August 14, 2023
An 8-year-old boy was referred for vision loss in his right eye. He is a healthy boy who sustained blunt trauma with a soccer ball during gym class two months ago. He had some eyelid swelling after the injury but did not see an eye doctor. He failed his school eye exam and was referred for an evaluation. On examination VA was OD: 20/150 and OS: 20/20. IOP and SLE were normal OU. DFE of the left eye was normal. In the right eye, there was a superonasal retinal dialysis without subretinal fluid as well as a full-thickness macular hole. A photo was not taken that day, but the OCT is below:
Both retinal findings are due to the blunt trauma from gym class. Retinal dialysis, or disinsertion, is a traumatic injury. It generally occurs superonasally or inferotemporally. It can be hard to see without scleral depression, so this must be performed after a traumatic ocular injury. If a hyphema is present, scleral depression can be delayed for a week. The retina does not necessarily detach immediately after a dialysis, especially in a young patient with a thick vitreous, but eventually, it usually will. Traumatic macular holes are rare and are always associated with reduced acuity. They should be observed for a month because occasionally the hyaloid will separate a few weeks after an injury, which can release the macular traction and create spontaneous hole closure. Since this patient’s injury occurred 2 months ago, that was unlikely to happen. We, therefore, agreed with the patient and his mother to proceed with surgical repair to both the macular hole and dialysis.
Surgery to repair a macular hole consists of a vitrectomy, creating a PVD, peeling the ILM, then putting in a short-acting gas bubble. The patient is face down for three days after surgery so the bubble can compress and close the edges of the hole. Treating the dialysis is done at the same time with a peripheral laser. Potential difficulties with an 8-year-old include elevating the hyaloid because it is tightly adherent and getting him to look down for 3 days. The hyaloid came up easily during surgery, the laser and ILM peel went well, and he was a very cooperative 8-year-old.
The post-op results were good but could have been better. Full healing after macular hole surgery takes up to a year. The hole did not fully close, but the edges came together and improved. The healing is shown below. The final vision was 20/60 which was satisfactory to the patient and his mother. Older patients who undergo macular hole surgery generally develop a cataract within a year. He will likely eventually develop a cataract but does not yet have one.
1 month Post-Op
6 months Post-Op