as spectral-domain optical coherence tomography (SD-OCT) analysis revealed an attached posterior vitreous in the majority of TMH cases (60%), whereas all eyes with IMH presented posterior vitreous detachment.

Conclusion

The vitreomacular interface in TMH and IMH shows significant differences. In TMH, glial cells are a rare finding on the vitreal side of the ILM.

Surgical Treatment for Traumatic Macular Holes: Reconstructive Changes in Foveal Microstructures and Visual Predictors Analysis

PURPOSE

To investigate the reconstructive changes in foveal microstructures postoperatively and analyze the visual predictors in eyes with surgically closed traumatic macular holes (TMHs).

METHODS

Seventy-one eyes with TMHs that underwent vitrectomy, internal limiting membrane (ILM) peeling, and gas tamponade were reviewed. Clinical data, best-corrected visual acuity, and spectral-domain optical coherence tomography (SD-OCT) images were recorded. The length of the ellipsoid zone (EZ) defect and the integrity of postoperative external limiting membrane (ELM) were measured. Preoperative and 1-month postoperative features were analyzed, respectively, as potential predictors of visual acuity at 6 months postoperatively.

RESULTS

The primary hole closure rate was 90.14% (64/71). In 43 cases of initially closed TMHs with SD-OCT scans preoperatively and at 1 and 6 months postoperatively, the number of eyes with intact ELM increased from 18 (41.86%) at 1 month to 26 (60.47%) at 6 months (p = 0.08), while the number of eyes with a restored EZ band remained the same in 2 eyes (4.65%). The mean length of the EZ defect progressively decreased postoperatively (p < 0.001). Poorer preoperative visual acuity (p = 0.002), lower mean macular hole (MH) height (p = 0.012), and greater preoperative mean length of EZ defect (p < 0.001) were associated with worse visual acuity 6 months postoperatively, but only the preoperative length of the EZ defect was proved to be a predictor, with the cutoff value of 1,800 μm provided by the receiver-operating characteristics (ROC) curve. Worse visual acuity and greater mean length of the EZ defect at 1 month were also associated with worse final visual acuity.

CONCLUSIONS

The mean length of the EZ defect both preoperatively and 1 month postoperatively were predictors of visual outcomes at 6 months postoperatively.

Etiologies, Characteristics, and Management of Pediatric Macular Hole

PURPOSE

To report on the etiologies and prognosis of macular hole (MH) in children and to explore the indicators of spontaneous hole closure and poor final visual outcome (vision worse than 20/200).

DESIGN

Consecutive, retrospective case series.

METHODS

A consecutive series of patients aged less than 16 years with a full-thickness macular hole treated from 2013 to 2019 in a singer tertiary center was retrospectively reviewed. Data collected from charts included age, sex, best-corrected visual acuity (BCVA), etiology of MH, size of MH, clinical findings, operations, and anatomic and functional outcomes. Logistic regression models were built to establish the predisposing factors.

RESULTS

Forty eyes of 40 patients were included. Patients were predominantly male with a mean age of 8.3 years. Among the etiologies, trauma prevailed in 29 (72.5%) eyes. Twenty-nine patients underwent surgery, and 18 (62.1%) had traumatic MH. All had achieved hole closure. BCVA improved at the final visit. Spontaneous closure was found in 10 (25%) eyes after an average 2 months after trauma. Regression analysis showed that a relatively smaller macular hole (P = .006) was likely to experience spontaneous closure. Presence of macular lesions (P = .001) was identified as risk factor for poor final vision.

CONCLUSIONS

Most pediatric MH was caused by blunt trauma. BCVA improved after MH closed, regardless of surgery or spontaneous closure. Smaller MH secondary to trauma was more likely to experience spontaneous closure with an average time of 2 months. Presence of macular lesions was a risk factor for final poor vision.

Treatment of Secondary Full-Thickness Macular Holes with Topical Therapy

PURPOSE

To report the outcomes of secondary full-thickness macular holes (FTMHs) treated with topical therapy.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients with secondary FTHMs initially treated with topical therapy in a referral-based retina practice.

