Macular Hole Formation after Pars Plana Vitrectomy for the Treatment of Valsalva Retinopathy: A Case Report
A 20-year-old female patient was referred to our hospital due to a sudden decrease in visual acuity in the left eye after heavy alcohol consumption. She denied any history of trauma or sexual contact. Her medical and ocular histories were unremarkable. Previous medical records reported that the patient had a history of severe vomiting following heavy drinking. In the left eye, the best-corrected visual acuity (BCVA) was hand motion. The anterior segment was unremarkable in both eyes. Fundus examination was normal in the right eye but revealed a well-circumscribed premacular hemorrhage about 4 DDs in size beneath a transparent membrane with glistening reflexes extending over the macula in the left eye. No posterior vitreous detachment (PVD) was evident. Time-domain OCT (TD-OCT) revealed an intact foveal contour and two membranes of differing optical reflectivity, identified as the internal limiting membrane (ILM) and the posterior hyaloid, respectively, with blood beneath the hyperreflective membrane ().\nDuring a nine-week follow-up period, the premacular hemorrhage resolved spontaneously, and the BCVA in the left eye returned to 20 / 100. Yellowish residual sub-ILM deposits, however, were present, and a thick preretinal membrane was visible over the fovea ().\nThe patient requested aggressive treatment. After full explanation of the expected effects and possible complications of vitrectomy, the patient provided informed consent. A 23-gauge pars plana vitrectomy was performed using a minimal core vitrectomy technique. PVD was created using triamcinolone acetonide and a vitreous cutter only around the posterior pole. The ILM was peeled off using 23-gauge microforceps after staining the ILM with indocyanine green (Diagnogreen; Daiichi Pharmaceutical, Tokyo, Japan). The ILM was removed from a 2- to 3-DD area centered on the fovea. The thick preretinal membrane and the ILM were removed, but the residual foveal deposits could not be extracted because they had adhered to the fovea. The surgeon expected the deposits to absorb spontaneously, so fluid-air exchange was not performed. Two weeks after the first vitrectomy, the foveal deposits had resolved, but a full thickness MH was observed. Postoperative SD-OCT, which was used to analyze the cross-sectional image almost every day (), did not reveal an MH during the first seven days. A second vitrectomy was performed using standard techniques to create a total PVD and to remove the remnant peripheral vitreous with fluid-air exchange through an extrusion cannula. The eye was flushed with a 15% perfluoropropane gas-air mixture to ensure complete exchange. After the second surgery, the patient was instructed to maintain a strict face-down position for three days in the hospital until MH closure was confirmed.\nSix months after the second surgery to close the MH, the BCVA in the left eye had improved to 20 / 25. SD-OCT showed that the MH had closed with only slight scarring of the photoreceptor inner segment/outer segment junction ().