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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 257-259

Spontaneous closure of stage 3 full-thickness macular hole after vitreomacular traction release in a renal transplant patient -a case report


1 Division of Retina, Jeddah Eye Hospital, Jeddah, Saudi Arabia
2 Department of Ophthalmology, College of Medicine, Qassim University, Al Qassim, Saudi Arabia
3 Division of Retina, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

Date of Submission03-Apr-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Adel Gady AlAkeely
Retina Division, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_27_20

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  Abstract 


The aim of our study is to describe spontaneous closure of a macular hole (MH) after vitreomacular traction (VMT) release in a 62-year-old patient with a history of renal transplant 6 months ago who was on tacrolimus, mycophenolate mofetil, nifedipine, and atorvastatin. The patient presented to our practice complaining of poor vision in his right eye for the past 6 months. On examination, he showed a full-thickness MH, Stage III, and VMT in the right eye evident in OCT which is an indication for surgical intervention. However, we elected to observe the patient upon his request. On further follow-up, visual acuity improved and OCT showed release of the VMT and closure of the MH. We attribute the release of the VMT to vitreolytic properties of atorvastatin. Our report highlights the possibility of observation of Stage 3 MHs in patients on atorvastatin as an option for the management.

Keywords: Atorvastatin, kidney transplant, spontaneous closure, Stage 3 full-thickness macular hole, vitreomacular traction


How to cite this article:
Abdulkarem M, Al-Muhaylib AA, AlAkeely AG. Spontaneous closure of stage 3 full-thickness macular hole after vitreomacular traction release in a renal transplant patient -a case report. Indian J Transplant 2020;14:257-9

How to cite this URL:
Abdulkarem M, Al-Muhaylib AA, AlAkeely AG. Spontaneous closure of stage 3 full-thickness macular hole after vitreomacular traction release in a renal transplant patient -a case report. Indian J Transplant [serial online] 2020 [cited 2020 Oct 20];14:257-9. Available from: https://www.ijtonline.in/text.asp?2020/14/3/257/296887




  Introduction Top


Vitreomacular traction (VMT) syndrome is a common disease characterized by an incomplete posterior vitreous detachment at the macula which can lead to a macular hole (MH).[1],[2] MH is a round full-thickness defect in the foveal center (FTMH).[2],[3] The International VMT Study Group formed a classification scheme for VMT and MH based on optical coherence tomography (OCT) findings.[4] The classification system was based on the hole size, the presence or the absence of a VMT, and the cause of the hole. The VMT was defined as present or absent. The hole size (diameter) was defined as small, medium, or large. Stage 1 is an impending MH with VMT. Stage 2 is a small or medium FTMH with VMT. Stage 3 is s medium or large FTMH with VMT. Whereas, Stage 4 is either small, medium, or large FTMH without VMT. Small holes have an aperture size <250 μm. A medium hole is defined by an aperture size ranging between 250 and 400 μm, whereas a large hole has an aperture size larger than 400 μm in diameter. Stage 1 MH mostly can be observed with a 50% chance of spontaneous closure. On the other hand, Stages 2, 3, and 4 almost always require surgical intervention.[4],[5]

Patients with a transplanted kidney already suffer from multiple systemic conditions. There is a high prevalence of cardiovascular disease and electrolyte imbalance. Moreover, this population of patients is vulnerable to serious infections due to the immunosuppressive medications they are using. Putting such patients under the stress of surgery would affect their systemic condition. Therefore, we suggest that observation would be beneficial for patients with Stage 3 full-thickness MH suffering from renal disease who are specifically on atorvastatin.[6],[7] Herein, we report a case of spontaneous closure of Stage 3 full-thickness MH after VMT release without surgical intervention in a kidney transplant recipient.


  Case Report Top


A 62-year-old man is known to have end-stage renal disease to which he underwent kidney transplant 6 months earlier. His medications included tacrolimus, mycophenolate mofetil, nifedipine, and atorvastatin.

The patient presented to our practice complaining of poor vision in his right eye for the past 6 months. He had no previous history of ocular surgeries or trauma.

His visual acuity (VA) was 20/400 in the right eye and 20/25 in the left eye.

