Full-thickness macular hole in a patient with diabetic cystoid macular oedema treated by intravitreal triamcinolone injections

Scoping review of nonsurgical treatment options for macular holes

Macular holes (MH) are full-thickness retinal defects affecting central vision. While vitrectomy with inner limiting membrane (ILM) peel is the conventional MH treatment, non-surgical alternatives are gaining interest to mitigate surgical risks. This study conducted a comprehensive literature review and analysis of nonsurgical MH management. A systematic literature search was conducted on PubMed, Embase, Scopus, and the Cochrane Library from January 1, 1973, to September 13, 2023. Treatments included laser therapy, carbonic anhydrase inhibitors (CAIs), nonsteroidal antiinflammatory drugs (NSAIDs), steroids (topical, subtenons, peribulbar, intravitreal), intravitreal gas, anti-vascular endothelial growth factors and ocriplasmin injections. Data extraction covered study details, patient characteristics, MH features, treatment outcomes, and recurrence rates. The initial search yielded 3352 articles, refined to 83 articles that met inclusion criteria following screening. Overall reported anatomical closure rates were 36% with laser photocoagulation, 37% with intravitreal ocriplasmin, 55% with intravitreal gas. Closures were more frequently observed with topical NSAIDs (79%), steroids (84%) and CAIs (73%). Closures were more often observed in patients with smaller MH and in the presence of cystic macular oedema. Although non-surgical MH management approaches show potential for conservative therapy, evidence is limited to support routine use. Stage 1 and traumatic MH may benefit from a short period of observation, but the gold standard approach for full-thickness MH remains to be vitrectomy with ILM peel.

Prostaglandin-Induced Macular Hole: A Brief Report

This case series reports on two patients who developed macular holes while on prostaglandin analogs (PGA) therapy. The first case involves a 63-year-old woman with a history of a macular hole of the left eye that had spontaneously closed. After starting PGA therapy for elevated intraocular pressure, cystoid macular edema formed, which resulted in reopening of the macular hole. The second case involves a 64-year-old man with primary open-angle glaucoma, on PGA therapy, with a newly diagnosed small macular hole of the right eye that closed after cessation of the PGA therapy. These cases demonstrate an association between prostaglandin analogs and the formation or reopening of full-thickness macular holes. [Ophthalmic Surg Lasers Imaging Retina 2024;55:112-115.].

Full-thickness macular hole formation following antivascular endothelial growth factor injection in a case of hemicentral retinal vein occlusion

A rare case reporting the occurrence of full-thickness macular hole (MH) formation following intravitreal antivascular endothelial growth factor injection in a case of hemicentral retinal vein occlusion and the subsequent management of the case. As described in few other similar case reports in the literature, there are quite a few probabilities of factors causing this pathology. An acute posterior vitreous detachment or sudden decompression of the macular edema can quite possibly lead to the above situation. This case report shares light on the evolution of a MH following intravitreal injection and the subsequent treatment process.

Centrifuged-Concentrated Intravitreal Slurry Triamcinolone Acetonide: An Inexpensive, Easy, and Viable Alternative to Long-Term Steroid Delivery

Purpose:

This work reports the duration, safety, and viability of intravitreal slurry triamcinolone acetonide (TA; 1.0 mL of 40-mg/mL TA centrifuge concentrated into a 0.1-mL pellet) to treat cystoid macular edema (CME).

Methods:

A retrospective, consecutive review was conducted of patients undergoing intravitreal slurry TA injections, July 2009 to December 2018.

Results:

In 143 eyes of 120 patients, slurry TA resolved CME for a mean of 327.15 (SD = 213.11) days, or 10.76 (SD = 7.00) months, per intravitreal injection (n = 466). In 100 eyes requiring multiple injections (n = 423), mean duration was 270.95 (SD = 177.14) days, or 8.91 (SD = 5.82) months, between injections. In 43 single-injection eyes, duration was 749.30 (SD = 483.17) days, or 24.63 (SD = 15.88) months. Mean duration decreased from 337.89 (SD = 210.46) days, or 11.11 (SD = 6.92) months, in nonvitrectomized eyes to 279.74 (SD 179.63) days, or 9.20 (SD = 5.91) months, in vitrectomized eyes (n = 74 injections, t = 2.24, P = .014, 1-tailed). Central foveal thickness as shown on optical coherence tomography decreased by 173.89μ (SD = 147.56μ), from 459.16μ (SD = 47.14μ) to 285.27μ (SD = 77.27μ; t = –25.31, P < .001), within 43.41 days (SD = 36.86). Visual acuity improved from 20/100 (logMAR 0.70, SD = 0.33) to 20/74 (logMAR 0.57, SD = 0.31; SD = 0.21; t = –11.01, P < .001), within 33.98 (SD 24.98) days. Fifteen of 31 phakic eyes (48.39%) underwent cataract extraction. Fifty-seven eyes (39.86%) developed a steroid response (> 10 mm Hg increase from baseline) 94.79 days (SD = 85.52 days), or 3.11 (SD = 2.81) months, following injection.

