Traumatic macular hole repair through topical dorzolamide: A case report

Hsin-Ai Huang; Kuan-Jen Chen; Chi-Chun Lai; Hung-Da Chou

doi:10.4103/IJO.IJO_2549_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 415-418

Traumatic macular hole repair through topical dorzolamide: A case report

Hsin-Ai Huang¹, Kuan-Jen Chen², Chi-Chun Lai³, Hung-Da Chou²
¹ Department of Medical Education, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
² Department of Medical Education; Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
³ Department of Medical Education, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan; Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan

Date of Submission	03-Oct-2022
Date of Acceptance	08-Feb-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Hung-Da Chou
Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan. No. 5 Fuxing Street, Guishan District, 333, Taoyuan
Taiwan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2549_22

Abstract

Traumatic macular holes (MHs) still have a guarded prognosis. Whether spontaneous closure or early surgical intervention leads to a more favorable outcome is unclear. Topical therapy with carbonic anhydrase inhibitors was reported to be a non-invasive but effective treatment for traumatic MHs. A 17-year-old boy, whose face was injured by a firework explosion, presented to our emergency department with decreased vision in his left eye (20/125). A bio-microscopic examination revealed a vitreous hemorrhage that partially obscured the fundus. Optical coherence tomography (OCT) revealed an MH in the fovea with mild intra-retinal edema and juxtafoveal outer retinal layer alterations. Dorzolamide (2%) was administered four times per day. Two weeks later, OCT revealed a closed MH, and the patient's visual acuity had improved to 20/30 at 2 months following the incident. Topical aqueous suppression therapy may potentiate the closure of traumatic MHs by reducing the amount of intra-retinal fluid. It can serve as a non-invasive therapy for small traumatic MHs, especially those with the intra-retinal fluid, or as a temporary therapy before a scheduled operation.

Keywords: Aqueous suppression, carbonic anhydrase inhibitors, ocular trauma, optical coherence tomography, retinal edema, topical therapy, vitrectomy

How to cite this article:
Huang HA, Chen KJ, Lai CC, Chou HD. Traumatic macular hole repair through topical dorzolamide: A case report. Indian J Ophthalmol Case Rep 2023;3:415-8

How to cite this URL:
Huang HA, Chen KJ, Lai CC, Chou HD. Traumatic macular hole repair through topical dorzolamide: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:415-8. Available from: https://www.ijoreports.in/text.asp?2023/3/2/415/374954

Traumatic macular holes (MHs) are a defect of the neuroretina resulting from ocular trauma. The incidence of traumatic MHs is approximately 1.4% and 0.15% for closed-globe and open-globe traumatic injuries, respectively.^[1] In contrast to idiopathic MHs, traumatic MHs occur more frequently among young men in their twenties.^[2] Furthermore, no clear correlation between the size of traumatic MHs and visual acuity has been reported. By contrast, larger idiopathic MHs are associated with a poorer final visual acuity.^[1]

The treatment of traumatic MHs and the optimal time point for vitrectomy in patients with traumatic MHs are still being debated. Although early vitrectomy has a higher rate of traumatic MH closure relative to initial observation,^[3] the related prognosis is still favorable, even in the absence of surgical intervention, for patients who are young, have a small MH, and do not have intra-retinal edema.^[2]

In addition to observation for spontaneous closure and pars plana vitrectomy (PPV), topical therapy was proposed as a relatively non-invasive initial therapy in the past 10 years. Several case series have suggested that regimens such as topical non-steroidal anti-inflammatory drugs, topical corticosteroids, and topical aqueous suppressants play a role in promoting hole closure.^[4]

In the present report, we discuss the case of a 17-year-old boy who presented with traumatic MH secondary to firework explosion injury and underwent topical dorzolamide treatment that resulted in prompt hole closure with improved visual acuity.

Case Report

Written informed consent from the patient was obtained for identifiable health information present in this case. A 17-year-old boy, whose face was injured by a firework explosion, presented to our emergency department with decreased vision in his left eye. He had no history of systemic diseases, eye conditions, or ocular injuries. His right eye was unremarkable with a visual acuity of 20/20. In his injured left eye, his light reflex was normal, but his best-corrected visual acuity was 20/125. A bio-microscopic examination did not reveal any open-globe injury, but a moderately injected conjunctiva was detected. The cornea was clear with a deep anterior chamber and microhyphema, and no traumatic cataract or phacodonesis was detected. Binocular indirect ophthalmoscopy revealed a vitreous hemorrhage that partially obscured the fundus. Ocular ultrasonography revealed vitreous opacities without retinal detachment or choroidal effusion.

