- Email: [email protected]
Spontaneous closure of traumatic macular hole in a pediatric patient
Accepted Manuscript Spontaneous closure of traumatic macular hole in a pediatric patient Isabel Pascual-Camps, MD, Honorio Barranco-González, MD, Rosa Dolz-Marco, MD, PhD, Roberto Gallego-Pinazo, MD, PhD PII:
S1091-8531(17)30572-4
DOI:
10.1016/j.jaapos.2017.04.009
Reference:
YMPA 2650
To appear in:
Journal of AAPOS
Received Date: 5 June 2016 Revised Date:
22 March 2017
Accepted Date: 8 April 2017
Please cite this article as: Pascual-Camps I, Barranco-González H, Dolz-Marco R, Gallego-Pinazo R, Spontaneous closure of traumatic macular hole in a pediatric patient, Journal of AAPOS (2017), doi: 10.1016/j.jaapos.2017.04.009. 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.
ACCEPTED MANUSCRIPT
Spontaneous closure of traumatic macular hole in a pediatric patient Isabel Pascual-Camps ,MD,a Honorio Barranco-González, MD,a Rosa Dolz-Marco, MD, PhD,b,c and Roberto Gallego-Pinazo, MD, PhDb,c,d
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Author affiliations: aUnit of Pediatric Ophthalmology, Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain; bHealth Research Institute, University and Polytechnic Hospital La Fe, Valencia, Spain; cRETICS RD160008 Ocular Diseases, Prevention, Early Detection, Treatment and Rehabilitation of Ocular Disease, Health Institute Carlos III, Madrid, Spain; dUnit of Macula, Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain
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Submitted June 5, 2016. Revision accepted April 8, 2017.
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Correspondence: Isabel Pascual Camps, Av. Fernando Abril Martorell 106, 46026, Valencia, Spain (email: [email protected]).
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Word count: 891
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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.
RI PT
Although macular holes are usually of idiopathic origin, traumatic macular holes (TMH) are not uncommon, especially in children. Nevertheless, they constitute an infrequent cause of vision loss during childhood. Most pediatric TMH are due to blunt trauma, and cases of spontaneous
SC
hole closure have been reported in the scientific literature, although vitrectomy remains as the therapeutic choice for their management. We present a case of spontaneous closure of TMH in a
M AN U
child. Case Report
A 14-year-old boy presented to the emergency room at University and Polytechnic Hospital La Fe after blunt trauma in his right eye. No relevant systemic or ocular history was referred. On
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examination, his visual acuity was 20/100 in the right eye and 20/20 in the left eye. Slit-lamp examination revealed mild anterior uveitis. Dilated fundus examination evidenced an inferotemporal vitreous hemorrhage, inferonasal retinal edema, intrarretinal hemorrhages in the
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inferior retina, and a central macular hole (Figure 1A). High-resolution macular optical coherence tomography (OCT) was performed, showing
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subretinal fluid and thinning of the external retinal layers, without complete defect of the retinal tissue. Hyperreflective dots in vitreous chamber secondary to vitreal hemorrhage were also observed (Figure 1B).
Five days later the lesion evolved into a full-thickness macular hole, 184 µm in diameter.
However, visual acuity improved to 20/50 in his right eye. In the OCT a macular hole affecting the complete neurosensory retina except for a minimal residual bridge of photoreceptors with
ACCEPTED MANUSCRIPT
disrupted outer segments could be observed (eFigure 1). Ten days after trauma visual acuity remained stable, and OCT scans revealed incomplete spontaneous closure of the macular hole, with bridging of the superficial retinal layers (eFigure
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2).
