- Email: [email protected]
Long-term Follow-up and Outcomes in Traumatic Macular Holes
Accepted Manuscript Long-term Follow-up and Outcomes in Traumatic Macular Holes John B. Miller, Yoshihiro Yonekawa, Dean Eliott, Ivana K. Kim, Leo A. Kim, John I. Loewenstein, Lucia Sobrin, Lucy H. Young, Shizuo Mukai, Demetrios G. Vavvas PII:
S0002-9394(15)00556-5
DOI:
10.1016/j.ajo.2015.09.004
Reference:
AJOPHT 9467
To appear in:
American Journal of Ophthalmology
Received Date: 11 April 2015 Revised Date:
3 September 2015
Accepted Date: 4 September 2015
Please cite this article as: Miller JB, Yonekawa Y, Eliott D, Kim IK, Kim LA, Loewenstein JI, Sobrin L, Young LH, Mukai S, Vavvas DG, Long-term Follow-up and Outcomes in Traumatic Macular Holes, American Journal of Ophthalmology (2015), doi: 10.1016/j.ajo.2015.09.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Purpose: To review presenting characteristics, clinical course, and long-term visual and anatomic outcomes of patients with traumatic macular holes at a tertiary referral center.
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Design: Retrospective case series.
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Methods: 28 consecutive patients with traumatic macular holes at a single tertiary referral center were reviewed. In addition to visual acuities and treatments throughout the clinical course, specific dimensions of the macular hole, including diameters, height, configuration, shape, and the presence of a cuff of fluid were examined using spectral-domain optical coherence tomography (OCT).
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Results: Twenty-eight patients were identified with a mean initial visual acuity (VA) of logMAR 1.3 (20/400) and a mean follow-up of 2.2 years. Eleven holes (39.3%) closed spontaneously in median 5.7 weeks. Eleven underwent vitrectomy with a median time to intervention of 35.1 weeks. Median time to surgery for the 5 eyes with successful hole closure was 11.0 weeks vs. 56.3 weeks for the 6 eyes that failed to close (P=.02). VA improved in closed holes (P<.01), whether spontaneously (P<.01) or via vitrectomy (P=.04), but VA did not improve in holes that did not close (P=.22). There was no relation between initial OCT dimensions and final hole closure status, although there was a trend that did not reach statistical significance towards small dimensions for those that closed spontaneously.
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Conclusions: A fairly high spontaneous closure rate was observed, with a trend towards smaller OCT dimensions. We found no relationship between hole closure and the OCT characteristics of the hole. Surgical intervention was less successful at hole closure when elected after 3 months.
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Short Title: Traumatic Macular Hole Outcomes
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Long-term Follow-up and Outcomes in Traumatic Macular Holes John B. Miller, Yoshihiro Yonekawa, Dean Eliott, Ivana K. Kim, Leo A. Kim, John I. Loewenstein, Lucia Sobrin, Lucy H. Young, Shizuo Mukai, and Demetrios G. Vavvas
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Retina Service Massachusetts Eye and Ear Infirmary Harvard Medical School Department of Ophthalmology 243 Charles Street, 12th floor Boston, MA 02114
Corresponding author: Demetrios G. Vavvas, MD PhD Retina Service Massachusetts Eye and Ear Infirmary Associate Professor Harvard Medical School 243 Charles Street, Boston, MA 02114 Telephone: 617-573-6874 Email: [email protected]
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Introduction:
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Traumatic macular holes occur in 1.4% of closed globe injuries and 0.15% of open globe injuries.1 They are most often associated with other retinal pathology, including commotio retinae, choroidal rupture, sclopetaria, or retinal breaks that can lead to severe vision loss. In contrast to idiopathic macular holes, traumatic macular holes arise from a sudden extrinsic force, often blunt trauma, creating dynamic forces within the sclera and vitreous.2 These variable forces lead to a wide range of clinical findings in traumatic macular holes. The advent of optical coherence tomography (OCT) and its more widespread clinical use allowed for more detailed analysis of these presenting characteristics. Huang et al., published the largest case series, reviewing the presenting OCTs of 73 traumatic macular holes.3 They reported average OCT measurements and configurations at presentation and compared those findings with those seen in a large series of idiopathic macular holes.4 However, they did not provide clinical course or OCT follow-up data on their traumatic macular hole cohort. Smaller case series and case reports have reviewed the clinical course of those traumatic macular holes that closed spontaneously. 5-9 Others have reviewed surgical outcomes in those cases that underwent vitrectomy. 2,10-13 The largest surgical outcomes review was a multicentered trial by Johnson et al. that reviewed 25 patients who underwent vitrectomy for traumatic macular hole at 9 different centers.2 A meta analysis of surgical outcomes in all published reports of vitrectomy for traumatic macular hole found a successful closure rate of 83%.14 Herein, we present the largest long-term follow-up case series of consecutive traumatic macular holes at a single tertiary referral center. By reviewing both initial and follow-up OCT data, we offer new insight into the evolution of this rare but debilitating condition. Furthermore, our analysis of surgical and non-surgical outcomes should assist retina specialists in making difficult management decisions.
