OCT and muti-focal ERG findings in spontaneous closure of bilateral traumatic macular holes

Size: px

Start display at page:

Download "OCT and muti-focal ERG findings in spontaneous closure of bilateral traumatic macular holes"

Nelson Miller
5 years ago
Views:

1 Doc Ophthalmol (2008) 116: DOI /s CASE REPORT OCT and muti-focal ERG findings in spontaneous closure of bilateral traumatic macular holes Hongling Chen Æ Mingzhi Zhang Æ Shizhou Huang Æ Dezheng Wu Received: 26 September 2007 / Accepted: 2 November 2007 / Published online: 18 January 2008 Ó Springer-Verlag 2008 Abstract Purpose To report the spontaneous closure of bilateral traumatic macular holes in a young patient, followed up with optical coherence tomography (OCT), muti-focal electroretinogram (mferg), and Humphrey visual field examination. Methods A 25-year-old male who suffered from bilateral blunt trauma to the eyes and developed traumatic macular holes was followed with ophthalmic examination, OCT, mferg, and Humphrey visual field examination. Results The OCT results revealed spontaneous closure in both eyes 2 weeks after trauma, and the macular holes remained closed in the 7 months of follow-up. Visual acuity improved to 0.7 in right and 0.9 in left eye finally. Visual field examination and mferg results improved slightly compared with the initial tests. However, there still were central scotomas in both eyes, especially in right eye at the end of follow-up, and the peaks of the retinal response density had not recovered in the macular area of the mferg topography. Conclusions Spontaneous closure of unilateral traumatic macular hole is not H. Chen M. Zhang Joint Shantou International Eye Center (JSIEC) of The Shantou University/The Chinese University of Hong Kong, North Dongxia Road (Guangxia New Town), Shantou, Guangdong , China S. Huang D. Wu (&) Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, 54 S. Xianlie Road, Guangzhou , China dezhengwu@126.com uncommon, but there is no report of spontaneous closure of bilateral traumatic macular holes as yet. Since the traumatic macular holes may close spontaneously, traumatic macular holes may be observed for a period of follow-up. Keywords Macular hole Traumatic Bilateral Muti-focal electroretinogram Introduction Traumatic macular hole (TMH) is a well-recognized complication of ocular trauma, especially with the documentation of optical coherence tomography (OCT). Previous reports [1 3] showed that spontenous closure of TMH is common and often occurs in young patients, and the macular hole rarely complicated with cuff of subretinal fluid, or posterior vitreous detachment. The macular hole closed spontaneously for 1 week to 4 months after trauma in about half of patients according to previous reports. Spontenous closure of TMH in previous reports was all unilateral, however, we reported a case of bilateral TMH with spontaneous resolution. Materials and methods A 25-year-old man who complained immediate bilateral vision drop following the hit on head by a

