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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 440-442

A rare finding of lamellar macular hole with lamellar hole-associated epiretinal proliferation in retinal vein occlusion

Department of Vitreo-Retina, Disha Eye Hospital, Kolkata, West Bengal, India

Date of Submission18-Aug-2021
Date of Acceptance25-Oct-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Kshitiz Kumar
Department of Vitreo-Retina, Disha Eye Hospital, Barrackpore, 88 (63A) Ghoshpara Road, Kolkata - 700120, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2139_21

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A 69-year-old female presented with right eye vision of 20/120 Snellens. Ultrawide-field fundus imaging showed old vitreous hemorrhage with superotemporal sclerosed vessels post venous occlusion. Spectral-domain optical coherence tomography revealed degenerative lamellar macular home (LMH) with lamellar hole-associated epiretinal proliferation (LHEP). The patient underwent surgery using vitrectomy with the embedding technique. Post surgery, good recovery of the foveal contour was achieved with vision improving to 20/40. LMH with LHEP can be a sequela of chronic macular edema in RVO.

Keywords: Internal limiting membrane peeling, lamellar hole-associated epiretinal proliferation (LHEP), lamellar macular hole, retinal vein occlusion, vitrectomy

How to cite this article:
Kumar K, Sinha TK, Bhattacharya D. A rare finding of lamellar macular hole with lamellar hole-associated epiretinal proliferation in retinal vein occlusion. Indian J Ophthalmol Case Rep 2022;2:440-2

How to cite this URL:
Kumar K, Sinha TK, Bhattacharya D. A rare finding of lamellar macular hole with lamellar hole-associated epiretinal proliferation in retinal vein occlusion. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:440-2. Available from: https://www.ijoreports.in/text.asp?2022/2/2/440/342928

International Vitreomacular Traction Study morphologically described lamellar macular hole (LMH) as a retinal condition characterized by a partial thickness defect of the fovea, separation between outer and inner retinal layers, irregular foveal profile, and persistence of the foveal photoreceptor layer.[1]

LMH is occasionally seen in eyes with old retinal vein occlusion (RVO).[2] Tsukada et al.[3] described spontaneous LMH formation in four eyes with chronic CME associated with RVO. Three eyes showed an epiretinal membrane, and one eye showed traction of a posterior hyaloid membrane to the fovea in their study.

Epiretinal membrane (ERM) has an essential role in the pathogenesis of LMH.[4] Govetto et al.[5] proposed differentiation of LMH into two subtypes: tractional LMH with associated C ERM (ERM with high reflectivity and tractional properties known as conventional ERM) and degenerative LMH associated with lamellar hole-associated epiretinal proliferation (LHEP)/A ERM (ERM with homogeneous medium reflectivity and without tractional properties labeled as hole-associated epiretinal proliferation (HEP) or atypical ERM).

There is a paucity of information in the existing literature on lamellar macular holes in association with retinal vein occlusion. To date, there have been only five reported cases of LMH in old RVO.[2],[3] Herein we describe a rare finding of LMH with LHEP in branch retinal vein occlusion (BRVO) and its successful management.

