Delayed closure of macular hole secondary to Terson syndrome after vitrectomy

Abstract

Rationale: Macular hole (MH) is a rare complication of Terson syndrome. Delayed closure of persistent MH after pars plana vitrectomy (PPV) is occasionally reported in literature, none of them is MH secondary to Terson syndrome. We describe a case of MH secondary to Terson syndrome and delayed closure occurred after PPV, and we also study the characteristics of delayed closure of persistent MH by reviewing related literatures. Patient concerns: A 61-year-old man presented with vitreous hemorrhage in right eye following a subarachnoid hemorrhage due to spontaneous rupture of his right vertebral artery dissecting aneurysm. The visual acuity was hand motion in the right eye and 20/30 in the left eye. Fundus examination showed dense and diffuse vitreous hemorrhage in the right eye. Diagnoses: Terson syndrome was diagnosed according to his subarachnoid hemorrhage history and vitreous hemorrhages in right eye. Interventions: PPV combined with phacoemulsification and intraocular lens implantation was performed in his right eye, and internal limiting membrane (ILM) peeling was also performed due to a MH noted during the surgery. Outcomes: One week after PPV, optical coherence tomography (OCT) showed a persistent MH. Without any intervention, the MH became smaller and flattened, with the best corrected visual acuity (BCVA) improved to 30/200 at 1 month after surgery. Six months later, the MH completely closed with BCVA improved to 20/40. According to our literature review, there are 8 cases of the delayed MH closure, which includes idiopathic MH (4 eyes), traumatic MH (2 eyes), and vitreomacular traction (2 eyes). There is no report about delayed closure of MH secondary to Terson syndrome. The times for these delayed closure occurred following PPV were ranged from 1 to 28 months. Holes even with obviously raised edges after PPV may spontaneously close, just like the case presented here. Lessons: Delayed closure of persistent MH after PPV is rarely reported. The significance of this case is to suggest that similar patients should be monitored carefully by OCT, and additional surgery for the MH may be delayed, since delayed closure is possible. The exact mechanisms of delayed closure of persistent MH still need to be clarified.

Delayed macular hole secondary to Terson syndrome: a case report and literature review

“…8,9 To better understand the characteristics of an MH secondary to Terson syndrome, we conducted a literature search. We found that an MH secondary to Terson syndrome was observed in only nine eyes in seven articles 4,6,[10][11][12][13][14] (Table 1). Although MH occasionally occurs as a complication of Terson syndrome, the exact cause is unclear.…”

“…Terson syndrome is defined as the presence of intraocular haemorrhage associated with intracranial haemorrhage and elevated intracranial pressure. 6 Based on the location of the haemorrhage, the clinical classification of intraocular haemorrhage can be categorized as sub-ILM, preretinal, intraretinal, subhyaloid, or intravitreal. 7 The physiopathology of Terson syndrome and the origin of intraocular blood remain controversial.…”

Macular hole with inner limiting membrane peeling off spontaneously in Terson syndrome

“…[10] It is well-accepted that the mechanism of MH is tangential anterior-posterior traction of the vitreomacular or macular ILM. [11] Moreover, a sudden bloody dissection of the ILM may produce tractional forces responsible for causing MH. In this case, the ILM was not peeled surgically.…”

Formation of Full Thickness Macular Hole Following Pars Plana Vitrectomy and Internal Limiting Membrane Peeling and Its Spontaneous Closure

“…1 It has been shown in the literature that such FTMHs can close spontaneously in many different clinical scenarios. 2 Distelmaier et al reported that a FTMH can recur following surgical repair but it was closed without any intervention. 3 Spontaneous closure has also been reported in context of posterior uveitis, cystoid macular oedema, 4 and following retinal detachment repair by pars plana vitrectomy.…”

“…Formation of FTMH following vitrectomy is rare with its incidence being reported as 0.24% [ 1 ]. It has been shown in the literature that such FTMHs can close spontaneously in many different clinical scenarios [ 2 ]. Distelmaier et al [ 3 ] reported that a FTMH can recur following surgical repair but it was closed without any intervention.…”