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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 532-534

Structural and functional recovery of macular atrophy following acute traumatic maculopathy


1 Department of Ophthalmology, Gold Coast Health, Gold Coast, Australia
2 Department of Ophthalmology, Gold Coast Health; Department of Ophthalmology, Gold Coast and Tweed Eye Doctors, Gold Coast, Australia

Date of Submission25-May-2020
Date of Acceptance02-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Duncan Lyons
Gold Coast University Hospital, 1 Hospital Boulevard Gold Coast, Queensland - 4215
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1651_20

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  Abstract 


This case report describes a rare case of spontaneous structural and functional recovery of macular atrophy following acute traumatic maculopathy. A 53-year-old man suffered a blunt left-eye injury. Initial optical coherence tomography showed evidence of macular hole formation. Over the following month, macular atrophy developed, with left best-corrected visual acuity ranging from 6/24 to 6/18. Following 14 months, the atrophy spontaneously resolved – correlating with left visual acuity improving to 6/6. Although the outcome from severe traumatic maculopathy and subsequent macular atrophy is almost uniformly considered to be poor, this rare case demonstrates that spontaneous recovery may still occur.

Keywords: Acute traumatic maculopathy, closed globe injuries, macular atrophy


How to cite this article:
Lyons D, Drury B. Structural and functional recovery of macular atrophy following acute traumatic maculopathy. Indian J Ophthalmol Case Rep 2021;1:532-4

How to cite this URL:
Lyons D, Drury B. Structural and functional recovery of macular atrophy following acute traumatic maculopathy. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Sep 24];1:532-4. Available from: https://www.ijoreports.in/text.asp?2021/1/3/532/319983



Closed globe injuries are common hospital presentations and can cause coup and contrecoup injuries, resulting in both anterior and posterior segment damage.[1] Posterior segment damage can include acute traumatic maculopathy, macular holes, macular atrophy, hypotony maculopathy, retinal tears, vitreous hemorrhage, and retinal hemorrhage.[1] This report demonstrates an unusual case of posterior segment damage with spontaneous structural and functional recovery of macular atrophy following acute traumatic maculopathy.


  Case Report Top


A 53-year-old man suffered a blunt left-eye injury from an octopus strap. Upon examination, the patient's visual acuity (VA) was R 6/6 and L 6/36 and intraocular pressure (IOP) was R 8 mmHg and L 36 mmHg. Ocular examination revealed left full-thickness lower lid laceration, microhyphema, and superficial corneal laceration. Retinal examination showed large areas of commotio retinae involving the superior and temporal aspects of the posterior pole extending into the macula. Primary treatment involved topical atropine 1% bd and prednisolone acetate 1% 4 hourly. The eyelid laceration was repaired using local anesthetic in the outpatient clinic the same day a macula optical coherence tomography (OCT) scan was performed within 24 h of presentation [Figure 1]. This showed increased reflectivity of the perifoveal outer retina and discontinuity of the outer foveal layers with an inner bridge of tissue remaining, suggestive of impending full-thickness macular hole formation. Over the following month, the central macular thickness (CMT) reduced and macular atrophy developed with loss of the majority of the subfoveal retinal layers, including the external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (IZ) [Figure 2]. This corresponded to the left eye VA of 6/24. Over the next 2 months, best-corrected visual acuity (BCVA) ranged from 6/24 to 6/18, with OCT at 2.5 months post injury showing interval improvement in the CMT and subfoveal retinal layers [Figure 3]. At 6.5 months post injury, there was only minor subtle interval improvement in the CMT and subfoveal retinal layers [Figure 4], with nil improvement in the BCVA.
Figure 1: (Top left). Optical coherence tomography demonstrating increased reflectivity of the perifoveal outer retina and discontinuity of the outer foveal layers with an inner bridge of tissue remaining, suggestive of impending full-thickness macular hole formation

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Figure 2: (Top middle). Optical coherence tomography 1 month post injury, showing further central macular thickness decline and macular atrophy developed with loss of the majority of the subfoveal retinal layers

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Figure 3: (Top right). Optical coherence tomography 2.5 months post injury, showing interval improvement in the central macular thickness and subfoveal retinal layers

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Figure 4: (Bottom left). Optical coherence tomography 6.5 months post injury, showing interval subtle improvement in the central macular thickness and subfoveal retinal layers

