Full-thickness macular hole repair with associated asteroid hyalosis

Abstract

Asteroid hyalosis has been described as a benign condition leading to dispersion of multiple complex lipid deposits throughout the vitreous. The presence of asteroid hyalosis has been infrequently associated with causing complications, including calcified intraocular silicone lenses1Stringham J Werner L Monson B Theodosis R Mamalis N. Calcification of different designs of silicone intraocular lenses in eyes with asteroid hyalosis.Ophthalmology. 2010; 117: 1486-1492Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar and rhegmatogenous retinal detachments.2Okuda Y Kakurai K Sato T et al.Two cases of rhegmatogenous retinal detachment associated with asteroid hyalosis.Case Rep Ophthalmol. 2018; 9: 49-54Crossref PubMed Scopus (1) Google Scholar Abnormalities of the vitreoretinal surface in the setting of asteroid hyalosis do not necessarily dictate a negative vitrectomy prognosis3Mouna A Berrod JP Conart JB. Visual outcomes of pars plana vitrectomy with epiretinal membrane peeling in patients with asteroid hyalosis: a matched cohort study.Ophthalmic Res. 2017; 58: 35-39Crossref PubMed Scopus (4) Google Scholar but can occasionally cause complications. We present a case illustrating enlargement of a full-thickness macular hole during surgical repair in a patient with very strong vitreoretinal adhesions around the macular hole and asteroid hyalosis. A 60-year-old woman with no past ocular history presented to the retina clinic with a 4-month history of constant difficulty focusing. Her past medical history was significant for hypertension. Visual acuity (VA) on presentation was 20/60 OD and 20/25 OS. Intraocular pressures were 16 mm Hg OD and 14 mm Hg OS. Slit-lamp examination of the anterior segment was normal except 1+ nuclear sclerosis bilaterally. Funduscopic examination of the right eye showed a macular hole. Colour funduscopic photographs of the right eye also revealed a macular hole with light-yellow plaques indicative of asteroid hyalosis (Fig. 1). Spectral domain optical coherence tomography (SD-OCT) illustrated an approximately 154 µm wide full-thickness macular hole with presence of cystoid macular edema (CME), attached vitreous, and hyper-reflective deposits in the vitreous corresponding to the asteroid hyalosis (Fig. 2A).Fig. 2(A) Preoperative spectral domain-optical coherence tomography (SD-OCT) showed a full-thickness macular hole (FTMH) with cystoid macular edema. (B) Postoperative 1-month visit SD-OCT showed an enlarged FTMH. (C) and (D) Postoperative 2-month and 9-month visit, respectively, showed a FTMH that continued to enlarge in size.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient underwent a 23-gauge pars plana vitrectomy (PPV) (Video 1) using visualization from the AVI lenses (Advanced Visual Instruments, Inc., New York, NY). The hyaloid was found to be firmly attached on the macula and around the equator. Dilute triamcinolone with balanced salt solution in a 1:5 ratio was injected into the vitreous cavity to allow for better visualization. Multiple attempts were made to engage and elevate the posterior hyaloid by aspirating through the vitrector and the soft-tip cannula. However, every time the posterior hyaloid was engaged and lifted slightly, it appeared too fine and feathery to be able to lift. Finally, a small ridge of elevated hyaloid between the optic nerve and macula was identified and engaged. As the posterior hyaloid around the macular hole was being elevated, due to its extremely adherent nature, the macular hole suddenly enlarged. Subsequent to this, the posterior hyaloid was engaged superior to the macula using a soft-tip cannula and lifted into the periphery. A peripheral wave of the posterior hyaloid detaching from the vitreous was visualized and the vitrectomy was completed to the vitreous base using the wide-angle AVI lens system. An air-fluid exchange was performed and dilute indocyanine green dye was instilled and removed as fluid was re-infused. Using visualization from the flat lens and intraocular forceps, the internal limiting membrane was peeled from around the macula. Peripheral scleral depression was performed to ensure there were no retinal breaks, then air-fluid exchange followed by 14% C3F8 infusion was performed. At the postoperative month 1 visit, VA was 20/300 OD. On SD-OCT, the full-thickness macular hole was evidently larger (951 µm) than prior to surgery, with ongoing CME present (Fig. 2B). At the postoperative month 2 visit, vision had improved to 20/250 OD, and SD-OCT showed an even larger width (1882 µm) of the full-thickness macular hole (Fig. 2C). At the most recent 9-month