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