Conclusions:

A single injection of slurry TA lasted on average 10.76 months with significant improvement of CME and visual acuity. Adverse ocular effects were comparable to currently available, long-term, implantable steroids. Slurry TA appears to be an easily reproducible, safe, and cost-effective alternative to long-term intraocular steroid delivery.

Two cases of diabetic macular edema complicated by an atypical macular hole

Background

Here we report two patients who developed an atypical macular hole (MH) during the treatment course for diabetic macular edema (DME).

Case presentations

Patient 1 was a 73-year-old male. Optical coherence tomography (OCT) revealed perifoveal retinoschisis (RS) in addition to cystoid macular edema and serous retinal detachment (SRD) in his left eye, and that an MH had developed during the clinical course. A convex surface was formed at the MH margin toward the vitreous cavity, and granular shadows were observed in the fluid cuff. Intraoperative findings revealed a thin epiretinal macular membrane (ERM) around the MH. Patient 2 was a 79-year-old male. Although the patient underwent pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) in both eyes, RS and a thin ERM in addition to SRD was observed in his left eye after surgery, and an MH developed during the clinical course. As in Patient 1, a convex surface was formed at the fluid cuff margin toward the vitreous cavity.

Conclusions

Both patients had persistent DME, SRD, RS, and a thin ERM before the development of the MH. OCT revealed the formation of a convex surface at the MH margin toward the vitreous cavity, suggesting that the fragility of the layered structure of the retina combined with tangential retinal traction may have been involved in the atypical MH form.

Case Series of Recurring Spontaneous Closure of Macular Hole

Macular hole can undergo spontaneous reopening and reclosure. This is a retrospective review of three patients who had spontaneous reopening and reclosure of previously spontaneously closed macular hole documented by optical coherence tomography. We report the first case of nivolumab-uveitis-associated macular hole formation. The authors hypothesize that cystoid macular edema (CME) might alter the integrity of foveal tissues or conversely the orientation of the macular hole edges and play a role in formation and resolution of a macular hole.

Lamellar macular hole formation in a patient with diabetic CME treated by intravitreal bevacizumab injections

A 49-year-old woman with a diagnosis of diabetic cystoid macular edema in both eyes presented with the appearance of a macular hole in the left eye 1 month after intravitreal bevacizumab injection. Optical coherence tomography demonstrated a lamellar macular hole in the left eye. Although vitreomacular traction and epiretinal membrane are the possible underlying causes for the development of lamellar macular hole formation in eyes with cystoid macular edema, in this case previous optical coherence tomography scans revealed the complete separation of the posterior hyaloid membrane and the absence of an epiretinal membrane. The exact mechanism involved in the progression of cystoid macular edema to lamellar macular hole and the contribution of the intravitreal bevacizumab injections to this transformation remain unclear.

Nine-month results of intravitreal bevacizumab versus triamcinolone for the treatment of diffuse diabetic macular oedema: a retrospective analysis

OBJECTIVE

To compare efficacy of intravitreal bevacizumab versus triamcinolone in the treatment of diffuse diabetic macular oedema (DME).

METHODS

This retrospective nonrandomized study includes 60 patients with diffuse DME treated with at least one intravitreal triamcinolone injection (ITA) or intravitreal bevacizumab injection (IBe). Regression analysis was performed for pretreatment, glycosylated haemoglobin level, visual acuity (VA) at baseline and central macular thickness (CMT) at baseline.

