Spontaneous closure and later recurrence of a macular hole requiring vitrectomy

This report presents a recurrent macular hole (MH) that initially closed spontaneously but reopened 4 years later due to partial vitreous traction, requiring pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peel and gas tamponade to obtain a final closure.

An MH is a vitreoretinal interface disorder characterised by a full-thickness defect in the foveal region of the retina, leading to central vision loss, metamorphopsia and reduced visual acuity (VA). The development of MH is mainly idiopathic and associated with age-related vitreomacular traction (VMT). Idiopathic MH can be classified into four stages: stage one involves foveal detachment with a minor partial-thickness defect, stage two represents early MH formation, stage three is a fully developed MH with persistent vitreofoveal attachment, and stage four is MH with complete posterior vitreous detachment (PVD).¹ Although spontaneous closure is possible, MH at stage two and beyond mainly require surgery.² During PPV, the vitreous gel is removed to relieve traction on the macula. The ILM peel helps release further traction and promotes MH closure by stimulating the retina to flatten and heal. Gas is used to temporarily tamponade the macula, allowing the edges of the hole to approximate, supporting its closure and recovery.

Case

A male in his 70s presented with a 4-week history of VA loss in the left eye (LE) and central metamorphopsia. The VA in the right eye (RE) was 6/9; in the LE, it was 6/36, improving to 6/18 with a pinhole. Upon examination, the cornea was clear, with moderate cataracts. The retina in the RE showed preserved morphology, while the LE revealed an MH with a horizontal diameter of 216μm at its narrowest point, with VMT and a bridge (Figure 1). A diagnosis of idiopathic MH was made, and the patient was waitlisted for PPV surgery.

The MH closed spontaneously 1 month later, improving VA to 6/12 and 6/7 over the next 3 months (Figure 2). However, 4 years and 6 months later, the patient presented with VA loss in LE due to the recurrence of a large MH with a horizontal diameter of 410μm at its narrowest point (Figure 3).

A combined procedure was performed, including phacoemulsification, intraocular lens insertion and 25-gauge PPV with peel and gas. Peripheral vitreous detachment (PVD) was induced with an inverted ILM flap and using 15% C3F8 gas as the endotamponade. The patient was instructed to maintain a face-down position for 3 days, followed by routine post-operative treatment with Chlorafast 4 times a day for 1 week and Pred Forte 4 times a day for 1 month. In the follow-up, VA improved to 6/24, and optical coherence tomography (OCT) confirmed MH closure. The patient returned to normal daily activities and remains healthy with regular eye examinations.

Discussion

Although uncommon, spontaneous closure of an MH has been reported, particularly in small or early-stage MH,^2,3 with contributing factors including retinal bridges, VMT or epiretinal membranes.⁴ Approximately 25% of small idiopathic full-thickness MH with a diameter ≤250μm and around 55% of MH with diameters <150μm can close spontaneously within 2 months of diagnosis.⁵ The formation of retinal bridges via glial cells, most likely Müller cells, is the most widely supported mechanism required for MH closure.⁶ 

In this case, the MH resolved spontaneously, identifying the presence of retinal bridges, but it recurred with a significant diameter increase, necessitating a surgical intervention. The inverted ILM flap technique, combined with PPV, uses the ILM covering over the MH as a scaffold for Müller cell proliferation and aids in hole closure.⁷ This approach further improves both functional and anatomic outcomes, particularly for larger MH >400μm.⁸ Surgical intervention grants success rates from 90% to 100%,⁹ though outcomes vary depending on individual case characteristics. The MH’s onset, type and stage are key prognostic factors.^9,10

This case highlights the implication of retinal bridges in MH spontaneous closure, but with the possibility or recurrence for persistent VMT. The presence of a large MH with significant traction is unlikely to resolve spontaneously, requiring surgical intervention.

View Figure 1–3.