  Case Report Top

A 69-year-old known hypertensive female presented with diminution of vision in the right eye (RE) for past 8 months. BCVA was 20/120 Snellens in RE. Slit-lamp examination showed cataractous lens. Fundus examination revealed hazy media due to old vitreous hemorrhage partially obscuring the retinal details, and sclerosed superotemporal vein and its branches with macula showing pseudohole in RE. Ultrawide-field fundus imaging captured using the Optos 200Tx documented the findings [Figure 1]a, [Figure 1]b. Spectral-domain optical coherence tomography (SD-OCT) done using RTVue (Optovue Inc, Fremont, CA) classified the pseudohole to be a degenerative lamellar macular hole [Figure 1]c. It had a partial-thickness macular lesion with round-edged intraretinal cavitation affecting all retinal layers without a foveal bump and disrupted external limiting membrane (ELM) with intact ellipsoid zone (EZ). The superior half of the macula had disorganized inner retinal layers (DRIL). There was non-tractional LHEP on the vitreoretinal interface. Residual foveal thickness was 96 microns. Treatment history revealed the use of multiple intravitreal anti-VEGF injections over last 2 years. Given the multifactorial cause for vision loss, the patient underwent combined phacoemulsification with intraocular lens implantation (IOL) for cataract and vitrectomy with sectoral endolaser for vitreous hemorrhage along with “LHEP embedding with ILM inversion” surgery. Embedding technique employed the use of BBG staining of ILM around yellowish LHEP surrounding the LMH and then raising multiple flaps of LHEP and ILM measuring approximately 1–1.5 times the diameter of the lamellar defect for 360° attached to the edge of LMH. This was followed by massaging the flaps to fill the lamellar defect during fluid air exchange. [Figure 2] summarizes the steps. At 1 month follow-up, the patient's BCVA improved to 20/40 in RE. UWFI showed clear media with attached retina, laser marks with no lamellar macular defect [Figure 3]a, [Figure 3]b. On SD-OCT, there was a smooth foveal contour with filled-up lamellar cavitation and intact EZ with a central foveal thickness (CFT) of 211 μm [Figure 3]c. At 6 months, the CFT had improved to 244 μm with recovered ELM, intact EZ, and BCVA at 20/40 [Figure 3]d. The patient was asked to review regularly.
Figure 1: UWF fundus photograph of the right eye (a) showing old vitreous hemorrhage with hazy details of underlying retina and (b) magnified image of posterior pole showing vitreous hemorrhage covering the superior half of the temporal arcade. SD-OCT vertical cross-line image of the right eye macula (c) showing degenerative LMH with LHEP. LHEP is visible on the vitreoretinal interface as homogeneous material with medium reflectivity with contact between the proliferation and the underlying retina without evidence of traction

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Figure 2: Intra-op photographs of embedding technique. (a) LHEP observed on the surface of the macula (yellow stars) surrounded by BBG stained ILM (blue arrows) and sclerosed superotemporal vessels. (b) Centripetal peeling of LHEP around LMH started and the small raised LHEP flap is visible (yellow arrow). (c) Large flap of raised LHEP (yellow arrows). (d) Whorl of multiple LHEP flaps seen around the LMH. (e) ILM peeling started with creation of ILM flaps (white arrow) circumferentially around the LHEP flaps and LMH. (f) LMH seen covered with LHEP & ILM flaps (yellow arrows)

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Figure 3: Post-op images. UWF fundus photograph of the right eye (a) showing clear media, sectoral PRP laser scars in the superotemporal quadrant, sclerosed vessels with attached retina & (b) magnified image of posterior pole showing dull foveal reflex with filled-up lamellar defect. SD-OCT vertical cross line image of the right eye macula (c) at 1 month showing smooth foveal contour with plugged lamellar cavitation, intact EZ, and thinned superior half of the macula, (d) at 6 months showing improved thickness of the fovea with recovered ELM and intact EZ

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  Discussion Top

There are no reports on the surgical intervention for LMH in association with retinal vein occlusion. This case demonstrated the use of the “LHEP embedding with ILM inversion” technique for degenerative LMH in branch retinal vein occlusion (BRVO) with good outcome in accordance with the recent studies on its use in degenerative LMH.[6],[7],[8]

The pathogenesis of transformation of chronic CME into LMH is not clear. The probable mechanism may be the deroofing of the CME, collapse of the inner retinal wall, centrifugal traction of the associated ERM, or contraction of the posterior hyaloid.[3] In the event of intravitreal injections for CME in RVO, posterior vitreous detachment can get induced, along with post-injection regression of macular edema volume with subsequently increased fibrosis additionally contributing to risk factors for LMH formation, as seen with FTMH development in such cases.[9] The average time interval of conversion of CME into LMH post RVO was more than 24 months,[3] thereby attributing unresolved chronicity as the single most important risk factor for LMH development as was evident in this case too.