Through the following weeks, the progressive closure was monitored with OCT. Visual acuity improved to 20/25 in the right eye by the time the OCT scans revealed closure of the
SC
defect of the superficial layers, with persistence of the external layers defect, 8 weeks later
(Figure 2). The actual outer nuclear layer thickness after closure was 31 µm, less than the 84 µm
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of the fellow eye. Discussion
Ocular trauma is associated with many retinal complications, including hemorrhages, edema, choroidal ruptures, and macular holes. Traumatic macular holes are uncommon, with an
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incidence of 1%-9% of ocular trauma cases.1
It has been hypothesized that the force transmitted to the macula by sudden compression of the globe may induce retinal stress resulting in foveal “rupture”2; it has also been observed
EP
that traumatic macular holes are usually elliptic, as was our patient’s, rather than round. The mechanism of spontaneous closure of traumatic macular holes remains poorly understood,
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however. The bridge seen in eFigure 2 may be the internal limiting membrane or the hyaloid crossing the gap, but it has been suggested that glial elements may play a role in repair of macular holes.3
The timing and procedures for a therapeutic approach to traumatic macular holes are
controversial. Johnson and colleagues2 reported 25 cases in which vitrectomy was performed, achieving 96% of anatomic success and visual acuity of at least 20/50 in 64% of cases.2 Wu and
ACCEPTED MANUSCRIPT
colleagues4 reported 13 pediatric patients in which vitrectomy with adjunctive autologous plasmin showed a closure rate of 92% and visual acuity of at least 20/50 in 50% of cases. Observation for spontaneous closure has also been considered. Mitamura and colleagues5
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observed 11 cases, reporting 64% spontaneous closure rate; all of the macular holes were small, with no posterior vitreous detachment and relatively good final visual acuity. Yamada and
colleagues6 also advocated waiting for spontaneous closure. There is no consensus on how long
SC
to wait for spontaneous closure before attempting surgical repair; however, 6 months has been suggested.6 Treatment recommendations in adults differs, because hole closure and visual acuity
M AN U
improvement in patients undergoing surgery are significantly higher than those observed in children.7
Arevalo and colleagues8 studied traumatic macular holes using OCT imaging and observed that there could be full-thickness loss of retinal tissue, an operculum totally detached or
TE D
partially adhering to the hole’s edge, epirretinal membrane, and abnormalities in the surrounding retina. Most importantly, they observed that the morphology of the edges of the defect depended on the time between trauma and diagnosis of macular hole.
EP
Traumatic macular holes have also been classified by OCT imaging. Huang and colleagues9 described 5 types depending on the presence of cysts in one or both edges, in vertical
AC C
or horizontal scans, presence of detachment and presence of thinning of the neurosensory retina. Chen and colleagues10 studied the prediction of spontaneous closure of traumatic macular
hole based on OCT and observed that the absence of intrarretinal cysts was associated with higher probability of spontaneous closure. Our case represents a spontaneous closure of a small full-thickness macular hole with excellent visual outcome, illustrated with OCT imaging from the initial visit, at which point only
ACCEPTED MANUSCRIPT
a partial-thickness macular hole and subretinal fluid was found. Spontaneous closure of traumatic macular holes is not rare. Treatment and observation are both acceptable options. We suggest observing for 6 months or until pronounced worsening, when surgery would be
RI PT
advisable. It is also essential to follow the patient with OCT imaging, because this can be helpful
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EP
TE D
M AN U
SC
in predicting outcomes and highlight signs of early initiation of spontaneous closure.
ACCEPTED MANUSCRIPT
References 1.
Gill MK, Lou PL. Traumatic macular holes. Int Ophthalmol Clin 2002;42:97-106.
2.
Johnson RN, McDonald HR, Lewis H, et al. Traumatic macular hole: observations,
3.
RI PT
pathogenesis, and results of vitrectomy surgery. Ophthalmology 2001;108:853-7.
Hara S, Sakuraba T, Nakazawa M. Morphological changes of retinal pigment epithelial and glial cells at the site of experimental retinal holes. Graefes Arch Clin Exp
4.
SC
Ophthalmol 2000;238:690-95.
Wu WC, Drenser KA, Trese MT, Williams GA, Capone A. Pediatric traumatic macular
M AN U
hole: results of autologous plasmin enzyme-assisted vitrectomy. Am J Ophthalmol 2007;144:668-72. 5.
Mitamura Y, Saito W, Ishida M, Yamamoto S, Takeuchi S. Spontaneous closure of traumatic macular hole. Retina 2001;21:385-9.
