Traumatic macular hole study: a multicenter comparative study between immediate vitrectomy and six-month observation for spontaneous closure

Abstract

Background: Closure of traumatic macular hole (TMH) can be achieved spontaneously or by surgical intervention. Thus far, there exist no prospective comparative studies that have analyzed the difference between the two modalities. This study aimed to compare the anatomical and visual recovery of eyes with TMH following either an immediate vitrectomy or six-month observation.

Methods: This was a multicenter prospective comparative study. Eight centers participated in the study. Patient data from 40 eyes with a recent history of blunt ocular trauma and newly formed full-thickness TMH were recruited in this study. The participating patients selected between an early vitrectomy or a six-month observation after a doctor explained the potential benefits and risks of both strategies in an unbiased manner. Twenty-five patients underwent an immediate vitrectomy, and 15 patients received six-month observation. Patients were assessed by spectral-domain optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA).

Results: Closure rates were 66.7% for the observational group, and 100% for the surgical group (P=0.002). There were no vision-threatening ocular complications in both groups. For the observational group, the mean closure time was 2.5±1.6 months, and 80% of the hole closure occurred within 3 months; cystic edema on the edge of the hole at baseline was significantly more frequent in the non-closed subgroup than in the closed subgroup (P=0.03). There were no significant differences in the foveal microstructure and in the final visual outcome between the spontaneously closed cases and the surgically closed cases.

Conclusions: TMH had a moderately high incidence of spontaneous closure, but an immediate vitrectomy achieved an even higher closure rate. Vitrectomy was effective and safe to treat TMH, while a 3-month observation for spontaneous closure may be an alternative modality for TMH management. Cystic edema on the edge of the hole may be an unfavorable factor for the spontaneous closure of TMH.

Keywords: Traumatic macular hole (TMH); observation; vitrectomy.

Figure 1

Measurements of the macular hole diameter by spectral domain-optical coherence tomography. The hole minimum diameter (a) was measured as the minimum inner diameter of the hole. The hole base diameter (b) was measured as the hole diameter at the level of the retinal pigment epithelium.

Figure 2

Closure of the hole was defined as the flattening of the elevated edges of the hole with resolution of the surrounding subretinal fluid cuff by spectral domain-optical coherence tomography. (A) Representing type 1 closure; indicating no interruptions in the continuity of the foveal tissue above the retinal pigment epithelium (RPE). The normal foveal contour is usually encountered in type 1 closures. (B) Representing type 2 closure; indicating an interruption in the continuity of the foveal tissue. Thus, the RPE is denuded. The hole edge is attached to the underlying RPE.

Figure 3

Spectral domain-optical coherence tomography (A) shows the length of the inner segment/outer segment (IS/OS) junction defect, which was measured as the length of loss of the hyper-reflective line corresponding to the IS/OS junction above the retinal pigment epithelium (RPE); (B) shows the central foveal thickness (CFT), which was measured as the minimum height from the vitreoretinal interface to the top of RPE at the fovea.

Figure 4

Flowchart showing patient selection of the study.

Figure 5

Spectral domain-optical coherence tomography (A) shows the perifoveal posterior vitreous detachment (PVD) and antero-posterior vitreous traction on the edge of the up drawn fovea is usually seen in a stage II idiopathic macular hole. This antero-posterior vitreoretinal traction prevents the hole from spontaneously closing. However, in a traumatic macular hole (B), perifoveal PVD and the continuous vitreous traction at the edge of the hole are seldom seen, due to the young healthy vitreous gel.