Subretinal tissue plasminogen-assisted vitrectomy for posttraumatic full-thickness macular hole with submacular hemorrhage

Abstract

A young male presented with diminution of vision left eye, attributable to full-thickness macular hole, and submacular hemorrhage, following closed globe injury 2 weeks ago. The patient was managed successfully with 25-gauge vitrectomy, subretinal injection of tissue plasminogen activator and aspiration of liquefied blood through the macular hole, internal limiting membrane peeling, short-acting gas tamponade, and prone positioning. This resulted in good visual improvement, type 1 macular hole closure, and restoration of foveal architecture. The outcome and rationale of treatment in this unique scenario is discussed.

Keywords: Closed globe injury; full-thickness macular hole; pars plana vitrectomy; subretinal hemorrhage; subretinal tissue plasminogen activator.

Figure 1

(a) Color fundus photograph at presentation shows full-thickness macular hole, subretinal hemorrhage extending across the fovea (extent marked by yellow arrows) and temporal choroidal rupture (white chevron). (b) Vertical swept source optical coherence tomography scan through the hole showing macular hole and subretinal bleed (yellow arrows)

Figure 2

(a) Intraoperative optical coherence tomography after injection of subretinal tissue plasminogen activator through the hole shows induction of shallow retinal detachment (white arrow). (b) Intraoperative color photographs show internal limiting membrane peeling in progress. (c) Aspiration of subretinal blood through the macular hole. (d) Intraoperative optical coherence tomography after aspiration of blood shows absence of subretinal bleed and persisting neurosensory detachment (white arrow)

Figure 3

(a) Color photograph at 1 week postoperatively shows closure of macular hole, residual subretinal bleed temporally (white chevron) and full extent of choroidal rupture (ends marked by yellow arrows). (b) Vertical swept source optical coherence tomography scan at 1-week visit confirms Type 1 closure of macular hole and discontinuous ellipsoid zone and external limiting membrane (yellow arrow). (c) Three months postoperative color photograph shows complete resolution of subretinal bleed. (d) Vertical swept source optical coherence tomography scan, congruous to 3b, shows restoration of ellipsoid zone and external limiting membrane (yellow arrow)