160 Doc Ophthalmol (2008) 116:159 164 football 3 days before had been followed up for 7 months.

2 160 Doc Ophthalmol (2008) 116: football 3 days before had been followed up for 7 months. Fundus examination, OCT, best-corrected visual acuity (BCVA), multi-focal electroretinogram (mferg), and Humphrey automated visual field were examinated during the follow-up. In order to compare the patient s mferg results with those of normal controls, present study also included mferg results of 13 patients (15 eyes) with age of 13- to 29-year-old (mean 22.3). mferg was recorded using the Visual Evoked Response Imaging System (VERIS) (EDI. San Mateo, CA) according to the ISCEV guidelines for basic mferg (2003) [4]. The stimulus matrix consisted of 103 hexagonal elements that were displayed through cathode ray tube (CRT) delivery system, and driven at 75 Hz frame rate. The hexagons were modulated between white (200 cd/m 2 ) and black (\2 cd/m 2 ) according to an m-sequence during recordings. The diameter of the stimulus array subtended a visual angle of approximately 45 and the 8 min recordings were made in second-long segments. Retinal signals were filtered at Hz and amplified 100,000- times. Pupils were maximally dilated with tropicamide and phenylephrine hydrochloride. A gold ground electrode was attached to the forehead. Retinal activity was recorded monocularly with a Burian-Allen bipolar contact lens electrode which was placed on the anesthesized cornea. retinal edema around upper vascular arc. The most important fundus finding was a small full-thickness macular hole in both the eyes. The OCT also revealed full-thickness macular hole in both eyes not complicated by cuff of subretinal fluid and posterior vitreous detachment (Fig. 1). Results of mferg the next day showed retinal response density decreased dramatically in the macular region in both eyes and the right eye was more severe (Fig. 2a, b). Retinal response density and implicit time of N1 and P1 were shown in Tables 1 and 2, respectively. Two weeks after the trauma, BCVA improved to 0.1 in right eye and 0.04 in left eye. OCT results showed macular hole was closed spontaneously with restoration of the foveal depression and hyperrelective Results Ophthalmic examination record shortly after the trauma in local hospital showed grade I hyphema in both eyes. Visual acuity was light perception in the right eye and finger counting in the left eye. During the 3 days of hospitalization in the local hospital, hemostyptic drugs were used and when he presented to us there was not obvious hyphema in both eyes. Thorough ophthalmic examinations were done by one of us. BCVA was 0.01 in both eyes with 3.5 diopters. Biomicroscopic slitlamp examination revealed both pupils were round with diameter of 4 mm, but light reflex is retarded slightly. Refracting media was clear in both eyes. Fundus examination revealed extensive Berlin retinal edema in the posterior pole, especially the temporal macular region in the right eye, while retinal edema in the left eye is much less obvious except a small region of 1 PD Fig. 1 Optical coherence tomography (OCT) results. Three days after blunt trauma, OCT revealed full-thickness macular holes in both eyes. Two weeks after the trauma, macular hole was closed with restoration of the foveal depression and hyperrelective tissue in the fovea in the right eye, while there was foveal retinal detachment-like finding in the left eye even though macular hole was also closed. OCT at the fourth week, third month and seventh month after blunt trauma showed the macular holes remained closed

Doc Ophthalmol (2008) 116:159 164 161 Fig. 2 MfERG images.

3 Doc Ophthalmol (2008) 116: Fig. 2 MfERG images. Three days after blunt trauma, retinal response density decreased dramatically in the macular region in both eyes and the right eye is more severe (a, b). At the end of follow-up, namely 7 months after blunt trauma, retinal response density in the macular region in both eyes increased slightly, but still far from normal with the absence of the central peak (c, d). Compared to the right eye, the recovery of final visual function of the left eye was a little better Table 1 Retinal response density and implicit time of N1 in normal youth and the patient Amplitude (nv/deg2) Implicit time (ms) Control 3 days 7 months Control 3 days 7 months OD OS OD OS OD OS OD OS Ring ± ± Ring ± ± Ring ± ± Ring ± ± Ring ± ± Ring ± ± Table 2 Retinal response density and implicit time of P1 in normal youth and the patient Amplitude (nv/deg2) Implicit time (ms) Control 3 days 7 months Control 3 days 7 months OD OS OD OS OD OS OD OS Ring ± ± Ring ± ± Ring ± ± Ring ± ± Ring ± ± Ring ± ±

4 162 Doc Ophthalmol (2008) 116: tissue in the fovea in the right eye, while there was foveal retinal detachment-like finding in the left eye even though macular hole was also closed (Fig. 1). Fundus examination found partially resolved macular edema in both eyes. Four weeks after the trauma, best-corrected visual acuity improved to 0.4 in right eye and 0.5 in left eye. OCT of both eyes showed macular holes remained closed (Fig. 1). However, Humphrey automated visual field test at that time revealed central scotoma in both eyes (Fig. 3a, b) and scotoma in the right eye is much more denser (Fig. 3a). At 6 weeks, 3 and 7 months after the trauma, OCT of both eyes showed macular holes remained closed (Fig. 1). Fundus photography and fluorescein angiography (FFA) at 4 months revealed RPE atrophy and scar in the macular region in both eyes, especially the right eye (Fig. 4). BCVA of both eyes improved gradually since the closure of macular holes. At the end of follow-up, namely 7 months after the trauma, BCVA was 0.7 in the right eye and 0.9 in the left eye. However, there was still dense central and paracentral scotoma in the right eye (Fig. 3c), while scotoma in the left eye is much less denser (Fig. 3d). Final results of mferg showed partial recovery of electrical activity at the posterior pole region, but still far from normal with the absence of the central peak (Fig. 2c, d). Retinal response density and implicit time of N1 and P1 were shown in Tables 1 and 2, respectively. Fig. 3 Central 10-2 visual field test results. Four weeks after the trauma, there was central scotoma at the nasal part of central 10 visual field in the right eye (a), while there was a relatively small scotoma at nasalinferior part of central 10 visual field in the left eye (b). At the end of follow-up, namely 7 months after the trauma, central scotoma had not changed very much in the right eye (c) while the central scotoma in the left eye became less dense (d)

Doc Ophthalmol (2008) 116:159 164 163 Fig. 4 Fundus photograph and fluorescein angiography.

