Long-term Outcome of Macular Microstructure Assessed by Optical Coherence Tomography in Eyes With Spontaneous Resolution of Macular Hole




Purpose


To evaluate the long-term anatomic features as assessed by optical coherence tomography (OCT) in patients with spontaneously closed full-thickness macular hole (MH).


Design


Retrospective, noncomparative, observational case series.


Methods


Six eyes of 6 patients who eventually showed spontaneous resolution of idiopathic MH were studied. The best-corrected visual acuity (BCVA) and OCT images of the fovea were examined before and until at least 3 years after spontaneous resolution.


Results


The MH closed spontaneously 1 to 4 months after the initial examination. There were 2 distinct macular abnormalities in the early period after spontaneous closure: 4 eyes showed outer foveal defects and the remaining 2 eyes showed persistent foveal detachment. However, the fovea regained its normal configuration and the photoreceptor inner segment/outer segment (IS/OS) junction recovered completely in all eyes. Although all 6 eyes showed visual improvement after the hole closure, the BCVA in the 4 eyes that showed delayed recovery of the IS/OS junction and foveal detachment was limited to 20/25 or worse.


Conclusion


Spontaneous closure of MH could acquire complete anatomic reconstruction. However, delayed restoration of the IS/OS junction and persistent foveal detachment after spontaneous closure might influence the functional outcomes.


Previous reports have described that an estimated 4% to 6% of full-thickness macular holes (MHs) show spontaneous resolution without any treatments. Although spontaneous closure of MHs is rare, ever since the introduction of time-domain optical coherence tomography (TD-OCT) and spectral-domain OCT (SD-OCT) as useful tools for noninvasive diagnosis and monitoring of macular diseases, investigators have studied the processes involved in the closure of macular holes and restoration of the macular architecture.


Some studies have reported the appearance of a defect of the photoreceptor inner segment/outer segment (IS/OS) junction after spontaneous resolution of MH. Furthermore, the mechanisms of spontaneous closure have been discussed based on the findings of OCT. However, no OCT studies of the reconstructive changes over time after spontaneous closure of MHs have been conducted. We now report the findings of long-term follow-up by OCT in patients showing spontaneous resolution of MHs. The anatomic changes as assessed by TD-OCT and SD-OCT were followed up until at least 3 years after the spontaneous closure, and the functional outcomes were also investigated.


Patients and Methods


We conducted a retrospective review of 6 eyes of 6 patients with idiopathic MH who had been referred to the Yokohama City University Medical Center between February 2007 and March 2008 and showed spontaneous closure of the MHs. Although vitreous surgery was scheduled for closure of the MHs, the MHs disappeared spontaneously before the scheduled surgical treatment. Spontaneous closure of the MHs was confirmed clinically by ophthalmoscopic and OCT examinations. The surgery was therefore canceled, and all 6 eyes were followed up for at least 3 years after the spontaneous closure of the MHs.


The examinations were performed with Stratus OCT3 (Carl Zeiss, Dublin, California, USA) and Cirrus high-definition OCT (Carl Zeiss). In the present series, the TD-OCT was analyzed by line scans and SD-OCT was performed for each eye using 5-line raster scans or a macular cube 200 × 200 combination. Representative images were selected. External limiting membrane (ELM) was represented by the thin back-reflecting feature just below the outer nuclear layer. The photoreceptor layer was imaged as a hyperreflective line showing the IS/OS junction above the retinal pigment epithelium (RPE). Diagnosis of defect of the IS/OS junction was made based on loss of the hyperreflective line corresponding to the IS/OS junction. By using the caliper function on the software package, the basal and minimum diameters of the MHs were measured.


Best-corrected visual acuity (BCVA) measurements and OCT imaging of the fovea were performed in all patients during the follow-up period. The macular reconstructive changes over time were also investigated. The BCVA was converted to the logarithm of the minimal angle of resolution (logMAR) equivalent.