Two days later, a follow-up clinical examination indicated a resolving vitreous hemorrhage. The optic disc head was unremarkable, and no retinal break or retinal detachment was detected. However, the retinal vasculature was slightly tortuous, and a mildly pale and edematous macula with a hole-like lesion in the fovea was noted [Figure 1]a. Spectral-domain optical coherence tomography (OCT) revealed an MH in the fovea with a minimal aperture of 82 μm, intra-retinal edema, and juxtafoveal outer retinal layer alterations [Figure 1]b. Because of the small size of the MH and the presence of intra-retinal edema, conservative therapy with dorzolamide 2% administered four times per day was prescribed.^[4]

Figure 1: (a) Fundus photograph showed Berlin's edema and an MH. (b) OCT revealed an MH with intra-retinal edema. The parafoveal ellipsoid zone and external limiting membrane were disrupted, and hyper-reflective lesions were observed in the outer nuclear layer. The patient's vision was 20/125

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Two weeks later, OCT revealed a closed MH and juxtafoveal disruption of the ellipsoid zone [Figure 2]. During the 2-month follow-up visit, OCT still indicated some disruption of the ellipsoid zone; nevertheless, the patient's best-corrected visual acuity had improved to 20/30.

Figure 2: After topical therapy, OCT revealed a closed MH with resolved intra-retinal edema. The patient's visual acuity improved to 20/30. There was still disruption in the ellipsoid zone, external limiting membrane, and outer nuclear layer

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Discussion

The pathogenesis of traumatic MH remains unclear, although several hypotheses have been proposed to explain how ocular trauma results in MH formation.^[1],[2] They included a) an increase in equatorial diameter, followed by a compression force parallel to the axis of the globe, which may induce vitreofoveal traction leading to traumatic MH; b) trauma caused by the development and subsequent rupture of a cyst; and c) the force of an impact that is transmitted to the macula.

Through OCT, traumatic MHs were revealed to be more irregular and eccentric than idiopathic MHs.^[1] Nevertheless, the mechanism of hole formation is still difficult to clarify because of the uncertainties associated with each individual case and the different types of sudden injuries that can occur.

Because of advances in surgical techniques and instruments, vitrectomy for traumatic MH has a high anatomic success rate of between 45% and 100% (median, 92.5%) and a functional success rate (≥2 lines of improvement) of between 27% and 100% (median, 84%).^[1] However, the spontaneous closure of traumatic MHs was commonly reported. In a review article of traumatic MH, the spontaneous hole closure rate was between 10% and 67% (median, 32%) and the closure occurred at 1.3 to 9 months (median, 3 months).^[1] A study reported that 50% and 28.6% of traumatic MHs in children and adults, respectively, close without surgery.^[5] Furthermore, a multi-center prospective comparative case study by Chen et al.^[3] revealed that patients with surgically closed and spontaneously closed MHs did not differ in terms of their final visual acuity. For young patients with a small hole or those without cystoid macular changes and the risk of permanent outer retinal changes, clinicians may prescribe conservative treatment for the first 3 months because of difficulties in inducing posterior vitreous detachment in young patients.^[1] If spontaneous closure does not occur within 3 months, surgical repair with vitrectomy is recommended because there is a lower hole closure rate via surgical intervention and spontaneous hole closure after 3 months.^[5]

Dorzolamide is a topical carbonic anhydrase inhibitor (CAI) that inhibits carbonic anhydrase in the ciliary process, which reduces aqueous humor production. It is commonly used to treat open-angle glaucoma and ocular hypertension, and it can be used as a first-line treatment for retinitis pigmentosa-associated cystoid macular edema. Retrospective studies have suggested that cystoid macular edema and intra-retinal fluid are factors adversely affecting the likelihood of spontaneous closure of traumatic MHs.^[2],[3] Despite the unclear mechanism of topical CAIs and the lack of related case studies, scholars have suggested that topical CAIs can reduce the amount of intra-retinal fluid or induce dehydration of retinal cysts in MHs to increase the likelihood of hole closure.^[4],[6]

In a retrospective case series reported by Niffenegger et al.,^[4] difluprednate and dorzolamide 2% were prescribed for nine eyes with secondary MHs, and in eight of them, hole closure and improved visual acuity were achieved [Table 1]. The authors speculate that topical aqueous suppression may potentiate the closure of traumatic MHs.

Table 1: Reports on macular holes treated by topical therapy

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Because of the small hole size, it was possible that a spontaneous hole occurs with observation alone. However, because of the ease of applying eyedrops and the non-invasive nature, topical dorzolamide was still prescribed as an initial management. Complete hole closure with substantial recovery of vision was achieved within 2 weeks, which was faster than the other reported cases [Table 1]. No discomfort or side effects were reported. Topical CAIs should be considered as a first-line therapy for traumatic MHs, especially for small MHs, MHs with intra-retinal edema, and MHs with both conditions. Furthermore, in young patients or patients who are unfit for surgery after trauma, topical CAIs can be administered as a less invasive option with a good safety profile or as a temporary therapy before further surgical intervention.

Conclusion

Topical aqueous suppression therapy may potentiate the closure of traumatic MHs by reducing the amount of intra-retinal fluid. It can serve as a non-invasive therapy for small traumatic MHs, especially those with the intra-retinal fluid, or as a temporary therapy before a scheduled operation.

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

This study was supported by a research grant from Chang Gung Memorial Hospital (CMRPG5L0091). The sponsor or funding organization had no role in the design or conduct of this research.

Conflicts of interest

There are no conflicts of interest.

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