5 Doc Ophthalmol (2008) 116: Fig. 4 Fundus photograph and fluorescein angiography. Four months after the trauma, there was large area of scar and RPE atrophy at the fovea and temporal region of macular in the right eye (a, b). There was 1/2 9 1/2 PD area of RPE atrophy and scar above the fovea and there was spots of RPE atrophy and scar in the fovea in the left eye (c, d) Discussion Spontaneous closure of TMH is common, but there is no report of bilateral spontaneous closure of TMH. Different mechanisms are believed to lead to the formation of TMH. Yanagiya et al. [5] found an attached vitreous body in most cases and hypothesized that trauma cause direct rupture of the fovea. Based on high-speed photography of blunt trauma, Johnson et al. [6] proposed that an outward extension of the equator caused flattening of the retina and tangential traction. The acute, transient nature of tangential traction may explain the frequent occurrence of spontaneous reapproximation of the edges of the hole. Yamashita et al. [3] reported 18 cases of unilateral TMH with 8 cases achieved spontaneous closure. All eight patients were males with a mean age of 14.6 years and the major cause of injury was sports-related accidents. The hole was small up to 0.3-disk diameter in size. All 8 eyes had a variable degree of commotio retinae in the posterior fundus. During a follow-up without surgical intervention the posterior commotio retinae resolved gradually and the macular hole closed with or without atrophic changes in the surrounding retina. In concert with the anatomic improvement, all 8 eyes showed visual acuity improvement. In the present report, we reported a case of bilateral TMH with spontaneous closure in both eyes in a 25-year-old man. Results were similar to those reported by Yamashita et al. [3]. In conclusion, spontaneous closure of TMH often occurs in young patients, and the macular hole rarely complicated with cuff of subretinal fluid, or posterior vitreous detachment. The macular hole closed spontaneously 1 week to 4 months after trauma in about half of patients according to previous reports. Tissue proliferation, possibly by glial cells or RPE cells may play an important role in the spontaneous closure of the macular hole, because cell proliferation is likely to be vigorous in young patients [1]. This suggestion is consistent with the clinicopathologic study of idiopathic macular hole by Guyer et al. [7], in which three idiopathic macular holes were spontaneously closed by RPE or glial cell proliferation. In the present report, OCT taken shortly after macular hole color showed edges of macular hole was connected by hyperrelective tissue which suggested to be glial RPE cell proliferation (Fig. 1). Direct or secondary factors of ocular contussion both can lead to permanent fovea damage or necrosis, so even if TMH is closed through fibroglial proliferation, the photoreceptor lost cannot be replaced.

6 164 Doc Ophthalmol (2008) 116: This may be the reason why the visual acuity, visual field and mferg remain abormal although the hole is closed. References 1. Kusaka S, Fujikado T, Ikeda T et al (1997) Spontaneous disappearance of traumatic macular holes in young patients. Am J Ophthalmol : Yamada H, Sakai A, Yamada E et al (2002) Spontaneous closure of traumatic macular hole. Am J Ophthalmol 134: Yamashita T, Uemara A, Uchino E, Doi N, Ohba N (2002) Spontaneous closure of traumatic macular hole. Am J Ophthalmol 133: Marmor MF, Hood DC, Keating D et al (2003) Guidelines for basic multifocal electroretinography (mferg). Doc Ophthalmol 106: Yanagiya N, Akiba J, Takahashi M et al (1996) Clinical characteristics of traumatic macular hole. Jpn J Ophthalmol 40: Johnson NR, McDonald RM, Lewis H, et al (2001) Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery. Ophthalmology 108: Guyer DR, Green WR, de Bustros S et al (1990) Histopathologic features of idiopathic macular holes and cysts. Ophthalmology 97:

Assessment of macular function by multifocal electroretinogram before and after macular hole surgery

Assessment of macular function by multifocal electroretinogram before and after macular hole surgery 420 Department of Ophthalmology, Gunma University School of Medicine, Japan Y-J Si S Kishi K Aoyagi Correspondence to: Ying-Jie Si, MD, Department of Ophthalmology, Gunma University School of Medicine,