On examination, he showed early nuclear sclerosis in both eyes, flat retina in both eyes with a full-thickness MH, Stage III, and VMT in the right eye evident in OCT [Figure 1].
Figure 1: Stage III full-thickness macular hole with focal vitreomacular traction

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Surgery was offered to the patient at that stage. However, he preferred to be observed. On follow-up, the patient noticed an improvement in his vision in the right eye 2 weeks after he started using atorvastatin. VA improved to 20/100. OCT showed release of the VMT and closure of the macula hole [Figure 2]. Six months later, the vision furthermore improved to 20/50 and OCT showed further normalization of the foveal contour [Figure 3].
Figure 2: Two months after with released vitreomacular traction

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Figure 3: Released vitreomacular traction with closed macular hole

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  Discussion Top


Stage 1 MH mostly can be observed with a 50% chance of spontaneous closure. On the other hand, Stage 2, 3, and 4 MHs almost always require surgical intervention to close.[4],[5] However, Tadayoni et al. reported two cases of spontaneous closure of Stage 3 and 4 full-thickness MHs which were associated with epiretinal membrane in one case and high myopia in the other case. He suggested that the mechanism of closure was related to a healing process rather than the release of VMT.[8] We suggest a different mechanism of closure in our case where the closure of the MH is secondary to the release of VMT which we attribute it to vitreolytic properties of atorvastatin which was started 2 weeks before the release of traction rather than a healing process as mentioned in Tadayoni's study and without any surgical intervention. Tuuminen et al. found lower intravitreal activity of angiopoietin (ANGPT-2), vascular endothelial growth factor (VEGF), factors involved in vascular permeability and inflammation, and lower activity of matrix metalloproteinase-2, the factor connected with breakdown of basement membrane and fibroproliferation, in patients using atorvastatin which possibly were the cause for the macular traction to release in our case.[9] We suggest that atorvastatin exerts its mechanism on the vitreoretinal interface, specifically the internal limiting membrane (ILM). The ILM is the basement membrane of the retinal Müller cells at the vitreoretinal interface. It contains various high-molecular-weight extracellular matrix proteins such as collagen (Type IV and XVIII), laminin, fibronectin, nidogen 1 and 2, agrin, and perlecan. It is a multilaminar structure and includes the fusing point of anchoring vitreous fibrils from the vitreous cortex, lamina densa, and lamina lucida.[10]

Another medication that may have played a role in the release of VMT through its effect in lowering the levels of transforming growth factor-β, platelet-derived growth factor, and fibroblast growth factor was tacrolimus which the patient was using at that stage.[11]


  Conclusion Top


This report demonstrates the spontaneous closure of a stage full-thickness MH with good anatomical and functional recovery in a kidney transplant patient after the use of atorvastatin and without any history of surgical intervention. This suggests the possible role of systemic therapy in the closure of later stages of full-thickness MH, especially if surgical intervention carries a high risk on the patient's general condition and observation might be considered an option for such patients in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Smiddy WE. Vitreomacular traction syndrome. In: Yanoff M, Duker JS, editors. Ophthalmology. 2nd ed. St. Louis: Mosby; 2004. p. 951-5.  Back to cited text no. 1
    
2.
Barak Y, Ihnen MA, Schaal S. Spectral domain optical coherence tomography in the diagnosis and management of vitreoretinal interface pathologies. J Ophthalmol 2012;2012:876472.  Back to cited text no. 2
    
3.
Takahashi A, Yoshida A, Nagaoka T, Takamiya A, Sato E, Kagokawa H, et al. Idiopathic full-thickness macular holes and the vitreomacular interface: A high-resolution spectral-domain optical coherence tomography study. Am J Ophthalmol 2012;154:881-9200.  Back to cited text no. 3
    
4.
Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, et al. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology 2013;120:2611-9.  Back to cited text no. 4
    
5.
Parravano M, Giansanti F, Eandi CM, Yap YC, Rizzo S, Virgili G. Vitrectomy for idiopathic macular hole. Cochrane Database Syst Rev 2015;5:CD009080.  Back to cited text no. 5
    
6.
Brusich KT, Acan I. Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery, Organ Donation and Transplantation-Current Status and Future Challenges, Georgios Tsoulfas, IntechOpen, 10.5772/intechopen. 74329; July 25th 2018.  Back to cited text no. 6
    
7.
Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, Theodoraki K, Papadimitriou L, Papadimitriou J. Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery. Anesth Analg 1999;89:613-22.  Back to cited text no. 7
    
8.
Tadayoni R, Massin P, Haouchine B, Cohen D, Erginay A, Gaudric A. Spontaneous resolution of small stage 3 and 4 full-thickness macular holes viewed by optical coherence tomography. Retina 2001;21:186-9.  Back to cited text no. 8
    
9.
Tuuminen R, Haukka J, Loukovaara S. Statins in rhegmatogenous retinal detachment are associated with low intravitreal angiopoietin-2, VEGF and MMP-2 levels, and improved visual acuity gain in vitrectomized patients. Graefes Arch Clin Exp Ophthalmol 2015;253:1685-93.  Back to cited text no. 9
    
10.
Chawla R, Tripathy K, Temkar S, Kumar V. Internal limiting membrane: The innermost retinal barrier. Med Hypotheses 2017;98:60-2.  Back to cited text no. 10
    
11.
Turgut B, Uyar F, Ustundag B, Celiker U, Akpolat N, Demir T. The impact of tacrolimus on growth factors in experimental proliferative vitreoretinopathy. Retina 2012;32:232-41.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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