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Clinicopathologic Reports, Case Reports, and Small Case Series
May 2002

Bilateral Giant Macular Holes With Excellent Visual Function

Arch Ophthalmol. 2002;120(5):661-663. doi:

Eyes with large macular holes have poor visual acuity and poor visual function in general. A previous report1 indicated that visual acuity of better than 20/50 was observed in only 1% of eyes that had a macular hole larger than 400 µm with no posterior vitreous detachment. We report a case with large bilateral macular holes, 1800 µm in vertical diameter in the right eye and 1500 µm in the left eye. The visual acuity was surprisingly good, ie, 20/40 OU, and the stereoacuity was 50 seconds with the Titmus stereo test. The possible reason for this good visual outcome is discussed.

Report of a Case

A 33-year-old woman was referred to our department with bilateral macular holes. She had first noticed a small scotoma about 2 years previously and experienced a gradual decrease in visual acuity. She had no personal or family history of ocular disease and did not use any medications.

Her best-corrected visual acuity at the time of her first visit was 20/40 OD (−5.5 diopters [D] sphere) and 20/40 OS (−5.0 D sphere). Her best stereoacuity was 50 seconds according to the Titmus stereo test. Fundus examination showed a large macular hole in each eye with vertical diameters of 1800 µm OD and 1500 µm OS (Figure 1). The retina partially bridged the hole in her right eye. No posterior vitreous detachment was observed in either eye. Fluorescein angiography showed a window defect corresponding to the hole. Microperimetry images obtained by scanning laser ophthalmoscopy showed that the fixation points were at the upper edges of the macular holes in both eyes (Figure 2). Optical coherence tomography demonstrated a detailed structure around the holes, the edges of which were swollen inferiorly in the right eye (Figure 3 A) and inferiorly and superiorly in the left eye (Figure 3 B). Both eyes retained similar visual function during a 7-month observation period.

Figure 1.
Color fundus photographs. A, The
macular hole in the right eye is 1800 µm in vertical diameter and the
retina partially bridges the hole. B, The hole in the left eye is 1500 µm
in vertical diameter.

Color fundus photographs. A, The macular hole in the right eye is 1800 µm in vertical diameter and the retina partially bridges the hole. B, The hole in the left eye is 1500 µm in vertical diameter.

Figure 2.
Microperimetry images obtained
by scanning laser ophthalmoscopy. The crosses represent fixation points in
the right (A) and the left (B) eyes. The fixation points are at the upper
edges of the macular holes for eccentric fixation. The open squares indicate
a dense scotoma at that part of the hole; the white squares indicate the points
at which the stimulus was recognized.

Microperimetry images obtained by scanning laser ophthalmoscopy. The crosses represent fixation points in the right (A) and the left (B) eyes. The fixation points are at the upper edges of the macular holes for eccentric fixation. The open squares indicate a dense scotoma at that part of the hole; the white squares indicate the points at which the stimulus was recognized.

Figure 3.
Optical coherence tomography in
vertical scan. The edges of the macular hole are swollen inferiorly in the
right eye (A) (arrow) and inferiorly and superiorly in the left eye (B) (arrows).

Optical coherence tomography in vertical scan. The edges of the macular hole are swollen inferiorly in the right eye (A) (arrow) and inferiorly and superiorly in the left eye (B) (arrows).

Comment

Eyes with stage 3 macular holes tend to have progressive deterioration of visual acuity before the vision stabilizes at 20/200 or worse.2 A previous report indicated that visual acuity better than 20/50 is observed in only 1% of eyes that had a macular hole larger than 400 µm with no posterior vitreous detachment.1 Our patient had surprisingly good visual acuity compared with that of patients with smaller holes. Moreover, bilateral fixation points were at almost the same locus in each eye, so that each eye could have steady fixation with that locus.

Although the cause of our patient's excellent visual function including visual acuity and stereoacuity was uncertain, we assumed that the macular hole function was related to the fixation loci and stability. We theorize that the bilateral enlargement of the holes and the shifting of the fixation points occurred simultaneously and gradually in our patient. Because of this, we believe, our patient retained good visual function.

We are grateful to thank Katsuhiko Fukui, MT, for technical assistance.

Corresponding author and reprints: Masumi Takeda, MD, PhD, Department of Ophthalmology, Asahikawa Medical College, Midorigaoka-Higashi 2-1-1-1, Asahikawa 078-8510, Japan (e-mail: masumi@asahikawa-med.ac.jp).

References
1.
Hikichi  TTrempe  CL Risk of decreased visual acuity in full-thickness idiopathic macular holes. Am J Ophthalmol. 1993;116708- 712.
2.
Lewis  MLCohen  SMSmiddy  WEGass  JDM Bilaterality of idiopathic macular holes. Graefes Arch Clin Exp Ophthalmol. 1996;234241- 245. Article
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