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This is a retrospective case series of consecutive patients with traumatic macular holes that were evaluated at the Massachusetts Eye and Ear Infirmary from 2007 to 2012. The study protocol was approved by the Institutional Review Board of Massachusetts Eye and Ear Infirmary (IRB protocol #12-138). The protocol allowed retrospective data collection of patients with traumatic macular holes. The study complied with the Health Insurance Portability and Accountability Act of 1996. The type and location of the injury were recorded. Operative reports were analyzed for time to surgery and type of surgery. Visual acuity (VA) at the initial, preoperative, and final visits was recorded and converted to LogMAR. Comparisons of means were conducted using the Mann-Whitney U test, paired variables were analyzed using the Wilcoxon signed-rank test, and proportions were compared using Fisher’s Exact test. All statistical tests were two-tailed and significance was defined as P < 0.05. Stata version 9.0 (StataCorp, LP, College Station, Texas) was used for all statistical analyses.
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Specifics of the macular hole, such as diameter, height, configuration, and the presence of cystoid edema and subretinal fluid, were examined using Spectral-Domain OCT (Heidelberg Spectralis, Heidelberg, Germany and Zeiss Cirrus, Oberkochen, Germany). We set out to standardize the way in which macular holes are measured. In addition to the height (internal limiting membrane [ILM] to retinal pigment epithelium [RPE]), we recorded four specific diameters: the apical diameter, basal diameter, basal diameter including cuff of fluid, and the narrowest diameter (often considered the standard diameter OCT measurement). (Figure 1)
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Clinical Findings Twenty-eight patients with traumatic macular holes were identified. The mean age was 21 years and 82% were men. At presentation, 2 (7.1%) had open globe injuries, 17 (57.1%) had hyphema, 13 (46.4%) had vitreous hemorrhage, 1 (3.6%) had a posterior vitreous detachment (PVD), and 10 (38.5% of 26 with a view and records) had foveal commotio. Three patients had choroidal rupture, with only one involving the hole. Mean follow-up was 2.2 years. Mean initial VA was logMAR 1.3 (20/400).
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Optical Coherence Tomography Characteristics at Presentation Twenty eyes out of the 28 were imaged by OCT early in their clinical course. Their OCTs were reviewed. Seven of these OCTs were recorded only on paper printouts, thus detailed measurements were not included, although we do report their qualitative characteristics. For the remaining 13 eyes, several OCT measurements were recorded, including height, diameter (in four dimensions: basal, basal with cuff of fluid, apical, narrowest.), shape (circular or eccentric), presence of a cuff of fluid, and configuration (flat or flap) for each hole. The average OCT measurements were: basal diameter 1027µm, basal diameter including cuff of fluid 1288 µm, narrowest diameter 283 µm, apical diameter 487 µm, and a height 268 µm. (Figure 2). OCT confirmed that there was only one PVD at presentation.
