Features
A macular hole is a full-thickness loss of the neurosensory retina, traditionally at the fovea, leading to decreased visual acuity and central visual distortion. Idiopathic macular holes caused by vitreous traction are more common than traumatic macular holes, but both types may result in significant vision loss. Traumatic macular holes, as compared to idiopathic holes, are more commonly seen in younger patients, males, and may have worse vision on presentation. Traumatic macular holes occur most often after blunt force trauma to the eye, but the mechanism of formation of the hole is still not clear. One possible hypothesis for the pathogenesis of a traumatic macular hole is the concept that with blunt trauma to the eye flattening of the cornea is seen, followed by an expansion of the globe in an anteroposterior direction. Upon recoil of the globe, there is a rapid posterior movement of the posterior pole leading to dynamic horizontal forces and a splitting of the retinal layers of the fovea. An alternate theory centers around the role of the vitreous in traumatic macular holes, such that sudden vitreous separation caused by blunt trauma leads to an excessive pulling by the vitreous and hole formation in the fovea. A final potential mechanism is that energy from the traumatic blow itself is transmitted through the globe and causes a rupture of the fovea. Despite the exact pathogenesis of a traumatic macular hole, there are certain characteristics which are common on exam of traumatic macular holes and a range of treatment options exist depending on the clinical scenario.
75.1.1 Common Symptoms
Patients generally present with sudden vision loss immediately after the traumatic event, though cases of delayed vision loss up to several days after trauma have been reported.
75.1.2 Exam Findings
On examination, patients present with a macular hole that may appear more ellipsoid in nature as compared to idiopathic macular holes which generally have a circular appearance with mildly elevated appearance to the edges of the hole. In addition, other sequelae of significant blunt trauma may be present, including vitreous hemorrhage, subretinal hemorrhage, choroidal rupture, and commotio retinae (▶ Fig. 75.1, ▶ Fig. 75.2, ▶ Fig. 75.3).
Fig. 75.1 Montage fundus photograph following high-speed projectile injury with a paintball. Examination revealed vitreous hemorrhage, choroidal rupture (*) and a full-thickness macular hole (arrow).
Fig. 75.2 Ultra-widefield fundus photo of chronic large macular hole. (a) Nasal subretinal fibrosis and multiple choroidal rupture sites are noted nasally. Optical coherence tomography demonstrating large persistent full-thickness macular hole without associated retinal edema and minimal subretinal fluid. (b) Extensive retinal pigment epithelium abnormalities are noted and outer retinal atrophy extends significantly past the edge of macular hole.
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