METHODS

Patients evaluated between April 14, 2016, and February 22, 2019, for secondary FTMHs who underwent topical therapy were included. Patient demographics, ocular history, type of drops used, duration of therapy, and duration of follow-up as well as anatomic features on OCT, including hole diameter and presence of vitreomacular traction, epiretinal membrane (ERM), and cystoid macular edema (CME), were analyzed.

MAIN OUTCOME MEASURES

Closure rate of FTMHs and change in visual acuity.

RESULTS

A total of 123 FTMHs were seen during the study, of which 12 were secondary macular holes. Topical therapy was attempted in 9 eyes (8 patients). Six of these 9 FTMHs were associated with prior retinal detachment (RD). Previous pars plana vitrectomy (PPV) had been performed in 3 eyes (1 for RD, 2 for ERM). One eye had vitreomacular traction and a remote history of blunt trauma. Average initial hole diameter was 79.6 μm (range, 44-132 μm). Average follow-up was 53 weeks (range, 5-153 weeks). All FTMHs had some element of ERM and CME. All patients received difluprednate with the addition of a topical carbonic anhydrase inhibitor in 6 eyes and nonsteroidal anti-inflammatory drug (NSAID) drops in 2 eyes. Eight eyes (89%) achieved successful hole closure and resolution of CME with concurrent improvement in visual acuity after an average of 6 weeks of therapy (range, 2-19 weeks). Average vision among all 9 eyes improved from 0.69 to 0.37 logarithm of the minimum angle of resolution (Snellen equivalent from approximately 20/100 to approximately 20/50). No episodes of corneal melts or ulcers occurred. One patient showed mild keratopathy and elevation of intraocular pressure with topical NSAID and steroid therapy that resolved when the topical NSAID was stopped and difluprednate was tapered down to once weekly.

CONCLUSIONS

Topical therapy achieved high closure rates in secondary FTMH and can be considered as an initial treatment option especially in those with small holes and CME.

[Vitreomacular Interface Diseases: Vitreomacular Adhesion, Vitreomacular Traction, Epiretinal Membranes, and Macular Hole]

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. This review presents the sequence of events due to complicated persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction, VMT; macular hole, MH; epiretinal membrane). Pathologic aspects, clinical features, diagnostic implications, and current management strategies are described. Observation, pharmacologic vitreolysis with Ocriplasmin, and surgical treatment are positioned as treatment options for different diseases.

Traumatic Macular Hole: Diagnosis, Natural History, and Management

Traumatic macular hole occurs most often in young men and can present after various types of injuries. Traumatic macular holes result from anteroposterior and tangential vitreoretinal traction and may exhibit concurrent additional pathologies such as Berlin's edema and subretinal fluid. Optical coherence tomography can play an essential role in patient management both at presentation and during follow-up. Initial management consists of observation, but macular hole repair can be performed if spontaneous resolution does not occur. Upon macular hole closure, vision may improve, on average, by two lines or more but may be limited by associated macular pathology.

Surgical Repair of Traumatic Macular Holes With Extreme Macular Pathology Using an Internal Limiting Membrane Flap Technique

This report describes the use of inverted internal limiting membrane (ILM) flap technique as a treatment option for traumatic macular holes (MHs) with severe macular pathology. An interventional case series of two patients who experienced blunt trauma is reported. One patient developed two adjacent MHs and the second patient a MH with focal tissue avulsion in the fovea. Each patient underwent pars plana vitrectomy with ILM flap creation and intraocular gas tamponade. The ILM flap technique was successfully used for closure of MHs in one patient with a traumatic double MH and another patient with MH with foveal tissue avulsion. Visual acuity and symptoms improved in both patients. The ILM flap technique is a useful option for patients even with advanced pathologic findings subsequent to traumatic MH formation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e143-e146.].

Spontaneous closure of traumatic macular hole in a pediatric patient

We present the case of a 14-year-old boy with ocular trauma and the complete eye-tracking OCT imaging follow-up of the development and later spontaneous closure of a secondary macular hole.