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Hole Closure Eleven holes closed spontaneously (39.3%) (median 5.6 weeks, range 1.7 to 67.3 weeks). All but two of these spontaneous closures occurred by 11 weeks, with only one occurring greater than 4.5 months after presentation. The mean age of those patients that had their macular holes close spontaneously was 17.6 years (range 11-26 years), whereas the mean age of those that did not close was 23.5 (range 10-60 years) (P=0.359). The spontaneous closure rate was greater in children (<18 years old) at 50.0% (7/14) than in adults, 28.6% (4/14), but did not reach statistical significance (P=0.440). Eleven patients elected to undergo vitrectomy. Median time to intervention was 35.1 weeks. Five of 11 patients had successful closure. Median time to surgery for the 5 eyes with successful hole closure was 11.0 weeks and 56.3 weeks for the 6 eyes that failed to close (P=0.017). All patients without a prior PVD had intraoperative induction of a PVD. Ten had epiretinal membrane peeling, with eight of these also having the
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internal limiting membrane (ILM) peeled. During membrane peeling, triamcinolone, in 5 cases, and indocyanine green (ICG), in 2 cases, were used to assist visualization. Gas was used in 10 (90.9%) cases, with silicone oil tamponade employed in the other case. There were no trends in surgical success among these varying surgical techniques. Six patients did not receive intervention and their holes remained open. Two declined surgical intervention, two had surgery deferred due to the presence of foveal commotio and then ultimately declined repair, and two were lost to follow-up after extended observation of at least one year. (Figure 3)
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Visual outcomes For all 28 eyes in our study, the visual acuity (VA) improved overall from median logMAR 1.15 to 0.7 at the final follow-up visit (P<0.001). The VA did not improve in holes that did not close (P=0.694). In the 16 eyes with holes that closed, the VA improved from median logMAR 1.3 to 0.42 (P<0.001). In the 11 eyes with spontaneous hole closure, the VA improved from median logMAR 1.3 to 0.3 (P=0.003). In the 11 eyes that underwent vitrectomy, the VA improved from median logMAR 1.2 to 0.8 (P=0.016) with the five that closed surgically noting VA improvement from median logMAR 1.6 to 0.6 (P=0.043). In the holes that closed, those with an intact ellipsoid zone (EZ) band by OCT had a trend for better final visual acuity (P=0.067). Among all patients, there was no difference in final visual acuity whether or not the patient had foveal commotio at presentation (median 0.65 vs 0.65, P=0.918).
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Predictive value of Optical Coherence Tomography There was no relation between the initial dimensions of all traumatic macular holes and final closure status (Table 1). There was also no relation to hole closure if holes were classified according to shape, (circular vs. eccentric, P=0.666), configuration (flat vs. flap, P=0.666) and presence or absence of a cuff of fluid (P=0.384) In cases of spontaneous hole closure, the average initial measurements were smaller for all parameters but did not reach statistical significance.
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Optical Coherence Tomography Progression Of the holes that remained open throughout follow-up, many of the hole dimensions increased with time but this increase was only statistically significant for the apical diameter (median initial 469 um to 649 um, P=0.046). Discussion:
Traumatic macular hole is a serious complication that can produce severe vision loss after ocular trauma. The need to undergo surgical repair and the timing of a possible intervention is not well defined. We present a large consecutive case series of this relatively rare condition at a single tertiary referral center. We hope to offer new insight into the care of these patients by providing additional OCT information over extended follow-up with visual and surgical outcomes. We identified a fairly high spontaneous hole closure rate at nearly forty percent across all patients. The median time to closure was 5.6 weeks, with resolution occurring as quickly as 1.7 weeks. The spontaneous closure rate was greater in
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children than adults (50% vs. 28.6%). Smaller OCT dimensions appear to make spontaneous closure more likely, although this did not reach statistical significance in our study. Of those that did not close with observation, OCT parameters increased in size from presentation to last follow-up. This hole enlargement may indicate a poor prognosis for spontaneous closure and merit further consideration of surgical intervention. Vitrectomy remains a successful treatment option for traumatic macular 2,12,14 . We found a shorter time to surgery for those holes that closed in our study, holes with a median time to intervention of 11 weeks. We would advise a two to three-month observation period after traumatic macular hole presentation based on our data. Although spontaneous hole closure can occur even after 3 months, this is less likely and extended observation beyond three months likely leads to diminishing returns on successful hole closure via vitrectomy. Importantly, vision improved in all patients with hole closure, regardless of how hole closure occurred (observation or vitrectomy). An intact ellipsoid zone in closed holes tended to correlate with better final visual acuities. The presence of foveal commotio on presentation did not appear to affect final visual acuity. Our study has several limitations. Its retrospective design inevitably carries biases inherent in such studies. While one of the largest series on traumatic macular holes, the sample size is still limited, and the results may not be generalizable to all populations. Furthermore, the subjects received care at a group practice with different practice patterns between surgeons, although this also allowed comparison of difference treatment modalities and algorithms. In conclusion, we offer a large consecutive case series of traumatic macular holes at a single tertiary referral center with extended follow-up. We demonstrate a moderate spontaneous closure rate that most commonly occurred within 3 months after presentation. A timely vitrectomy within three months was more successful in closing traumatic macular holes than a delayed intervention. Our data suggest an initial observation period of up to three months followed by surgical repair with vitrectomy.