RESULTS

After 1-, 3-, 6- and 9-month follow-up, there was no significant change in either VA or CMT treatment in the ITA and IBe groups. There was no statistically significant difference between the two treatment groups. Changes in CMT and VA in the subgroups were not significant. Only predictive factor independent of HbA1c level and VA was CMT at baseline in both treatment groups. The thicker CMT at baseline, the higher was reduction in CMT. After 1 month, the IBe group had a significantly higher decrement than the ITA group.

CONCLUSION

In our study collective, neither IBe nor ITA treatment was able to improve VA during follow-up, significantly. CMT was reduced in both treatment groups, however not significantly. Our data demonstrates that reduction in CMT with either IBe or ITA treatment was significantly influenced by degree of CMT at baseline.

Foveal atrophy and macular hole formation following intravitreal ranibizumab with/without photodynamic therapy for choroidal neovascularization secondary to age-related macular degeneration

BACKGROUND

To report the occurrence of foveal atrophy and macular hole formation following intravitreal ranibizumab with or without photodynamic therapy for choroidal neovascularization caused by age-related macular degeneration.

METHODS

This was a retrospective, interventional case series, in which 78 eyes of 76 patients were treated for wet age-related macular degeneration between February 2007 and August 2007. Of these, three eyes developed foveal atrophy following treatment. Two eyes underwent combination photodynamic therapy and intravitreal ranibizumab, and one eye underwent intravitreal ranibizumab alone. One of the two eyes that underwent combination therapy progressed to develop a macular hole.

RESULTS

On the first follow-up visit, all three eyes showed thinning of the fovea on optical coherence tomography. Subsequently, treatment was continued with repeat intravitreal ranibizumab injections. At the last follow-up, although choroidal neovascularization regressed in all eyes, extensive foveal atrophy developed in two eyes with macular hole formation in one eye.

CONCLUSION

The possibility of foveal atrophy and macular hole formation must be borne in mind before initiating ranibizumab in combination with or without photodynamic therapy. However, larger studies with longer follow-up are required to understand such adverse effects better.

Secondary macular hole formation after vitrectomy

PURPOSE

The purpose of this study was to report the incidence and the underlying ocular pathology of a macular hole (MH) that develops in vitrectomized eyes and to evaluate its prognosis.

METHODS

A retrospective chart review was performed in patients who underwent vitrectomy between March 2004 and June 2009. Cases that developed an MH in vitrectomized eyes were identified, and the data from all ophthalmology examinations were collected. Patients with recurrent MHs after the initial MH surgery were excluded.

RESULTS

We identified 10 cases of secondary MH during a period of 64 months (incidence, 8 of 3,279 [0.24%]). Two cases of secondary MHs were not included in the calculations because the initial vitrectomies were performed before March 2004. The initial vitrectomy was performed on four eyes with vitreous hemorrhage caused by proliferative diabetic retinopathy, three eyes with retinal detachment from high myopia, one eye with combined retinal detachment with uveitis, one eye with rhegmatogenous retinal detachment, and one eye with an epiretinal membrane. The macular pathology identified before MH formation included cystoid macular edema in two eyes, epiretinal membrane in four eyes, and no specific lesion in another four eyes. The secondary MHs were managed by additional vitrectomy, peeling of the internal limiting membrane, and intravitreal gas tamponade. Nine of 10 eyes achieved hole closure after the secondary surgery, and 8 eyes recovered their previous visual acuity; the other 2 eyes had visual loss within 2 Snellen chart lines, and none of the 9 patients had a recurrence during a mean follow-up of 20.7 months (range, 4-31 months).

CONCLUSION

The development of secondary MHs after vitrectomy is rare. Pathogenic mechanisms other than idiopathic MH may be involved in these cases. The anatomical and functional outcome of the secondary MHs that developed after vitrectomy was good, although the final visual acuity was dependent on the underlying ocular pathology.

Full Thickness Macular Hole Formation in a Patient with Cystoid Macular Edema Caused by CRVO Treated with Intravitreal Bevacizicumab

Recent studies have shown the beneficial effect of intravitreal injections of Bevacizicumab in several ocular neovasular disorders, however, the possible adverse effects of this treatment have not been fully described. The authors report the development of a full thickness macular hole (FTMH) in a 44-year-old patient with cystoid macular edema secondary to central retinal vein occlusion after treatment with intravitreal injection of Bevacizicumab and describe its course after vitrectomy, internal limiting membrane peeling and gas tamponade.