There is no consensus on the management of LMH in association with RVO for the risk of suboptimal visual gain secondary to underlying retinal and macular ischemia with poor functional state of foveal photoreceptor cells caused by long-standing CME.[3] So far, the standard technique of double-membrane peeling for degenerative LMH has resulted in progression of LMH into FTMH on several occasions.[8],[10] For the factors discussed above, surgery for degenerative LMH in this case of old RVO was questionable altogether. However, one has to address the situation surgically if there is documented progression of LMH with a drop in vision at 3–6 monthly follow-ups and disruption of ELM sign on SD-OCT.

However, we used the novel technique of vitrectomy with LHEP embedding and ILM inversion in this case with gratifying results. The surgical steps and difficulties of making LHEP flaps for embedding were similar in both degenerative idiopathic vis-à-vis acquired LMH with LHEP. LHEP tissue was gummy and strongly adherent to underlying retina. The rationale behind the use of this technique has been detailed in our published case series.[6] There was remarkably smooth foveal contour recovery with increased CFT, regenerated ELM, and intact EZ post surgery by using the modified technique despite underlying retinal ischemia and degeneration in this case. Concurrently the vision improved markedly due to clear media with IOL, no hemorrhage, and filled-up lamellar defect.

  Conclusion Top

Degenerative LMH can develop in cases of RVO with chronic CME, and in the event of progression of LMH with vision loss, skilled surgery in the form of vitrectomy with the modified technique of LHEP embedding with ILM inversion can be used.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report along with the consent to publish the images.

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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest. The authors alone are responsible for the content and writing of this article.

  References Top

Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, et al. The international vitreomacular traction study group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology 2013;120:2611-9.  Back to cited text no. 1
Trempe CL, Takahashi M, Topilow HW. Vitreous changes in retinal branch vein occlusion. Ophthalmology 1981;88:681-7.  Back to cited text no. 2
Tsukada K, Tsujikawa A, Murakami T, Ogino K, Yoshimura N, et al. lamellar macular hole formation in chronic cystoid macular edema associated with retinal vein occlusion. Jpn J Ophthalmol 2011;55:506-13.  Back to cited text no. 3
Michalewska Z, Michalewski J, Odrobina D, Nawrocki J. Non-full-thickness macular holes reassessed with spectral domain optical coherence tomography. Retina 2012;32:922-9.  Back to cited text no. 4
Govetto A, Dacquay Y, Farajzadeh M, Platner E, Hirabayashi K, Hosseini H, et al. lamellar macular hole: Two distinct clinical entities? Am J Ophthalmol 2016;164:99-109.  Back to cited text no. 5
Kumar K, Sinha TK, Bhattacharya D. Modified surgical technique for lamellar macular holes with lamellar hole-associated epiretinal proliferation (LHEP). Int Ophthalmol 2021;41:2197-204.  Back to cited text no. 6
Takahashi K, Morizane Y, Kimura S, Shiode Y, Doi S, Okanouchi T, et al. Results of lamellar macular hole-associated epiretinal proliferation embedding technique for the treatment of degenerative lamellar macular hole. Graefes Arch Clin Exp Ophthalmol 2019;257:2147-54.  Back to cited text no. 7
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. 8
Mishra C, Kannan NB, Sen S, Singh K, Damodaran S, Kohli P, et al. Clinical presentation and prognostic factors affecting surgical outcomes of secondary macular holes after retinal vein occlusions. Int Ophthalmol 2020;40:2817-25.  Back to cited text no. 9
Choi WS, Merlau DJ, Chang S. Vitrectomy for macular disorders associated with lamellar macular hole epiretinal proliferation. Retina 2018;38:664-9.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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