Delayed, spontaneous conversion of type 2 closure to type 1 closure following surgery for traumatic macular hole associated with submacular hemorrhage
A 42-year-old man presented with sudden diminution of vision in the left eye following a firecracker injury, sustained two days prior. On examination, his BCVA was 20/20 in the right eye and 20/125 in the left eye. Examination of the right eye was essentially normal. Gonioscopic examination of the left eye revealed a 270-degree angle recession. Fundus examination revealed vitreous hemorrhage, full-thickness macular hole with underlying submacular hemorrhage and choroidal rupture (arrow) []. Clinical findings were confirmed on optical coherence tomography (OCT) []. The patient underwent 23G pars plana vitrectomy (PPV), with induction of posterior vitreous separation, tissue plasminogen activator (tPA)–assisted evacuation of the submacular hemorrhage through the pre-existing macular hole (10 μg/0.1 ml injected into the submacular hemorrhage), ILM peeling after staining with 0.05% Brilliant blue G dye, and 14% C3F8 gas tamponade, one week following injury. Postoperative prone position was maintained for 12–14 hours / day for two weeks. Two months after surgery, the submacular hemorrhage had completely resolved and the edges of the macular hole appeared in flat apposition to the retinal pigment epithelium (RPE) [] and BCVA was stable at 20 / 125. Clinical findings were confirmed with OCT []. No further intervention was advised. He was reviewed again after two months and cataract progression was noted. BCVA was 20/200 with persistence of type 2 closure. The patient underwent phacoemulsification with intraocular lens implantation and the BCVA improved to 20/80, N6, at the seven-month follow-up and fundus examination revealed a type 1 closed macular hole, which was confirmed on OCT [Figure and ]. The patient also had a curvilinear scar, inferior to the fovea, secondary to choroidal rupture. During the seven-month follow-up, the intraocular pressure was under control, with topical antiglaucoma medications (brimonidine tartrate 0.1%, twice daily).