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CASE REPORT
Ahead of print publication  

Temporal and double inverted internal limiting membrane flap for bilateral choroidal ruptures complicated by bilateral macular holes


1 Department of Ophthalmology, Eye Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
2 Department of Ophthalmology, Eye Center, China Medical University Hospital; School of Medicine, College of Medicine, China Medical University; Department of Optometry, Asia University, Taichung, Taiwan
3 Department of Ophthalmology, Eye Center, China Medical University Hospital, China Medical University, Taichung, Taiwan; Byers Eye Institute, Stanford University School of Medicine, Stanford, CA, USA
4 Department of Ophthalmology, Eye Center, China Medical University Hospital; Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan

Date of Submission03-Jan-2022
Date of Acceptance12-Mar-2022
Date of Web Publication19-May-2022

Correspondence Address:
Chun-Ju Lin,
Department of Ophthalmology, 2 Yuh-Der Road, Taichung City 40447
Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjo.tjo_20_22

  Abstract 


Choroidal ruptures occur in 5% to 10% closed-globe injuries with wide variation in visual prognosis, which depending on the visual acuity at presentation, the location of the rupture, and other associated ocular injuries. We reported a case of bilateral traumatic choroidal rupture with a large macular hole. We performed surgery in the right eye of microincisional vitrectomy, temporally inverted internal limiting membrane (ILM) flap, and C3F8 tamponade; then microincisional vitrectomy, fibrotic scar removal, double inverted ILM flap, and C3F8 tamponade in the left eye. After surgery, she achieved both good anatomical and visual acuity improvement in the right eye, but limited visual acuity improvement in the left eye due to subfoveal choroidal scar formation.

Keywords: Choroidal rupture, inverted internal limiting membrane flap, macular hole



How to cite this URL:
Huang LY, Lin CJ, Lai CT, Hsia NY, Bair H, Tien PT, Chen WL, Lin JM, Chiang CC, Tsai YY. Temporal and double inverted internal limiting membrane flap for bilateral choroidal ruptures complicated by bilateral macular holes. Taiwan J Ophthalmol [Epub ahead of print] [cited 2022 Sep 28]. Available from: https://www.e-tjo.org/preprintarticle.asp?id=345499




  Introduction Top


Choroidal ruptures are breaks in the retinal pigment epithelium (RPE), Bruch's membrane, and choroid that occur in 5% to 10% closed-globe injuries, especially of patients with angioid streaks are at higher risk.[1],[2] There is wide variation in visual prognosis, depending on the visual acuity at presentation, the location of the rupture, and other associated ocular injuries. The length of the choroidal rupture and the location of the rupture at the fovea are regarded as important factors in predicting the final visual outcome. Raman and Desai reported that macular hole, macular pigmentary disturbance, choroidal neovascularization (CNV), and optic atrophy generally result in limited visual recovery.[3] Internal limiting membrane (ILM) peeling with inverted flap technique is useful in large macular hole treatment. Muller cells contained at peeled-off ILM can induce gliosis, thus help in macular hole healing.[4] We presented a case of bilateral choroidal rupture and full-thickness macular hole after ocular blunt injury and significant visual improvement after surgical treatment.


  Case Report Top


A 24-year-old female presented with bilateral blurred vision following blunt injury in a traffic accident 35 days ago. Her best-corrected visual acuity (BCVA) was 20/100 in the right eye and 20/100 in the left eye. Her intraocular pressure was normal. Anterior segment examination was unremarkable. Fundus examinations revealed traumatic choroidal rupture located peripapillary and temporal to the disc in both eyes complicated with full-thickness macular hole (hole size 1207 μm) and everted edge shown by optical coherence tomography (OCT) in the right eye [Figure 1]a and [Figure 1]b. Traumatic choroidal rupture with full-thickness macular hole (hole size 375 μm) [Figure 2]a was also noted in the left eye. OCT demonstrated epiretinal membrane (ERM) and scar tissue across the fovea [Figure 2]b.
Figure 1: Series examination of right eye. (a) Infrared image showed two crescent-shaped choroidal rupture are concentric to the optic disc (b) optical coherence tomography at presentation revealed choroidal rupture with full thickness macular hole (hole size 1207 μm) (c) Autofluorescence image after surgery showed hypoautofluorescence in areas of choroidal rupture and retinal pigment epithelium disruption (d) optical coherence tomography image revealed closed macular hole with thinned inverted flap after surgery

