Macular hole formation, progression, and surgical repair: case series of serial optical coherence tomography and time lapse morphing video study

Abstract

Background: To use a new medium to dynamically visualize serial optical coherence tomography (OCT) scans in order to illustrate and elucidate the pathogenesis of idiopathic macular hole formation, progression, and surgical closure.

Case presentations: Two patients at the onset of symptoms with early stage macular holes and one patient following repair were followed with serial OCTs. Images centered at the fovea and at the same orientation were digitally exported and morphed into an Audiovisual Interleaving (avi) movie format. Morphing videos from serial OCTs allowed the OCTs to be viewed dynamically. The videos supported anterior-posterior vitreofoveal traction as the initial event in macular hole formation. Progression of the macular hole occurred with increased cystic thickening of the fovea without evidence of further vitreofoveal traction. During cyst formation, the macular hole enlarged as the edges of the hole became elevated from the retinal pigment epithelium (RPE) with an increase in subretinal fluid. Surgical repair of a macular hole revealed initial closure of the macular hole with subsequent reabsorption of the sub-retinal fluid and restoration of the foveal contour.

Conclusions: Morphing videos from serial OCTs are a useful tool and helped illustrate and support anterior-posterior vitreofoveal traction with subsequent retinal hydration as the pathogenesis of idiopathic macular holes.

Figure 1

a-e. Case 1. OCT image of the right eye demonstrated vitreofoveal separation with a small defect in the ILM (yellow arrow) in the center of the fovea (Figure 1a). Serial OCTs, performed ten days (Figure 1b), 3 weeks (Figure 1c), and six weeks (Figure 1d) later demonstrated progression to a stage 2 macular hole without evidence of traction. Post-operative OCT revealed closure of the macular hole with restoration of normal foveal contour (Figure 1e). OCTs were performed using OCT 2000, (Humphrey Instruments, San Leandro, CA)

Figure 2

a-e. Case 2. OCT image of the right eye demonstrated a stage 1 macular hole or cyst with focal attachment of the hyaloid to the fovea. The yellow arrow designates a discontinuity of the outer fovea (yellow arrow) (Figure 2a). OCT, performed 3 weeks later, revealed avulsion of the inner portion of the foveal cyst with a break in the ILM and progression of the macula hole to a full thickness stage 2 hole with overlying operculum (Figure 2b). Further enlargement of the hole was documented one month (Figure 2c) and two months later (Figure 2d) without evidence of traction. Post-operative OCT revealed closure of the macular hole with restoration of normal foveal contour (Figure 2e). OCTs were performed using OCT 2000, (Humphrey Instruments, San Leandro, CA)

Figure 3

a-d. Case 3. OCT image of the right eye demonstrated a full thickness stage 2 macular hole with underlying drusen (Figure 3a). Post-operative OCT images, performed 2 weeks (Figure 3b), 4 weeks (Figure 3c), and 8 weeks (Figure 3d) after surgery, demonstrated closure of the hole with absorption of the sub-retinal fluid (yellow arrow). OCTs were performed using OCT 3000, (Humphrey Instruments, San Leandro, CA)