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Macular atrophy persisted on serial OCT examinations until examination at 14 months following injury, where there was a spontaneous resolution of the atrophy with the formation of an epiretinal membrane [Figure 5] and CMT increased to 325 μm. At this time point, the patient reported subjective improvement in their VA, which correlated with BCVA improving to 6/6.
Figure 5: (Bottom middle). Optical coherence tomography 14 months post injury, showing resolution of the macular atrophy and formation of an epiretinal membrane

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  Discussion Top


Traumatic maculopathy (TM) is characterized by injury to the photoreceptor cell bodies and outer segments, which can result in further degeneration of the retinal pigment epithelium cells and subsequent loss of vision.[1] OCT is a useful diagnostic tool in TM for assessing the location and extent of the injuries to the posterior segment of the eye.[2] In TM, OCT demonstrates an increase in reflectivity of the inner segment/outer segment (IS/OS) photoreceptor junction and loss of the hypo-reflective optical space.[1],[2] Milder lesions, with favorable visual outcomes, showed normal to transient hyper-reflectivity of the EZ, IZ, and ELM. Eyes with poorer outcomes show disruption or loss of the IZ, EZ, ELM, and additional findings such as retinal atrophy. A study focusing on OCT grading of macular commotio retinae (CR) found that all cases with defects to the cone outer segment, IS/OS junction, and ELM had VA of <20/200 at final follow up.[3] Only one eye in this series showed anatomical recovery of all three photoreceptor layers.[3] In contrast, our case demonstrated excellent anatomical and functional recovery despite previously marked macular atrophy.

There are no approved medical treatments for CR; in most cases, the prognosis for visual recovery is positive, with complete spontaneous resolution within 2 to 4 weeks.[4] Patients with CR involving the macula, however, have a poorer prognosis. Studies have shown that such patients have a high risk of developing a traumatic macular hole (THM) and subsequently increased risk of macular atrophy.[3],[4] In addition, these studies found that this often leads to permanent vision impairment with limited treatments to improve visual outcomes.

To the authors knowledge, there are no reports of similar levels of anatomical and functional recovery following severe macular atrophy and as a result of traumatic maculopathy. The incidence of spontaneous closure of TMHs ranges from 10–44%.[5] Several explanations have been proposed to explain this phenomenon. One of such explanations includes the formation of a contractile epiretinal membrane (ERM) that results in cell proliferation at the base, shrinkage and closure of the hole, and retinal tissue bridging across the hole.[5],[6] In our case, we hypothesize that a posterior vitreous detachment was induced as a result of blunt trauma, resulting in ERM formation. The ERM may have provided a scaffold to allow cell proliferation, and the subsequent contraction resulted in apposition of the residual macular tissue.


  Conclusion Top


Although the outcome from severe traumatic maculopathy and subsequent macular atrophy is almost uniformly considered to be poor, this case demonstrates that spontaneous recovery may be possible in rare cases.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments.

Declaration of patient consent

Written informed consent was obtained by the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chen K, Sun M, Sun C, Wang N, Chiun-Ho H, An-Lun W, et al. Traumatic maculopathy with massive subretinal haemorrhage after closed-globe injuries. Ophthalmol Retina 2019;3:53-60.  Back to cited text no. 1
    
2.
Mendes S, Campos A, Beselga D, Campos J, Neves A. Traumatic maculopathy 6 months after injury: A clinical case report. Case Rep Ophthalmol 2014;5:78-82.  Back to cited text no. 2
    
3.
Ahn S, Woo S, Kim K, Dong-Hyan J, Jeeyun A, Kyu-Hyung P. Optical coherence tomography morphologic grading of macular commotio retinae and its association with anatomic and visual outcomes. Am J Ophthalmol 2013;156:994-1001.  Back to cited text no. 3
    
4.
Blanch R. Understanding and Preventing Visual Loss in Commotio Retinae. Birmingham: University of Birmingham; 2014.  Back to cited text no. 4
    
5.
Chen H, Chen W, Zheng K, Peng K, Xia H, Zhu L. Prediction of spontaneous closure of traumatic macular hole with spectral domain optical coherence tomography. Sci Rep 2015;5:12343.  Back to cited text no. 5
    
6.
Menchini U, Virgili G, Giacomelli G, Cappelli S, Giansanti F. Mechanism of spontaneuous closure of traumatic macular hole: OCT study of one case. Retina 2003;23:104-6.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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