Treatment of Macular Hole and Macular Hemorrhage Associated With Retinal Arterial Macroaneurysm Rupture

Author: Fran Drnovsek (Slovenia)

Co-authors: Xhevat Lumi

Purpose

To show a different treatment approach of a macular hole (MH) secondary to a retinal arterial macroaneurysm (RAMA) rupture by pars plana vitrectomy (PPV) and autologous transplantation of a free flap of internal limiting membrane (ILM) during primary surgery.

Setting/Venue

Eye Hospital, University Medical Centre Ljubljana, Slovenia.

Methods

A 60-year-old female patient presented with a one-day history of sudden loss of central vision in her right eye. Best-corrected visual acuity (BCVA) upon arrival at the hospital was counting fingers at 0.5 meters. Fundus examination revealed a large sub-ILM hemorrhage involving the macula in her right eye and grade 2 hypertensive retinopathy in her left eye. On the third day after presentation of symptoms, further deterioration with vitreous hemorrhage developed. We performed a 25-gauge PPV, with ILM peel overlaying the macular hemorrhage. A ruptured RAMA was revealed in the inferotemporal macular region. After removal of the thick blood clot under the ILM with vitreous cutter, we detected a full-thickness MH approximately one-third the size of the optic disc over-lying the submacular hemorrhage. Part of the submacular clot was protruding through the hole, indicating a preexisting full-thickness MH. The protruding clot was removed through the hole using a soft-tip backflash instrument. Due to subretinal hemorrhage, retina at the edges of the hole was fixed. The ILM was then further peeled off outside the vascular arcades and transplanted as a free flap into the MH. We instilled 10% C3F8 gas as tamponade at the end of the surgery.

Results

At the follow-up examinations 3 months and 1 year after the surgery, anatomical closure of the MH was observed. Functional and anatomical results were comparable to the results of patients treated for idiopathic MHs. Optical Coherence Tomography (OCT) scan showed early restoration of the outer retinal layers. We observed improvement of visual acuity to 20/200, however there was also development of a significant cataract. The patient was referred for cataract surgery. At the last follow-up examination two years after the surgery, MH remained closed and the BCVA improved to 10/20 on Snellen chart.

Conlusions

Autologous transplantation of an ILM free flap during primary surgery resulted in successful closure of MH following RAMA rupture. OCT showed early restoration of the outer retinal layers, and the patient had significant improvement of vision. This technique can be an efficient surgical approach for treatment of MH related to ruptured RAMA in selected cases.

Financial Disclosure

No financial disclosure

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