Yamada H, Sakai A, Yamada E, Nishimura T, Matsumura M. Spontaneous closure of
TE D
6.
traumatic macular hole. Am J Ophthalmol 2002;134:340-47. 7.
Gao M, Liu K, Lin Q, Liu H. Management modalities for traumatic macular hole: a
8.
EP
systematic review and single-arm meta-analysis. Curr Eye Res 2017;42:287-96. Arevalo JF, Sanchez JG, Costa RA, et al. Optical coherence tomography characteristics
9.
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of full-thickness traumatic macular holes. Eye (Lond) 2008;22:1436-41.
Huang J, Liu X, Wu Z, et al. Classification of full-thickness traumatic macular holes by
optical coherence tomography. Retina 2009;29:340-48.
10.
Chen H, Chen W, Zheng K, Peng K, Xia H, Zhu L. Prediction of spontaneous closure of traumatic macular hole with spectral domain optical coherence tomography. Sci Rep 2015;5:12343.
ACCEPTED MANUSCRIPT
Legends FIG 1. A, Fundus photograph showing inferotemporal vitreous hemorrhage and central macular hole. B, Macular OCT showing subretinal fluid and thinning of the external retinal layers,
RI PT
without complete defect of the retinal tissue; there are hyperreflective dots in the vitreous, in the context of the vitreal hemorrhage.
FIG 2. Macular OCT 8 weeks after trauma revealing closure of the defect of the internal layers,
upper (A) and lower (C) cuts show no residual hole.
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with persistence of the external layers defect and subretinal fluid could be observed (B). The
M AN U
eFIG 1. A, Fundus photograph showing macular hole. B, Macular OCT showing the macular hole affecting the complete neurosensory retina. The outer nuclear layer is dissected, and there is almost a lamellar dissection of the photoreceptor layer nasally to the fovea. There is a minimal thin line that bridges the limits of the hole.
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eFIG 2. Macular OCT 10 days after trauma, showing incomplete spontaneous closure of the
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macular hole and bridging of the superficial retinal layers.
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S1091-8531(17)30572-4
DOI:
10.1016/j.jaapos.2017.04.009
Reference:
YMPA 2650
To appear in:
Journal of AAPOS
Received Date: 5 June 2016 Revised Date:
22 March 2017
Accepted Date: 8 April 2017
Please cite this article as: Pascual-Camps I, Barranco-González H, Dolz-Marco R, Gallego-Pinazo R, Spontaneous closure of traumatic macular hole in a pediatric patient, Journal of AAPOS (2017), doi: 10.1016/j.jaapos.2017.04.009. 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.
ACCEPTED MANUSCRIPT
Spontaneous closure of traumatic macular hole in a pediatric patient Isabel Pascual-Camps ,MD,a Honorio Barranco-González, MD,a Rosa Dolz-Marco, MD, PhD,b,c and Roberto Gallego-Pinazo, MD, PhDb,c,d
RI PT
Author affiliations: aUnit of Pediatric Ophthalmology, Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain; bHealth Research Institute, University and Polytechnic Hospital La Fe, Valencia, Spain; cRETICS RD160008 Ocular Diseases, Prevention, Early Detection, Treatment and Rehabilitation of Ocular Disease, Health Institute Carlos III, Madrid, Spain; dUnit of Macula, Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain
SC
Submitted June 5, 2016. Revision accepted April 8, 2017.
M AN U
Correspondence: Isabel Pascual Camps, Av. Fernando Abril Martorell 106, 46026, Valencia, Spain (email: [email protected]).
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Word count: 891
ACCEPTED MANUSCRIPT
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.