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Figure 2: Series examination of left eye. (a and b) Infrared image and optical coherence tomography at presentation revealed choroidal rupture with scar tissue at macula area (hole size 375 μm) (c) Autofluorescence image after surgery showed hypoautofluorescence in areas of choroidal rupture and retinal pigment epithelium disruption (d) optical coherence tomography image revealed decreased macular hole

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Standard three-port 25-gauged pars plana vitrectomy, temporally inverted ILM flap, and 13% C3F8 tamponade were performed in the right eye first [Figure 3]a. After core vitrectomy, triamcinolone acetonide-assisted (2.5 mg/ml) posterior hyaloid removal followed by forceps removal of any ERM was performed. An indocyanine green (ICG) solution (25 mg ICG in 15 ml 5% glucose-water solution and final concentration = 1.7 mg/ml) was carefully applied within the arcade. Excessive ICG was immediately removed by suction. Direct forceps grasping was then used to initiate an ILM break. The peeling of the ILM was restricted to the temporal side of the fovea only, then the macular hole was covered with the temporal ILM flap. The patient was kept in a facedown position overnight and was allowed to take any position except supine for approximately 2 weeks.
Figure 3: Surgery demonstration. (a and b) Upper images showed surgical method of temporally inverted internal limiting membrane flap in the right eye, and double inverted internal limiting membrane flap in the left eye. (c and d) Postoperative color photo showed scar formation at choroidal rupture area

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After surgery, her BCVA improved to 20/40 and OCT showed smaller macular hole with foveal neurosensory retinal defect.

Due to greater macular hole and choroidal rupture vertically across the center of fovea, we performed microincisional vitrectomy, fibrotic scar removal, double inverted ILM flap from temporal and nasal side, and 13% C3F8 tamponade in the left eye [Figure 3]b. The peeling of the ILM was restricted to the temporal and nasal side of the choroidal rupture, respectively. Then, the ILM flaps anchoring on the rupture edge were covered on the choroidal rupture using intraocular forceps. The patient was educated to keep in a facedown position overnight. However, she was lost follow-up after surgery due to personal reasons. Two years postoperatively, her BCVA improved to 20/30 in the right eye, scar formation at choroidal rupture site, and OCT showed sealed macular hole with ellipsoid zone restoration [Figure 1]c, [Figure 1]d and [Figure 3]c. Her BCVA remained 20/100 in the left eye, also had scar formation at choroidal rupture site and OCT showed hyperreflective subfoveal choroidal scar formation [Figure 2]c, [Figure 2]d and [Figure 3]d. At the last follow-up, there was no CNV noted at fundus and OCT examinations.


  Discussion Top


The areas of choroidal rupture had early hemorrhage with increased fibrovascular activity, then well-defined scar formation. In some cases, there is an exuberant healing process, with scar tissue extending into the subretinal space, the retina, and/or vitreous. Visual acuity at presentation can range from 20/20 to light perception, depending on the location of the rupture, the degree of associated hemorrhage, and other associated ocular injuries. Ruptures are more commonly located temporal to the disc than nasal, and usually in the horizontal meridian.[1] With time, these ruptures evolve into white streaks with pigmented margins due to RPE hyperplasia.

Marinali Patel noted that 81.2% of patients were morbid with CNV after choroidal rupture within the 1st year after the injury. More frequent follow-up was suggested in the 1st year after trauma.[1] OCT is a useful method for the evaluation of the integrity, length, and severity of posttraumatic choriocapillaris/RPE complex and retina. Fluorescein angiography, ICG angiography, and fundus autofluorescence can also enable visualization of ruptures initially ophthalmoscopically hidden by hemorrhage, commotio retinae, or RPE abnormalities, or ruptures too small to see clinically.

Choroidal ruptures usually have no effective treatment. Poor visual outcome was associated with foveal choroidal rupture and baseline visual acuity of <20/40.[2],[3] Laser photocoagulation was reported to be used in the treatment of CNV from choroidal ruptures as early as the first reports of CNV after choroidal rupture in the early 1970s. Photodynamic therapy and anti-vascular endothelial growth factor agents have been reported to be effective in the management of CNV secondary to ocular trauma.[5],[6],[7] However, there are limited case reports about surgical treatment for the macular hole complicated with choroidal rupture.

Combined with inverted ILM flap can induce gliosis on the surface of ILM and release tangential forces acting on the macular hole, thus help in healing.[8] Successful macular hole closure had been reported by Deependra Vikram Singh,[9] whom performed vitrectomy with ILM peeling and SF6 gas injection in a patient with full-thickness macular hole with choroidal rupture across papillomacular bundle. Stuti Astir[4] also reported successful closed macular holes after inverted flap technique for a large traumatic macular hole (hole size 899 μm) with choroidal rupture across papillomacular bundle. The most reliable factors affecting the surgical outcome following surgery are the size of the hole and the location of the choroidal rupture.