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Acknowledgements/Disclosures A. Funding/support: S Mukai: Mukai Fund of MEEI (Boston, MA).
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B. Financial disclosures: JB Miller: none; Y Yonekawa: none; D Eliott: consultant for Acucela (Tokyo, Japan), Alcon (Fort Worth, Texas), Alimera (Alpharetta, Georgia), Allergan (Dublin, Ireland), ArcticDx (Toronto, Canada), Avalanche (Menlo Park, California), Bausch & Lomb (Rochester, New York), Biogen (Cambridge, MA), Dutch Ophthalmic (Zuidland, Netherlands), Genentech (South San Francisco, California), Juvenile Diabetes Research Foundation (Wellesley, MA), Ocata Therapeutics (Marlborough, MA), Ophthotech (Princeton, New Jersey), Regeneron (Tarrytown, New York), Foundation for Fighting Blindness (Columbia, Maryland), Thrombogenics (Leuven, Belgium); IK Kim: none; LA Kim: none; JI Loewenstein: none; L Sobrin: Santen (Osaka, Japan); LH Young: none; S Mukai: Novartis (Basel, Switzerland); DG Vavvas: none.
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C. Contributions of Authors: Design and conduct of the study (JBM, YY, DGV); Collection, management, analysis, and interpretation of data (JBM, YY, DE, IKK, LAK, JIL, LS, LHY, SM, DGV); Preparation, review, or approval of the manuscript (JBM, YY, DE, IKK, LAK, JIL, LS, LHY, SM, DGV).
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References: Kuhn F, Morris R, Witherspoon CD, Mann L. Epidemiology of Blinding Trauma in the United States Eye Injury Registry. Ophthalmic Epidemiol. 2006;13(3):209– 216.
2.
Johnson RN, McDonald HR, Lewis H, et al. Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery. Ophthalmology. 2001;108(5):853–857.
3.
Huang J, Liu X, Wu Z, et al. Classification of full-thickness traumatic macular holes by optical coherence tomography. Retina. 2009;29(3):340–348.
4.
Huang J, Liu X, Wu Z, Sadda S. Comparison of full-thickness traumatic macular holes and idiopathic macular holes by optical coherence tomography. Graefes Arch Clin Exp Ophthalmol. 2010;248(8):1071–1075.
5.
Kusaka S, Fujikado T, Ikeda T, Tano Y. Spontaneous disappearance of traumatic macular holes in young patients. Am J Ophthalmol.1997;123(6):837-839.
6.
Yamashita T, Uemara A, Uchino E, Doi N, Ohba N. Spontaneous closure of traumatic macular hole. Am J Ophthalmol. 2002;133(2):230–235.
7.
Yamada H, Sakai A, Yamada E, Nishimura T, Matsumura M. Spontaneous closure of traumatic macular hole. Am J Ophthalmol. 2002;134(3):340–347.
8.
Lai MM, Joshi MM, Trese MT. Spontaneous resolution of traumatic macular holerelated retinal detachment. Am J Ophthalmol. 2006;141(6):1148–1151.
9.
Chen H, Zhang M, Huang S, Wu D. OCT and muti-focal ERG findings in spontaneous closure of bilateral traumatic macular holes. Doc Ophthalmol. 2008;116(2):159–164.
10.
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(12):1840–1845.
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García-Arumí J, Corcostegui B, Cavero L, Sararols L. The role of vitreoretinal surgery in the treatment of posttraumatic macular hole. Retina. 1997;17(5):372– 377. Amari F, Ogino N, Matsumura M, Negi A, Yoshimura N. Vitreous surgery for traumatic macular holes. Retina. 1999;19(5):410–413.
13.
Chow DR, Williams GA, Trese MT, Margherio RR, Ruby AJ, Ferrone PJ. Successful closure of traumatic macular holes. Retina. 1999;19(5):405–409.
14.
Miller JB, Yonekawa Y, Eliott D, Vavvas DG. A review of traumatic macular hole: diagnosis and treatment. Int Ophthalmol Clin. 2013;53(4):59–67. 7
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Figure Captions
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Figure 1. Traumatic Macular Hole Diameter Illustration. A representative optical coherence tomography scan of a traumatic macular hole is shown, demonstrating the four diameters recorded for our study: apical diameter (A), narrowest diameter (N), basal diameter (BD), and basal diameter plus cuff of fluid (BD+C).