RI PT
Although macular holes are usually of idiopathic origin, traumatic macular holes (TMH) are not uncommon, especially in children. Nevertheless, they constitute an infrequent cause of vision loss during childhood. Most pediatric TMH are due to blunt trauma, and cases of spontaneous
SC
hole closure have been reported in the scientific literature, although vitrectomy remains as the therapeutic choice for their management. We present a case of spontaneous closure of TMH in a
M AN U
child. Case Report
A 14-year-old boy presented to the emergency room at University and Polytechnic Hospital La Fe after blunt trauma in his right eye. No relevant systemic or ocular history was referred. On
TE D
examination, his visual acuity was 20/100 in the right eye and 20/20 in the left eye. Slit-lamp examination revealed mild anterior uveitis. Dilated fundus examination evidenced an inferotemporal vitreous hemorrhage, inferonasal retinal edema, intrarretinal hemorrhages in the
EP
inferior retina, and a central macular hole (Figure 1A). High-resolution macular optical coherence tomography (OCT) was performed, showing
AC C
subretinal fluid and thinning of the external retinal layers, without complete defect of the retinal tissue. Hyperreflective dots in vitreous chamber secondary to vitreal hemorrhage were also observed (Figure 1B).
Five days later the lesion evolved into a full-thickness macular hole, 184 µm in diameter.
However, visual acuity improved to 20/50 in his right eye. In the OCT a macular hole affecting the complete neurosensory retina except for a minimal residual bridge of photoreceptors with
ACCEPTED MANUSCRIPT
disrupted outer segments could be observed (eFigure 1). Ten days after trauma visual acuity remained stable, and OCT scans revealed incomplete spontaneous closure of the macular hole, with bridging of the superficial retinal layers (eFigure
RI PT
2).
Through the following weeks, the progressive closure was monitored with OCT. Visual acuity improved to 20/25 in the right eye by the time the OCT scans revealed closure of the
SC
defect of the superficial layers, with persistence of the external layers defect, 8 weeks later
(Figure 2). The actual outer nuclear layer thickness after closure was 31 µm, less than the 84 µm
M AN U
of the fellow eye. Discussion
Ocular trauma is associated with many retinal complications, including hemorrhages, edema, choroidal ruptures, and macular holes. Traumatic macular holes are uncommon, with an
TE D
incidence of 1%-9% of ocular trauma cases.1
It has been hypothesized that the force transmitted to the macula by sudden compression of the globe may induce retinal stress resulting in foveal “rupture”2; it has also been observed
EP
that traumatic macular holes are usually elliptic, as was our patient’s, rather than round. The mechanism of spontaneous closure of traumatic macular holes remains poorly understood,
AC C
however. The bridge seen in eFigure 2 may be the internal limiting membrane or the hyaloid crossing the gap, but it has been suggested that glial elements may play a role in repair of macular holes.3
The timing and procedures for a therapeutic approach to traumatic macular holes are
controversial. Johnson and colleagues2 reported 25 cases in which vitrectomy was performed, achieving 96% of anatomic success and visual acuity of at least 20/50 in 64% of cases.2 Wu and
ACCEPTED MANUSCRIPT
colleagues4 reported 13 pediatric patients in which vitrectomy with adjunctive autologous plasmin showed a closure rate of 92% and visual acuity of at least 20/50 in 50% of cases. Observation for spontaneous closure has also been considered. Mitamura and colleagues5
RI PT
observed 11 cases, reporting 64% spontaneous closure rate; all of the macular holes were small, with no posterior vitreous detachment and relatively good final visual acuity. Yamada and
colleagues6 also advocated waiting for spontaneous closure. There is no consensus on how long
SC
to wait for spontaneous closure before attempting surgical repair; however, 6 months has been suggested.6 Treatment recommendations in adults differs, because hole closure and visual acuity
M AN U
improvement in patients undergoing surgery are significantly higher than those observed in children.7
Arevalo and colleagues8 studied traumatic macular holes using OCT imaging and observed that there could be full-thickness loss of retinal tissue, an operculum totally detached or
TE D
partially adhering to the hole’s edge, epirretinal membrane, and abnormalities in the surrounding retina. Most importantly, they observed that the morphology of the edges of the defect depended on the time between trauma and diagnosis of macular hole.
