Case report 12/10/2014 Delphine Lam ; Dr Mayer Srour Service d ophtalmologie Professeur E.Souied
Medical history Man, 75 years old Complaint: Vision loss in left eye in June 2014 Past ophthalmologic history: Glaucoma -> trabeculectomy left eye in 2013 Cataract surgery left eye (February 2014) Medication: hypotensive eyedrop
Examination Right Eye 20/32 P2 +0,50 (-2,25, 75 ) Opacification of the lens IOP: 13 mmhg C/D: 0.7, macula normal Left eye 20/64 P5-1,5 (-0,5, 110 ) Add+3 Filtration bleb + IOL correct IOP: 15 mmhg Fundus: C/D =0.7, splitting of retinal layers
SD-OCT left eye 06/26/2014 Lam Delphine
Left eye 06/26/2014 Maxi (average) central thickness: 504 µm (428)
06/26/2014 27s- 40s
06/26/2014 2 min
Right eye Lam Delphine
What is your diagnosis? Macular hole? Irvine-Gass syndrome? Hypothesis: Irvine-Gass syndrome Treatment: Oral acetazolamide: 125mgx 3/day Potassium supplement Dexafree*: 3/day Indocollyre*: 3/day Stop Xalatan* -> Timolol
07/31/2014 Left Eye: 20/32- P2 IOP 8 mmhg Right eye: no change
Left eye 07/31/2014 Lam Delphine
Left eye 07/31/2014 Maxi (average)central thickness: 349 µm (303)
2014/07/31 2014/08/28 Better Same treatment Visual acuity LE: 20/32 P2
Left eye 2014/08/28 Lam Delphine
2014/08/28 OCT: No macular edema, no macular hole Treatement decrease: Acetazolamide : 125 mg x3/day for 3 weeks; 125 mgx2/day for 3 weeks Next examination: 2 months
2014/10/30 Visual acuity: 20/32 P2 IOP: 9 mmhg
Left eye 2014/10/30 Lam Delphine
Left eye 10/30/2014 Maxi (average) central thickness: 436µm (377)
=> Relapse Increase the treatement Reexamination 12/18/2014 Conclusion: Stage II macular hole? (probably no posterior vitreous detachment in this case) Irvine-Gass syndrome? Both? What about IVT with dexamethasone?
Idiopathic macular hole Defect of the foveal retina Full thickness Knapp (1869), posttraumatic Different from macular hole in high myopia, posttraumatic, inflammation, retinopathy Different theories: Cystic Degenerative (Morgan and Shatz) Tangential vitreous traction (Gass, 1999)++ Vitreomacular traction
Epidemiology: 0.33% > 55yo Age > 50 yo Female (2:1) Symptoms: No symptoms (5%) Vision loss Central or paracentral scotoma Metamorphopsia Micropsia
Gass macular hole stages Stage IA: localized foveal detachment, macular cyst. prominence of xanthophyll pigment, yellow dot stage Stage IB: extend foveal detachment, yellow ring, loss of foveal depression Stage II: full-thickness macular hole, < 400 µm. Retina with crescent shaped, eccentric oval, or horseshoe in appearance => No posterior vitreous detachment Stage III (A,B,C): full-thickness macular hole, > 400 µm, partial vitreomacular adhesion/traction. +/- Operculum Stage IV: full-thickness macular hole, complete separation of the vitreous from the macula and the optic disc (complete PVD)
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Idiopathic macular hole: spontaneous closure Stage I (impending macular hole): 30-50% ( -> normal or lamellar hole) Stage II: 4-30% Stage III-IV: possible if appears rapidly and associated with vitreous detachment
MH.Errera, L. Wickham ans Al. Spontaneous macular hole closure without posterior vitreous detachment in a patient previously treated for diabetic maculopathy. Acta Ophthalmol. 2013 Mar;91(2):e156-7. doi:10.1111/j.1755-3768.2012.02543.x. Epub 2012 Sep 81 13. year-old patient, type 2 diabetes mellitus 7 years ago: laser photocoagulation for diffuse diabetic macular edema in both eyes (macular grid) 5 years later: vitreomacular traction, best-corrected Visual Acuity (VA) in Left Eye: 20/80 Full thickness macular hole (FTMH) stage 2, no PVD (SD- OCT), 337 µm 2 months later: spontaneous hole closure (SD-OCT and angiography) in the absence of PVD Improvement of his best corrected VA 20/63 Stable central foveal thickness 249 µm
72 year-old man 4 weeks after cataract surgery right eye -> Irvine- Gass sd (BCVA: 1.0 -> 0.5) 6 weeks later (BCVA: 0.2) -> cystoid ME and FTMH => ME may lead to MH: Mechanical force and biochemical changes Vitreo macular traction Inflammation (thinning of the fovea) Rare complication of Irvine-Gass syndrome
Idiopathic macular hole: spontaneous closure Mecanisms? Release of the vitreomacular traction, posterior vitreous detachment Retinal laser injury (studies in mice)=> Glial reaction, Müller cells activation (outer nuclear layer) (Tackenberg et al. 2009) Proliferation of inner glial cells( Freund et al.2002; Abe et al.2010) Fibroglial proliferation, hole rims come closer
Bibliography A. Mathis, V. Pagot et al. Trou maculaire dégénératif et menace de trou. EMC V. Deral, R.Vignal et al. Spontaneous closure of bilateral macular hole stage 3 and 1. Journal français d ophtalmologie.115 e congrès de la SFO MH.Errera, L. Wickham et al. Spontaneous macular hole closure without posterior vitreous detachment in a patient previously treated for diabetic maculopathy. Acta Ophthalmol. 2013 Mar;91(2):e156-7. doi:10.1111/j.1755-3768.2012.02543.x. Epub 2012 Sep 13. M. Moschos et al. Macular hole formation in a patient with Irvine-Gass syndrome: coincidence or rare complication? Clinical Ophthalmology,12 July 2013 G.Souteyrand et al. Documentation par OCT-3 de la résolution spontanée d un trou maculaire post-traumatique. J Fr Ophtalmol,2008;31, 4, 422-426 A.Susini, P.Gastaud. Ces trous maculaires qu il vaut mieux ne pas opérer J Fr Ophtalmol,2008;31,2,214-220 A.Catier, R. Tadayoni et al. Oedeme maculaire. EMC Angelo Maria Minnella et al. Spectral-Domain Optical Coherence Tomography in Irvine-Gass syndrome. Retina 32:581-587, 2012