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Figure 2. Average Traumatic Macular Hole Measurements Based on Clinical Course and Outcome. The average initial optical coherence tomography measurements are shown for each of the different dimensions based on final outcome and treatment method.
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Table Initial Traumatic Macular Hole Measurements Based on Final Closure Status Open
Closed
p value
Basal Diameter
877.3
1093
0.1590
Narrowest Diameter
354.3
252
Apical Diameter
498.8
481.2
Height
243.5
278.6
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(all in µm)
0.2704 0.9093 0.4250
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Biosketch
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Dr. John B. Miller is a new retina faculty member at Harvard and Mass. Eye and Ear Infirmary. After studying biology as an undergrad at MIT, he went on to medical school at the University of Michigan. He completed his ophthalmology residency and vitreoretinal fellowship at Mass. Eye and Ear. He completed a Heed Fellowship and won the Retina Society Margherio Award and the Macula Society Gragoudas awards during fellowship.
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S0002-9394(15)00556-5
DOI:
10.1016/j.ajo.2015.09.004
Reference:
AJOPHT 9467
To appear in:
American Journal of Ophthalmology
Received Date: 11 April 2015 Revised Date:
3 September 2015
Accepted Date: 4 September 2015
Please cite this article as: Miller JB, Yonekawa Y, Eliott D, Kim IK, Kim LA, Loewenstein JI, Sobrin L, Young LH, Mukai S, Vavvas DG, Long-term Follow-up and Outcomes in Traumatic Macular Holes, American Journal of Ophthalmology (2015), doi: 10.1016/j.ajo.2015.09.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Purpose: To review presenting characteristics, clinical course, and long-term visual and anatomic outcomes of patients with traumatic macular holes at a tertiary referral center.
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Design: Retrospective case series.
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Methods: 28 consecutive patients with traumatic macular holes at a single tertiary referral center were reviewed. In addition to visual acuities and treatments throughout the clinical course, specific dimensions of the macular hole, including diameters, height, configuration, shape, and the presence of a cuff of fluid were examined using spectral-domain optical coherence tomography (OCT).
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Results: Twenty-eight patients were identified with a mean initial visual acuity (VA) of logMAR 1.3 (20/400) and a mean follow-up of 2.2 years. Eleven holes (39.3%) closed spontaneously in median 5.7 weeks. Eleven underwent vitrectomy with a median time to intervention of 35.1 weeks. Median time to surgery for the 5 eyes with successful hole closure was 11.0 weeks vs. 56.3 weeks for the 6 eyes that failed to close (P=.02). VA improved in closed holes (P<.01), whether spontaneously (P<.01) or via vitrectomy (P=.04), but VA did not improve in holes that did not close (P=.22). There was no relation between initial OCT dimensions and final hole closure status, although there was a trend that did not reach statistical significance towards small dimensions for those that closed spontaneously.
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Conclusions: A fairly high spontaneous closure rate was observed, with a trend towards smaller OCT dimensions. We found no relationship between hole closure and the OCT characteristics of the hole. Surgical intervention was less successful at hole closure when elected after 3 months.
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Short Title: Traumatic Macular Hole Outcomes
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Long-term Follow-up and Outcomes in Traumatic Macular Holes John B. Miller, Yoshihiro Yonekawa, Dean Eliott, Ivana K. Kim, Leo A. Kim, John I. Loewenstein, Lucia Sobrin, Lucy H. Young, Shizuo Mukai, and Demetrios G. Vavvas
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Retina Service Massachusetts Eye and Ear Infirmary Harvard Medical School Department of Ophthalmology 243 Charles Street, 12th floor Boston, MA 02114
Corresponding author: Demetrios G. Vavvas, MD PhD Retina Service Massachusetts Eye and Ear Infirmary Associate Professor Harvard Medical School 243 Charles Street, Boston, MA 02114 Telephone: 617-573-6874 Email: [email protected]
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Introduction:
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Traumatic macular holes occur in 1.4% of closed globe injuries and 0.15% of open globe injuries.1 They are most often associated with other retinal pathology, including commotio retinae, choroidal rupture, sclopetaria, or retinal breaks that can lead to severe vision loss. In contrast to idiopathic macular holes, traumatic macular holes arise from a sudden extrinsic force, often blunt trauma, creating dynamic forces within the sclera and vitreous.2 These variable forces lead to a wide range of clinical findings in traumatic macular holes. The advent of optical coherence tomography (OCT) and its more widespread clinical use allowed for more detailed analysis of these presenting characteristics. Huang et al., published the largest case series, reviewing the presenting OCTs of 73 traumatic macular holes.3 They reported average OCT measurements and configurations at presentation and compared those findings with those seen in a large series of idiopathic macular holes.4 However, they did not provide clinical course or OCT follow-up data on their traumatic macular hole cohort. Smaller case series and case reports have reviewed the clinical course of those traumatic macular holes that closed spontaneously. 5-9 Others have reviewed surgical outcomes in those cases that underwent vitrectomy. 2,10-13 The largest surgical outcomes review was a multicentered trial by Johnson et al. that reviewed 25 patients who underwent vitrectomy for traumatic macular hole at 9 different centers.2 A meta analysis of surgical outcomes in all published reports of vitrectomy for traumatic macular hole found a successful closure rate of 83%.14 Herein, we present the largest long-term follow-up case series of consecutive traumatic macular holes at a single tertiary referral center. By reviewing both initial and follow-up OCT data, we offer new insight into the evolution of this rare but debilitating condition. Furthermore, our analysis of surgical and non-surgical outcomes should assist retina specialists in making difficult management decisions.