postoperative follow-up, VA remained stable at 20/250 OD, but SD-OCT illustrated a continually enlarging full-thickness macular hole (Fig. 2D) with an approximate width of 2641 µm. No further retinal surgical intervention was recommended given the degree of enlargement of the macular hole. This case demonstrates the challenges of performing a posterior hyaloid peel and vitrectomy to repair a full-thickness macular hole in the setting of strong hyaloid attachments in a patient with asteroid hyalosis. As described in the case, the very strong attachment of the posterior hyaloid created a significant challenge in being able to successfully engage and lift the hyaloid. When the hyaloid was released from the retina, the tension in the strong vitreoretinal adhesions led to enlargement of the macular hole. It is very rare for a macular hole to coexist with asteroid hyalosis, but it is important for vitreoretinal surgeons to be aware of this as they perform PPV with elevation of the posterior hyaloid in such patients. Although some studies have found no additional complications with PPVs and epiretinal membrane peels specifically in patients with asteroid hyalosis,2Okuda Y Kakurai K Sato T et al.Two cases of rhegmatogenous retinal detachment associated with asteroid hyalosis.Case Rep Ophthalmol. 2018; 9: 49-54Crossref PubMed Scopus (1) Google Scholar splitting of the posterior vitreous cortex and incarceration of anterior vitreous fibers during PPV in this population have been reported.4Shimada H Nakashizuka H Hattori T Mori R Mizutani Y Yuzawa M. Clear visualization of anterior vitreous incarceration into cannulae during 25-gauge vitrectomy in eyes with asteroid hyalosis.Eur J Ophthalmol. 2012; 22: 293-295Crossref PubMed Scopus (5) Google Scholar If the patient has already had a posterior vitreous detachment, as is the case with most retinal detachments and epiretinal membranes, this difficulty lifting hyaloid would not be encountered. The occurrence of a macular hole in patients with asteroid hyalosis is rare but has been previously described in limited reports. In 2 cases of full-thickness macular hole repair described by Kitagaki et al., the vitreous was strongly adhered to the mid-peripheral retina and required creation of an artificial PVD with multiple iatrogenic retinal breaks at the posterior pole, leading to recurrent localized retinal detachments occurring in one of the cases. However, both cases had relatively loose and easy to peel adhesions around the macular hole, allowing for successful closure of the full-thickness macular hole.5Kitagaki T Suzuki H Kohmoto R et al.Idiopathic macular hole with asteroid hyalosis.Medicine (Baltimore). 2018; 97: e11243Crossref PubMed Scopus (3) Google Scholar More recently, Rahman et al. discussed the complexities of macular hole repair in a patient with adhesions from proliferative diabetic retinopathy and hyaloid attachments from asteroid hyalosis. Similar to the other reports, the area of hyaloid around the macular hole was able to be released from the adhesions with ease, leading to successful macular hole repair.6Rahman E Bahadorani S Khalaf H. Full thickness macular hole repair in a patient with proliferative diabetic retinopathy and asteroid hyalosis.Retina Today. 2019; (https://retinatoday.com/articles/2019-apr/full-thickness-macular-hole-repair-in-a-patient-with-proliferative-diabetic-retinopathy-and-asteroid-hyalosis. Accessed December 1, 2020)Google Scholar In contrast, in our patient, the position and strength of the adhesions around the macular hole resulted in sudden enlargement of the full-thickness macular hole upon release of the traction from the posterior hyaloid. This case highlights the importance of fully considering the risks involved with performing a vitrectomy in a patient with strongly attached hyaloid in the setting of asteroid hyalosis. In situations where surgical intervention is necessary due to vision loss secondary to various retinal processes (e.g., full-thickness macular hole, retinal detachments), it is important to be aware of the potential for strong adherence of the posterior hyaloid patients with associated asteroid hyalosis and the surgical complexity of such cases in addition to the downstream consequences that might occur. Dr. Shah has no conflicts of interests. Dr. Bakri has served as a consultant for Allegro, Alimera, Allergan, Kala, Genentech, Novartis, Roche, Zeiss. Authors have no grant support or funding for this project and have no propriety interests related to the article. https://www.canadianjournalofophthalmology.ca/cms/asset/3a72fbeb-9e56-45c3-97d6-7856f49f0952/mmc1.mp4Loading ... Download .mp4 (4.11 MB) Help with .mp4 files