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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 146-148

Management of macular hole secondary to presumed chronic solar phototoxicity from sun-gazing

Retina-Vitreous Service, Ratan Jyoti Netralaya, Gwalior, Madhya Pradesh, India

Date of Submission19-Feb-2021
Date of Acceptance29-Jun-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Dhananjay Shukla
18 Vikas Nagar, Ratan Jyoti Netralaya, Gwalior - 474 002, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_423_21

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A 70-year-old man presented with gradual visual decline in both eyes; the vision had become worse in the right eye recently. On fundus examination, the right eye was found to have a large macular hole; the left eye was unremarkable. The best-corrected visual acuity was 20/100 in the right eye and 20/63 in the left eye. Optical coherence tomography confirmed the macular hole in the right eye and revealed an unsuspected foveal atrophy with interruption of outer retinal bands in the left eye, suggestive of macular phototoxicity. Based on this evaluation, leading questions were asked, whereupon he admitted to a long-time morning ritual of sun-gazing. After vitrectomy with internal limiting membrane peeling in the right eye, the macular hole closed, and the best-corrected visual acuity improved to 20/40. A full-thickness macular hole presumably secondary to sun-gazing was successfully treated with significant visual improvement.

Keywords: Macular hole, macular phototoxicity, photochemical injury, sun-gazing, vitrectomy

How to cite this article:
Shukla D. Management of macular hole secondary to presumed chronic solar phototoxicity from sun-gazing. Indian J Ophthalmol Case Rep 2022;2:146-8

How to cite this URL:
Shukla D. Management of macular hole secondary to presumed chronic solar phototoxicity from sun-gazing. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:146-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/146/334950

Excessive light can damage macula in several ways: through acute photomechanical effects, subacute photothermal effects or chronic photochemical effects.[1] Chronic macular phototoxicity is a subtle, cumulative, and, therefore, underdiagnosed and underreported photochemical injury.[1],[2] The optical coherence tomography (OCT) picture is characteristic but not pathognomonic, and a history of light exposure often needs to be elicited to reveal the cause.[3] Religious and cultural associations perpetuate the harmful practice of sun-gazing even today across various ethnic populations.[4] A PubMed search did not reveal a macular hole secondary to any type of chronic phototoxicity (e.g. welding arc, sun-gazing, etc.) in the literature. A large full-thickness macular hole presumably secondary to long-term sun-gazing and its successful surgical management are described herein.

  Case Report Top

A 70-year-old diabetic and hypertensive man presented to a tertiary eye care center with blurring of vision in both eyes for 10–12 months; the vision had become worse in the right eye recently. His best-corrected visual acuity was 20/100 in the right eye and 20/63 in the left. Anterior segment biomicroscopy showed minimal posterior subcapsular cataract in the right eye; the left eye was normal. Fundus examination of the right eye revealed a full-thickness macular hole; the posterior segment of the left eye was clinically unremarkable [Figure 1]a and [Figure 1]e. There was no diabetic or hypertensive retinopathy in either eye. OCT (Avanti Optovue, Fremont, California) revealed a large macular hole (687 microns in the horizontal diameter) in the right eye [Figure 1]b and an unsuspected foveal atrophy in the left eye (central foveal thickness was 83 microns). The ellipsoid zone was attenuated and the interdigitation zone was interrupted in the central fovea in the left eye [Figure 1]f. Fundus-camera-based autofluorescence imaging was unremarkable in both eyes.
Figure 1: (a) Macular hole in the right eye is hazily seen due to posterior subcapsular cataract. (b) OCT confirms a large macular hole (687 μ). (c and d) The hole closed without any central neurosensory defect after vitrectomy; corrected Snellen acuity improved (20/100 to 20/40) over 21 months. (e) Left fundus was unremarkable. (f) OCT left eye was suggestive of chronic phototoxicity: there was a central attenuation and paracentral focal interruption of ellipsoid zone. Interdigitation zone was interrupted over the entire extent of foveal atrophy. The central macular thickness was substantially reduced (83 μ)

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On eliciting relevant history, the patient revealed that he regularly looked at the morning sun for a few minutes every day for more than a decade, as advised by a religious guru. There was no history of consumption of any psychoactive, hallucinogenic, or photosensitizing drugs, besides the usual medications for diabetes and hypertension. After an informed consent was obtained, the patient underwent vitrectomy, internal limiting membrane peeling, and perfluoropropane gas tamponade along with cataract surgery and intraocular lens implantation in the right eye. The macular hole was observed to be closed 1 month after surgery [Figure 1]c and [Figure 1]d. By the last follow-up at 21 months, BCVA had improved to 20/40 in the right eye. The left eye retained status quo. The study was performed in compliance with the tenets of the Declaration of Helsinki.