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This is a retrospective case series of consecutive patients with traumatic macular holes that were evaluated at the Massachusetts Eye and Ear Infirmary from 2007 to 2012. The study protocol was approved by the Institutional Review Board of Massachusetts Eye and Ear Infirmary (IRB protocol #12-138). The protocol allowed retrospective data collection of patients with traumatic macular holes. The study complied with the Health Insurance Portability and Accountability Act of 1996. The type and location of the injury were recorded. Operative reports were analyzed for time to surgery and type of surgery. Visual acuity (VA) at the initial, preoperative, and final visits was recorded and converted to LogMAR. Comparisons of means were conducted using the Mann-Whitney U test, paired variables were analyzed using the Wilcoxon signed-rank test, and proportions were compared using Fisher’s Exact test. All statistical tests were two-tailed and significance was defined as P < 0.05. Stata version 9.0 (StataCorp, LP, College Station, Texas) was used for all statistical analyses.
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Specifics of the macular hole, such as diameter, height, configuration, and the presence of cystoid edema and subretinal fluid, were examined using Spectral-Domain OCT (Heidelberg Spectralis, Heidelberg, Germany and Zeiss Cirrus, Oberkochen, Germany). We set out to standardize the way in which macular holes are measured. In addition to the height (internal limiting membrane [ILM] to retinal pigment epithelium [RPE]), we recorded four specific diameters: the apical diameter, basal diameter, basal diameter including cuff of fluid, and the narrowest diameter (often considered the standard diameter OCT measurement). (Figure 1)
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Clinical Findings Twenty-eight patients with traumatic macular holes were identified. The mean age was 21 years and 82% were men. At presentation, 2 (7.1%) had open globe injuries, 17 (57.1%) had hyphema, 13 (46.4%) had vitreous hemorrhage, 1 (3.6%) had a posterior vitreous detachment (PVD), and 10 (38.5% of 26 with a view and records) had foveal commotio. Three patients had choroidal rupture, with only one involving the hole. Mean follow-up was 2.2 years. Mean initial VA was logMAR 1.3 (20/400).
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Optical Coherence Tomography Characteristics at Presentation Twenty eyes out of the 28 were imaged by OCT early in their clinical course. Their OCTs were reviewed. Seven of these OCTs were recorded only on paper printouts, thus detailed measurements were not included, although we do report their qualitative characteristics. For the remaining 13 eyes, several OCT measurements were recorded, including height, diameter (in four dimensions: basal, basal with cuff of fluid, apical, narrowest.), shape (circular or eccentric), presence of a cuff of fluid, and configuration (flat or flap) for each hole. The average OCT measurements were: basal diameter 1027µm, basal diameter including cuff of fluid 1288 µm, narrowest diameter 283 µm, apical diameter 487 µm, and a height 268 µm. (Figure 2). OCT confirmed that there was only one PVD at presentation.