Results


The Table summarizes the clinical characteristics of the 6 patients enrolled in this study. Of the 6 patients, 2 were men and 4 were women, with the patients ranging in age from 65 to 78 years (mean age ± standard deviation, 71.7 ± 5.5 years). According to Gass’s classification, 3 eyes had stage 2 MH, 2 eyes had stage 3 MH, and the remaining 1 eye had stage 4 MH. Three eyes (Patients 2, 3, and 6) had no clinically significant cataract, while the remaining 3 eyes (Patients 1, 4, and 5) were pseudophakic. The mean minimal diameter of the MHs was 209 ± 80 μm (range, 135 to 333 μm), and the mean MH basal diameter was 427 ± 212 μm (range, 239 to 781 μm). The MHs closed spontaneously 1 to 4 months after the initial examination.



TABLE

Clinical Characteristics of the 6 Eyes With Spontaneous Closure of Macular Hole








































































































Patient Age Sex MH Stage Basal Diamter in MH (μm) Minimal Diamter in MH (μm) Time to SC (Months) Follow-up Periods After SC (Months) Period Needed for Complete Recovery of IS/OS Junction (Months) Type of Macular Abnormalities BCVA Period Needed for Maximum VA (Months)
Initial Maximum
1 78 F 4 280 135 3 40 6-9 Outer foveal defects 20/40 20/20 1
2 76 F 2 343 280 2 36 9-12 Outer foveal defects 20/100 20/25 9
3 73 M 2 239 156 3 49 3-9 Outer foveal defects 20/50 20/20 9
4 65 F 2 333 333 1 43 33-36 Outer foveal defects 20/63 20/32 2
5 73 M 3 781 197 3 42 6-9 Foveal detachments 20/100 20/25 2
6 65 F 3 588 152 4 36 1-4 Foveal detachments 20/100 20/30 1

BCVA = best-corrected visual acuity (Snellen); F = female; IS/OS = inner segment/outer segment; M = male; MH = macular hole; SC = spontaneous closure; VA = visual acuity.


The mean follow-up period in the subjects showing spontaneous MH closure was 41.0 ± 4.9 months (range, 36 to 49 months). The ELM seemed to have recovered by the time the spontaneous closure was confirmed, although in Patients 1, 2, and 3, in whom the evaluation was performed by TD-OCT, the status could not be clearly identified because of the lower resolution of this imaging modality. There were 2 distinct macular abnormalities in the early period after spontaneous closure: 4 of the 6 eyes showed outer foveal defects and the remaining 2 showed persistent foveal detachment. In the eyes (Patients 1–4) that showed outer foveal defects, the defects of the IS/OS junction disappeared completely within 3 years ( Figure ). On the other hand, the persistent foveal detachments found in 2 patients (Patients 5 and 6) were spontaneously absorbed within 9 months ( Figure ). Finally, the fovea had regained its normal configuration and the IS/OS junction had completely recovered in all 6 eyes.