  Discussion Top

Macular holes have been reported after acute photomechanical as well as photothermal injuries for over two decades.[1],[5],[6] Though Rosen[7] reported and reviewed several “small macular holes” presumably related to exposure to sun soon after World War II, a Medline search did not reveal any macular hole secondary to solar phototoxicity, documented by OCT. One reason for this lacuna may be the underreporting of chronic solar retinopathy itself, which might be common in individuals exposed to direct or reflected sunlight geographically, occupationally, or as a religious practice.[3],[4],[7] A few sporadic exposures to bright light are mostly harmless.[1],[2],[4] Individuals exposed to excessive light over long term lose vision slowly and are therefore often oblivious of the recurrent, habitual exposure. They may need to be proactively questioned to unravel the source of phototoxic injury.[3],[4]

The insidious, cumulative development of phototoxicity was the reason the patient reported after a decade of sun-gazing, only when the right eye suffered additional visual loss due to macular hole.

The suspicion of phototoxicity is aroused by the characteristic OCT findings like interruption of outer retinal bands – especially the ellipsoid and interdigitation zones – in most cases, foveal atrophy in more severe or chronic cases worsens the visual prognosis [Figure 1]f.[1],[2],[3],[4] The reported patient suffered gradual, incremental phototoxicity because he looked at the morning (not bright) sun. However, even longer wavelengths of light from a morning sun can cause insidious damage on prolonged and repeated exposures,[1],[2] more so because of greater pupillary dilatation in low ambient light in the morning. He had further visual loss in the right eye due to macular hole formation, which eventually led to clinical consultation. Solar retinopathy per se may affect the two eyes asymmetrically.[3] An antecedent vitreomacular traction might have triggered a dehiscence of the photochemically compromised foveal Muller's cells precipitating the macular hole formation, similar to the suggested mechanism in macular holes secondary to accidental laser burns.[5] Ironically, this event turned out to be propitious for the patient, as he regained better visual acuity in the operated eye than the fellow eye.

Macular holes after accidental laser burns due to Nd: YAG laser (photomechanical tissue disruption) and handheld lasers (both photomechanical and photothermal mechanisms) very occasionally close spontaneously (when small) and usually enlarge if not operated.[5],[6],[8] Successful surgical closure with visual improvement has been reported with both the types of laser-induced macular holes. The temporal relationship of macular hole with the photic insult may have prognostic value. The macular holes that form immediately after light exposure are likely to have more tissue loss (for example, Nd: YAG laser) and worse prognosis, while those developing later may have greater contribution of vitreomacular traction, which surgery can address better.[5],[8] Another prognostic variable is the morphology of the macular hole: a secondary macular hole that looks like a primary macular hole (smooth contours and elevated, oedematous edges) generally closes like one.[8]

  Conclusion Top

This case alerts clinicians to the potential harm from still prevalent pernicious rituals like sun-gazing.[4] At the same time, the presented favorable surgical experience alludes to the possibility of a treatable pathology in an otherwise irreversible macular injury in chronic solar phototoxicity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their 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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Symons A, Chan H, Mainster MA. Photic retinal injuries: Mechanisms, hazards, and prevention. In: Schachat AP, editor. Ryan's Retina. 6th ed. St. Louis, U.S.: Elsevier; 2018. p. 1746-56.  Back to cited text no. 1
Hunter JJ, Morgan JI, Merigan WH, Sliney DH, Sparrow JR, Williams DR. The susceptibility of the retina to photochemical damage from visible light. Prog Retin Eye Res 2012;31:28-42.  Back to cited text no. 2
dell'Omo R, Konstantopoulou K, Wong R, C Pavesio. Presumed idiopathic outer lamellar defects of the fovea and chronic solar retinopathy: An OCT and fundus autofluorescence study. Br J Ophthalmol 2009;93:1483-7.  Back to cited text no. 3
Begaj T, Schaal S. Sunlight and ultraviolet radiation-pertinent retinal implications and current management. Surv Ophthalmol 2018;63:174-92.  Back to cited text no. 4
Alsulaiman SM, Alrushood AA, Almasaud J, Alkharashi AS, Alzahrani Y, Abboud EB, et al. Full-thickness macular hole secondary to high-power handheld blue laser: Natural history and management outcomes. Am J Ophthalmol 2015;160:107-13.  Back to cited text no. 5
Qi, Y, Wang Y, You Q, Tsai F, Liu W. Surgical treatment and optical coherence tomographic evaluation for accidental laser-induced full-thickness macular holes. Eye 2017;31:1078-84.  Back to cited text no. 6
Rosen E. Solar retinitis. Br J Ophthalmol 1948;32:23-35.  Back to cited text no. 7
Shukla D. Secondary macular holes: When to jump in and when to stay out. Exp Rev Ophthalmol 2013;8:437-46.  Back to cited text no. 8


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