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Hole Closure Eleven holes closed spontaneously (39.3%) (median 5.6 weeks, range 1.7 to 67.3 weeks). All but two of these spontaneous closures occurred by 11 weeks, with only one occurring greater than 4.5 months after presentation. The mean age of those patients that had their macular holes close spontaneously was 17.6 years (range 11-26 years), whereas the mean age of those that did not close was 23.5 (range 10-60 years) (P=0.359). The spontaneous closure rate was greater in children (<18 years old) at 50.0% (7/14) than in adults, 28.6% (4/14), but did not reach statistical significance (P=0.440). Eleven patients elected to undergo vitrectomy. Median time to intervention was 35.1 weeks. Five of 11 patients had successful closure. Median time to surgery for the 5 eyes with successful hole closure was 11.0 weeks and 56.3 weeks for the 6 eyes that failed to close (P=0.017). All patients without a prior PVD had intraoperative induction of a PVD. Ten had epiretinal membrane peeling, with eight of these also having the
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internal limiting membrane (ILM) peeled. During membrane peeling, triamcinolone, in 5 cases, and indocyanine green (ICG), in 2 cases, were used to assist visualization. Gas was used in 10 (90.9%) cases, with silicone oil tamponade employed in the other case. There were no trends in surgical success among these varying surgical techniques. Six patients did not receive intervention and their holes remained open. Two declined surgical intervention, two had surgery deferred due to the presence of foveal commotio and then ultimately declined repair, and two were lost to follow-up after extended observation of at least one year. (Figure 3)
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Visual outcomes For all 28 eyes in our study, the visual acuity (VA) improved overall from median logMAR 1.15 to 0.7 at the final follow-up visit (P<0.001). The VA did not improve in holes that did not close (P=0.694). In the 16 eyes with holes that closed, the VA improved from median logMAR 1.3 to 0.42 (P<0.001). In the 11 eyes with spontaneous hole closure, the VA improved from median logMAR 1.3 to 0.3 (P=0.003). In the 11 eyes that underwent vitrectomy, the VA improved from median logMAR 1.2 to 0.8 (P=0.016) with the five that closed surgically noting VA improvement from median logMAR 1.6 to 0.6 (P=0.043). In the holes that closed, those with an intact ellipsoid zone (EZ) band by OCT had a trend for better final visual acuity (P=0.067). Among all patients, there was no difference in final visual acuity whether or not the patient had foveal commotio at presentation (median 0.65 vs 0.65, P=0.918).
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Predictive value of Optical Coherence Tomography There was no relation between the initial dimensions of all traumatic macular holes and final closure status (Table 1). There was also no relation to hole closure if holes were classified according to shape, (circular vs. eccentric, P=0.666), configuration (flat vs. flap, P=0.666) and presence or absence of a cuff of fluid (P=0.384) In cases of spontaneous hole closure, the average initial measurements were smaller for all parameters but did not reach statistical significance.
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Optical Coherence Tomography Progression Of the holes that remained open throughout follow-up, many of the hole dimensions increased with time but this increase was only statistically significant for the apical diameter (median initial 469 um to 649 um, P=0.046). Discussion:
Traumatic macular hole is a serious complication that can produce severe vision loss after ocular trauma. The need to undergo surgical repair and the timing of a possible intervention is not well defined. We present a large consecutive case series of this relatively rare condition at a single tertiary referral center. We hope to offer new insight into the care of these patients by providing additional OCT information over extended follow-up with visual and surgical outcomes. We identified a fairly high spontaneous hole closure rate at nearly forty percent across all patients. The median time to closure was 5.6 weeks, with resolution occurring as quickly as 1.7 weeks. The spontaneous closure rate was greater in
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children than adults (50% vs. 28.6%). Smaller OCT dimensions appear to make spontaneous closure more likely, although this did not reach statistical significance in our study. Of those that did not close with observation, OCT parameters increased in size from presentation to last follow-up. This hole enlargement may indicate a poor prognosis for spontaneous closure and merit further consideration of surgical intervention. Vitrectomy remains a successful treatment option for traumatic macular 2,12,14 . We found a shorter time to surgery for those holes that closed in our study, holes with a median time to intervention of 11 weeks. We would advise a two to three-month observation period after traumatic macular hole presentation based on our data. Although spontaneous hole closure can occur even after 3 months, this is less likely and extended observation beyond three months likely leads to diminishing returns on successful hole closure via vitrectomy. Importantly, vision improved in all patients with hole closure, regardless of how hole closure occurred (observation or vitrectomy). An intact ellipsoid zone in closed holes tended to correlate with better final visual acuities. The presence of foveal commotio on presentation did not appear to affect final visual acuity. Our study has several limitations. Its retrospective design inevitably carries biases inherent in such studies. While one of the largest series on traumatic macular holes, the sample size is still limited, and the results may not be generalizable to all populations. Furthermore, the subjects received care at a group practice with different practice patterns between surgeons, although this also allowed comparison of difference treatment modalities and algorithms. In conclusion, we offer a large consecutive case series of traumatic macular holes at a single tertiary referral center with extended follow-up. We demonstrate a moderate spontaneous closure rate that most commonly occurred within 3 months after presentation. A timely vitrectomy within three months was more successful in closing traumatic macular holes than a delayed intervention. Our data suggest an initial observation period of up to three months followed by surgical repair with vitrectomy.