Temporal inverted ILM flap technique had been compared with classic inverted ILM flap technique and shown as effective as the classic technique for the repair of large macular holes with less frequent dissociated optic nerve fiber layer appearance.[10] In our case, we performed temporally inverted ILM flap for right eye macular hole, with good anatomic and visual improvement. However, limited visual improvement was achieved in the left eye despite the successful closure of macular hole. Although Raman and Desai reported foveal involvement by itself can be compatible with good visual recovery results from the presence of functioning subfoveal RPE.[3] Subfoveal choroidal scar formation might compromise the blood supply of the photoreceptors, leading to poor visual outcome.

A double inverted ILM flap technique has been reported as inverted both ERM and ILM flaps for the treatment of idiopathic lamellar macular holes with atypical ERM.[11] Here, we performed the double inverted flap including both nasal and temporal side inverted ILM flaps. This technique could be beneficial for patients with macular hole and choroidal rupture which cross the fovea vertically.

There are some limitations of this study. First, the surgical techniques are not identical in both eyes of the same patient. However, this also accentuates the diversity of ocular trauma. The retinal surgeons should do their best to individualize the management of different situations after blunt injury. Second, only two eyes of one patient were included. Further studies with a large case number should be done to further evaluate these surgical methods.

To the best of our knowledge, this is the first case of a double inverted ILM flap for the treatment of traumatic choroidal rupture and macular hole. Although limited visual acuity improvement due to choroidal scar formation in the left eye, anatomical improvement was achieved in both eyes. Nevertheless, larger studies of double inverted ILM flap will be required to validate our results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declare that there are no conflicts of interests of this paper.



 
  References Top

1.
Patel MM, Chee YE, Eliott D. Choroidal rupture: A review. Int Ophthalmol Clin 2013;53:69-78.  Back to cited text no. 1
    
2.
Ament CS, Zacks DN, Lane AM, Krzystolik M, D'Amico DJ, Mukai S, et al. Predictors of visual outcome and choroidal neovascular membrane formation after traumatic choroidal rupture. Arch Ophthalmol 2006;124:957-66.  Back to cited text no. 2
    
3.
Raman SV, Desai UR, Anderson S, Samuel MA. Visual prognosis in patients with traumatic choroidal rupture. Can J Ophthalmol 2004;39:260-6.  Back to cited text no. 3
    
4.
Astir S, Shroff D, Gupta C, Shroff C. Inverted flap technique for a large traumatic macular hole with choroidal rupture and subretinal hemorrhage. Oman J Ophthalmol 2018;11:68-70.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Lupidi M, Muzi A, Castellucci G, Kalra G, Piccolino FC, Chhablani J, et al. The choroidal rupture: Current concepts and insights. Surv Ophthalmol 2021;66:761-70.  Back to cited text no. 5
    
6.
Fuller B, Gitter KA. Traumatic choroidal rupture with late serous detachment of macula. Report of successful argon laser treatment. Arch Ophthalmol 1973;89:354-5.  Back to cited text no. 6
    
7.
Lorusso M, Micelli Ferrari L, Nikolopoulou E, Micelli Ferrari T. Optical coherence tomography angiography evolution of choroidal neovascular membrane in choroidal rupture managed by intravitreal bevacizumab. Case Rep Ophthalmol Med 2019;2019:5241573.  Back to cited text no. 7
    
8.
De Benedetto U, Battaglia Parodi M, Knutsson KA, Librando A, Bandello F, Lanzetta P, et al. Intravitreal bevacizumab for extrafoveal choroidal neovascularization after ocular trauma. J Ocul Pharmacol Ther 2012;28:550-2.  Back to cited text no. 8
    
9.
Singh DV, Reddy RR, Kuniyal L, Sharma YR. Excellent visual outcome after vitrectomy for traumatic macular hole associated with choroidal rupture across papillomacular bundle. Oman J Ophthalmol 2018;11:90-1.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Michalewska Z, Michalewski J, Dulczewska-Cichecka K, Adelman RA, Nawrocki J. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: A comparative study. Retina 2015;35:1844-50.  Back to cited text no. 10
    
11.
Frisina R, Parrozzani R, Pilotto E, Midena E. A double inverted flap surgical technique for the treatment of idiopathic lamellar macular hole associated with atypical epiretinal membrane. Ophthalmologica 2019;242:49-58.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

 
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