Full-Thickness Macular Hole Following Selective Laser Trabeculoplasty

Case Report

Austin Ophthalmol. 2022; 6(2): 1038.

Full-Thickness Macular Hole Following Selective Laser Trabeculoplasty

Miguel Kurc*, Christina Ann Mathew, Rashi Arora

Salisbury NHS Foundation Trust, Odstock Road, SP2 8BJ, UK

*Corresponding author: Miguel Kurc, Salisbury NHS Foundation Trust, Odstock Road, SP2 8BJ, UK

Received: May 31, 2022; Accepted: June 28, 2022; Published: July 05, 2022

Introduction

Glaucoma is the second leading cause of blindness worldwide and is predicted to affect nearly 80 million people globally by the end of the decade [1]. Characterized by progressive optic nerve damage and visual field loss, the cornerstone of glaucoma treatment involves reduction of intraocular pressure (IOP) by means of topical therapy, lasers or surgery in a bid to slow or prevent further progression of optic nerve damage and visual loss [1].

While lasers were first introduced to reduce IOP in the 1970s, early iterations of laser trabeculoplasty were met with limited success [1]. But since selective laser trabeculoplasty (SLT) was introduced by Latina and Park in 1995, it has increasingly been used as first line treatment or adjunctive therapy among open angle glaucoma and ocular hypertensive patients [2]. SLT utilizes a 532 nm Q-switched, frequency doubled Nd-Yag laser delivered at shorter pulse duration to target the pigmented trabecular meshwork (TM) while preventing the dissipation of heat outside the pigmented TM thereby sparing the adjacent tissue and maintaining the anterior chamber angle architecture [3].

While SLT is known to increase aqueous outflow through the TM, the mechanism by which this occurs remains ambiguous. Studies have shown that there are minimal coagulative and mechanical changes in the TM which supports the notion that changes to the TM are more likely to be of a chemical nature.(3)Several possible theories have been postulated including TM monocyte recruitment which aids in the phagocytosis of TM debris and promotion of healthy TM cells to optimize outflow, cytokine and matrix metalloproteinase production resulting in extracellular matrix remodeling which in turn increases aqueous outflow and changes in gene expression related to ‘cell motility, extracellular matrix production, membrane repair and reactive oxygen species production’ [1].

The benefits of SLT are multifold as it is a short outpatient procedure with relatively rapid recovery. Moreover, it is an effective and cost-efficient treatment for a wide range of glaucoma subtypes [4]. However, while it has a relatively good safety profile, some studies have shown a varying range of complications particularly among patients with deeply pigmented TM [4]. Since SLT has increasingly been employed to lower intraocular pressure, clinicians must be aware of these potential complications. These complications include IOP spikes, uveitis, corneal haze, macular oedema and foveal burns burns [4,5]. The following case describes an atypical complication where the patient developed a macular hole following routine SLT.

Case

A 64-year-old patient presented to the glaucoma clinic in December 2017. Vision in the right eye was stable at 6/7.5 (Snellen’s chart). Incidental finding was lamellar hole and epiretinal membrane in the right eye, confirmed on OCT Scan (See Figure 1). It was noted that despite topical treatment with latanoprost and brinzolamide, the patient’s IOP remained above the target range. The patient was consented and underwent SLT treatment in the right eye. Following treatment, the patient noted deterioration in their central vision and metamorphopsia approximately 2-3 week’s post-SLT. Following a visit with the optician, an urgent referral was made to the eye unit with a primary diagnosis of full-thickness macular hole which was noted on OCT at the optician’s practice. The patient was then seen in the eye unit on February 2018 and the diagnosis of a full-thickness macular hole was confirmed (Figure 2).