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Acknowledgements/Disclosures A. Funding/support: S Mukai: Mukai Fund of MEEI (Boston, MA).
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B. Financial disclosures: JB Miller: none; Y Yonekawa: none; D Eliott: consultant for Acucela (Tokyo, Japan), Alcon (Fort Worth, Texas), Alimera (Alpharetta, Georgia), Allergan (Dublin, Ireland), ArcticDx (Toronto, Canada), Avalanche (Menlo Park, California), Bausch & Lomb (Rochester, New York), Biogen (Cambridge, MA), Dutch Ophthalmic (Zuidland, Netherlands), Genentech (South San Francisco, California), Juvenile Diabetes Research Foundation (Wellesley, MA), Ocata Therapeutics (Marlborough, MA), Ophthotech (Princeton, New Jersey), Regeneron (Tarrytown, New York), Foundation for Fighting Blindness (Columbia, Maryland), Thrombogenics (Leuven, Belgium); IK Kim: none; LA Kim: none; JI Loewenstein: none; L Sobrin: Santen (Osaka, Japan); LH Young: none; S Mukai: Novartis (Basel, Switzerland); DG Vavvas: none.
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C. Contributions of Authors: Design and conduct of the study (JBM, YY, DGV); Collection, management, analysis, and interpretation of data (JBM, YY, DE, IKK, LAK, JIL, LS, LHY, SM, DGV); Preparation, review, or approval of the manuscript (JBM, YY, DE, IKK, LAK, JIL, LS, LHY, SM, DGV).
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References: Kuhn F, Morris R, Witherspoon CD, Mann L. Epidemiology of Blinding Trauma in the United States Eye Injury Registry. Ophthalmic Epidemiol. 2006;13(3):209– 216.
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Johnson RN, McDonald HR, Lewis H, et al. Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery. Ophthalmology. 2001;108(5):853–857.
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Huang J, Liu X, Wu Z, et al. Classification of full-thickness traumatic macular holes by optical coherence tomography. Retina. 2009;29(3):340–348.
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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(12):1840–1845.
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García-Arumí J, Corcostegui B, Cavero L, Sararols L. The role of vitreoretinal surgery in the treatment of posttraumatic macular hole. Retina. 1997;17(5):372– 377. Amari F, Ogino N, Matsumura M, Negi A, Yoshimura N. Vitreous surgery for traumatic macular holes. Retina. 1999;19(5):410–413.
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Chow DR, Williams GA, Trese MT, Margherio RR, Ruby AJ, Ferrone PJ. Successful closure of traumatic macular holes. Retina. 1999;19(5):405–409.
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Miller JB, Yonekawa Y, Eliott D, Vavvas DG. A review of traumatic macular hole: diagnosis and treatment. Int Ophthalmol Clin. 2013;53(4):59–67. 7
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Figure Captions
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Figure 1. Traumatic Macular Hole Diameter Illustration. A representative optical coherence tomography scan of a traumatic macular hole is shown, demonstrating the four diameters recorded for our study: apical diameter (A), narrowest diameter (N), basal diameter (BD), and basal diameter plus cuff of fluid (BD+C).
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Figure 2. Average Traumatic Macular Hole Measurements Based on Clinical Course and Outcome. The average initial optical coherence tomography measurements are shown for each of the different dimensions based on final outcome and treatment method.
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Table Initial Traumatic Macular Hole Measurements Based on Final Closure Status Open
Closed
p value
Basal Diameter
877.3
1093
0.1590
Narrowest Diameter
354.3
252
Apical Diameter
498.8
481.2
Height
243.5
278.6
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(all in µm)
0.2704 0.9093 0.4250
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Biosketch
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Dr. John B. Miller is a new retina faculty member at Harvard and Mass. Eye and Ear Infirmary. After studying biology as an undergrad at MIT, he went on to medical school at the University of Michigan. He completed his ophthalmology residency and vitreoretinal fellowship at Mass. Eye and Ear. He completed a Heed Fellowship and won the Retina Society Margherio Award and the Macula Society Gragoudas awards during fellowship.
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