FIGURE


Images from 6 cases demonstrating spontaneous closure of a macular hole (MH). (Top left series) Patient 1, a 78-year-old woman. (Top image) Her visual acuity (VA) was 20/40 in the right eye. Biomicroscopic examination revealed a MH with a Weiss ring. Optical coherence tomography (OCT) also showed a full-thickness MH, stage 4. (Second image) The MH disappeared spontaneously within 3 months. OCT also revealed closure of the MH with tissue bridging and an outer foveal defect. The external limiting membrane (ELM) seemed to have recovered. Her VA increased to 20/30. (Third image) OCT image obtained 1 month after the closure of the MH showed amelioration of the inner segment/outer segment (IS/OS) junction defect. The maximum VA acquired was 20/20. (Fourth image) OCT scan obtained 6 months after the closure of the MH showed that the IS/OS junction defect had gradually ameliorated, but still persisted. (Fifth image) By 9 months after the spontaneous closure, the IS/OS junction defect had completely disappeared. (Sixth image) Forty months after the MH closure, almost-normal macular configuration was seen. The VA was maintained at 20/20. (Top middle series) Patient 2, a 76-year-old woman. (Top image) Her VA was 20/100 in the right eye. OCT confirmed a full-thickness MH with posterior vitreous detachment (PVD). (Second image) The MH spontaneously disappeared within 2 months. Her VA improved slightly to 20/50. OCT also revealed closure of the MH with tissue bridging and an outer foveal defect. The ELM seems to have recovered. (Third image) At 6 months after the spontaneous closure, OCT showed amelioration of the IS/OS junction defect. (Fourth image) By 9 months after the MH closure, the maximum VA of 20/25 was achieved, although the IS/OS junction defect still remained. (Fifth image) By 12 months after the closure of MH, complete recovery of the IS/OS junction was observed. (Sixth image) By 36 months after spontaneous closure, OCT showed almost-normal foveal configuration with a regular IS/OS junction. The VA was maintained at 20/25. (Top right series) Patient 3, a 73-year-old man. (Top image) His VA was 20/50 in the left eye. OCT also showed a full-thickness MH and a pseudo-operculum attached to the shallow PVD at the posterior pole. (Second image) By 2 months after baseline exam, the full-thickness MH spontaneously closed, with elevation of the tissue connecting the edge of the MH. A tiny IS/OS junction defect was observed and recovery of the ELM was identified. The VA remained at 20/63. (Third image) By 3 months after spontaneous closure, the IS/OS junction defect had become smaller. The VA increased to 20/32. (Fourth image) Nine months after spontaneous closure, the VA recovered to 20/20. OCT showed normal foveal configuration with complete IS/OS junction recovery. (Fifth image) At 49 months after the closure, the VA maintained at 20/20. OCT showed a normal IS/OS junction. (Bottom left series) Patient 4, a 65-year-old woman. (Top image) Her VA was 20/63 in the left eye. OCT also showed a full-thickness MH with a retinal operculum still attached to the edges of the hole. (Second image) The MH spontaneously disappeared by 1 month after initial visit. Her VA remained at 20/63. OCT also revealed closure of the MH, with vitreofoveal separation. Although the IS/OS junction defect persisted, recovery of ELM was identified. (Third image) By 2 months after the closure, the VA improved to 20/32, although the IS/OS junction defect persisted. (Fourth image) At 33 months after the closure, the IS/OS junction defect still remained. (Fifth image) By 36 months after the closure, the IS/OS junction had completely recovered, although the VA remained at 20/32. (Bottom middle series) Patient 5, a 73-year-old man. (Top image) His VA was 20/100 in the left eye. OCT also showed a full-thickness MH with a fluid cuff. (Second image) However, the MH disappeared spontaneously by 3 months after basal exam. The VA improved slightly to 20/50. OCT also revealed closure of the MH and persistent foveal detachment. The ELM had completely recovered. (Third image) At 2 months after the closure, the VA was 20/25 and the foveal detachment had slightly improved. (Fourth image) At 6 months after the closure, the foveal detachment still remained. (Fifth image) However, at 9 months, it had recovered completely. (Sixth image) At 42 months, the VA was maintained at 20/25. OCT showed almost-normal foveal configuration. (Bottom right series) Patient 6, a 65-year-old woman. (Top image) The VA was 20/100 in the left eye. OCT also showed a full-thickness MH with a fluid cuff and a pseudo-operculum attached to the shallow PVD at the posterior pole. (Second image) The MH had spontaneously closed by 4 months after initial visit. The VA increased slightly to 20/50. OCT revealed closure of the MH and persistent foveal detachment. The ELM had completely recovered. (Third image) At 1 month after the closure, the VA was 20/30 and the foveal detachment had slightly improved. (Fourth image) By 4 months after the closure, the foveal detachment had completely recovered, although the VA remained at 20/30. (Fifth image) At 36 months after the closure, the VA stabilized at 20/30. OCT showed almost-normal foveal configuration with a regular IS/OS junction.

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. The Effect of General Anesthesia and Strabismus Surgery on the Intellectual Abilities of Children: A Pilot Study
  2. Retinal Adherence and Fibrillary Surface Changes Correlate With Surgical Difficulty of Epiretinal Membrane Removal
  3. A Randomized Comparison of Pupil-Centered Versus Vertex-Centered Ablation in LASIK Correction of Hyperopia
  4. Reply

Stay updated, free articles. Join our Telegram channel
Tags:
Jan 12, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Long-term Outcome of Macular Microstructure Assessed by Optical Coherence Tomography in Eyes With Spontaneous Resolution of Macular Hole

Full access? Get Clinical Tree
Get Clinical Tree app for offline access