Two cases of diabetic macular edema complicated by an atypical macular hole

Abstract

Background: Here we report two patients who developed an atypical macular hole (MH) during the treatment course for diabetic macular edema (DME). Case presentations: Patient 1 was a 73-year-old male. Optical coherence tomography (OCT) revealed perifoveal retinoschisis (RS) in addition to cystoid macular edema and serous retinal detachment (SRD) in his left eye, and that an MH had developed during the clinical course. A convex surface was formed at the MH margin toward the vitreous cavity, and granular shadows were observed in the fluid cuff. Intraoperative findings revealed a thin epiretinal macular membrane (ERM) around the MH. Patient 2 was a 79-year-old male. Although the patient underwent pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) in both eyes, RS and a thin ERM in addition to SRD was observed in his left eye after surgery, and an MH developed during the clinical course. As in Patient 1, a convex surface was formed at the fluid cuff margin toward the vitreous cavity. Conclusions: Both patients had persistent DME, SRD, RS, and a thin ERM before the development of the MH. OCT revealed the formation of a convex surface at the MH margin toward the vitreous cavity, suggesting that the fragility of the layered structure of the retina combined with tangential retinal traction may have been involved in the atypical MH form.

Secondary Full-thickness Macular Holes after Diabetic Vitrectomy: Clinical Manifestations and Rational Approaches to the Treatment

“…The management of secondary MH after DV has rarely been discussed in the literature. In previous case reports, most patients received primary DV due to non-clearing VH [ 4 , 14 , 31 – 33 ], which was less complicated than in our cases. Most patients underwent ERM removal with or without ILM peeling as MH repair surgery.…”

“…ERM was the most common predisposing factor for secondary MH after DV as reported in the literature [ 4 , 30 , 31 , 35 ]. The tangential traction exerted on the weakened fovea caused subsequent MH formation within 7 months to 5 years [ 4 , 30 , 31 , 35 ]. In the present study, Cases 4–9 (6 eyes) also showed ERM and subsequent MH formation after primary DV.…”

Full-Thickness Macular Hole Closure Following a Single Intravitreal Injection of Aflibercept in an Eye With Diabetic Macular Edema

“…13 Paradoxically, several case reports have also linked FTMH formation to anti-VEGF injections. Lee and Kim 3 and Yoshida et al 8 reported FTMH formation in a patient with DME after an intravitreal injection of bevacizumab and aflibercept, respectively. Similarly, Muramatsu et al 17 identified FTMH formation following intravitreal injection of ranibizumab in a patient with CME secondary to a branch retinal vein occlusion.…”

“…FTMH has been reported as a rare complication of CME secondary to diabetes mellitus, central retinal vein occlusion, and uveitis. 4,8 The mechanisms of formation are likely the result of the tractional forces applied perpendicularly to the inner retinal layers by cystoid intraretinal fluid combined with intrinsic inner retinal layer weakness. [8][9][10] Anterior tractional forces applied by a tightly adherent vitreous is another well-known cause of FTMH.…”

Case of Repeated Full-Thickness Macular Hole Formations and Spontaneous Closure following Intravitreal Bevacizumab Treatment for Central Retinal Vein Occlusion

“…Therefore, a possible mechanism for the FTMH formation in our case is an increased anterior-posterior traction on the fragile retina with an incomplete PVD caused by the rapid shrinkage of the retina due to resolution of the ME. In fact, there have been two reports of FTMH formation in eyes with persistent diabetic macular edema [ 8 , 9 ], and it was also suggested that vitreous injections in eyes with an incomplete PVD may create focal traction which increased the chance of FTMH formation [ 6 ]. On the other hand, a spontaneous closure of an idiopathic macular hole has been reported to occur with the release of vitreous traction due to a complete PVD.…”