EP
Traumatic macular holes have also been classified by OCT imaging. Huang and colleagues9 described 5 types depending on the presence of cysts in one or both edges, in vertical
AC C
or horizontal scans, presence of detachment and presence of thinning of the neurosensory retina. Chen and colleagues10 studied the prediction of spontaneous closure of traumatic macular
hole based on OCT and observed that the absence of intrarretinal cysts was associated with higher probability of spontaneous closure. Our case represents a spontaneous closure of a small full-thickness macular hole with excellent visual outcome, illustrated with OCT imaging from the initial visit, at which point only
ACCEPTED MANUSCRIPT
a partial-thickness macular hole and subretinal fluid was found. Spontaneous closure of traumatic macular holes is not rare. Treatment and observation are both acceptable options. We suggest observing for 6 months or until pronounced worsening, when surgery would be
RI PT
advisable. It is also essential to follow the patient with OCT imaging, because this can be helpful
AC C
EP
TE D
M AN U
SC
in predicting outcomes and highlight signs of early initiation of spontaneous closure.
ACCEPTED MANUSCRIPT
References 1.
Gill MK, Lou PL. Traumatic macular holes. Int Ophthalmol Clin 2002;42:97-106.
2.
Johnson RN, McDonald HR, Lewis H, et al. Traumatic macular hole: observations,
3.
RI PT
pathogenesis, and results of vitrectomy surgery. Ophthalmology 2001;108:853-7.
Hara S, Sakuraba T, Nakazawa M. Morphological changes of retinal pigment epithelial and glial cells at the site of experimental retinal holes. Graefes Arch Clin Exp
4.
SC
Ophthalmol 2000;238:690-95.
Wu WC, Drenser KA, Trese MT, Williams GA, Capone A. Pediatric traumatic macular
M AN U
hole: results of autologous plasmin enzyme-assisted vitrectomy. Am J Ophthalmol 2007;144:668-72. 5.
Mitamura Y, Saito W, Ishida M, Yamamoto S, Takeuchi S. Spontaneous closure of traumatic macular hole. Retina 2001;21:385-9.
Yamada H, Sakai A, Yamada E, Nishimura T, Matsumura M. Spontaneous closure of
TE D
6.
traumatic macular hole. Am J Ophthalmol 2002;134:340-47. 7.
Gao M, Liu K, Lin Q, Liu H. Management modalities for traumatic macular hole: a
8.
EP
systematic review and single-arm meta-analysis. Curr Eye Res 2017;42:287-96. Arevalo JF, Sanchez JG, Costa RA, et al. Optical coherence tomography characteristics
9.
AC C
of full-thickness traumatic macular holes. Eye (Lond) 2008;22:1436-41.
Huang J, Liu X, Wu Z, et al. Classification of full-thickness traumatic macular holes by
optical coherence tomography. Retina 2009;29:340-48.
10.
Chen H, Chen W, Zheng K, Peng K, Xia H, Zhu L. Prediction of spontaneous closure of traumatic macular hole with spectral domain optical coherence tomography. Sci Rep 2015;5:12343.
ACCEPTED MANUSCRIPT
Legends FIG 1. A, Fundus photograph showing inferotemporal vitreous hemorrhage and central macular hole. B, Macular OCT showing subretinal fluid and thinning of the external retinal layers,
RI PT
without complete defect of the retinal tissue; there are hyperreflective dots in the vitreous, in the context of the vitreal hemorrhage.
FIG 2. Macular OCT 8 weeks after trauma revealing closure of the defect of the internal layers,
upper (A) and lower (C) cuts show no residual hole.
SC
with persistence of the external layers defect and subretinal fluid could be observed (B). The
M AN U
eFIG 1. A, Fundus photograph showing macular hole. B, Macular OCT showing the macular hole affecting the complete neurosensory retina. The outer nuclear layer is dissected, and there is almost a lamellar dissection of the photoreceptor layer nasally to the fovea. There is a minimal thin line that bridges the limits of the hole.
TE D
eFIG 2. Macular OCT 10 days after trauma, showing incomplete spontaneous closure of the
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macular hole and bridging of the superficial retinal layers.
AC C
EP
TE D
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