Ocular Vaccinia With Severe Restriction of Extraocular Motility

2009 Archives of Ophthalmology  
positive Watzke sign. Optical coherence tomography showed an FTMH (Figure 2A ). At this time topical nepafenac, 0.1%, was started 4 times per day in the right eye (off-label treatment). Eleven weeks later, his visual acuity had improved to 20/30 and the FTMH was closed on OCT ( Figure 2B ). To ensure that a very small macular hole was not overlooked, care was taken to image the central fovea each time OCT was performed. Comment. Macular edema is likely involved in FTMH pathogenesis and
more » ... ce. 1 In our case, the macular edema reduction occurred first, presumably as a result of NSAID therapy. Closure of the macular hole followed. This implies a direct cause-and-effect relationship with NSAID treatment. Topical NSAIDS have been shown to reduce macular edema more than 24 months after cataract extraction, but persistent use is often needed. 2 The cause of macular edema and FTMH reopening in our patient is not readily evident but may relate to an abnormality of the retinal surface. The foveal contour in one of the most recent OCT images is irregular but shows no epiretinal membrane ( Figure 2C ). In some patients with FTMH, histopathologic study revealed that a thin rim of cortical vitreous remains attached to the retinal surface. Unfortunately, this layer cannot be seen consistently with biomicroscopy, OCT, or ultrasonography. 3 Although we found no other cases of FTMH closure related to topical NSAID use, we did find a case report of a patient with an FTMH and macular edema associated with HLA-B27-associated uveitis. Treatment of the macular edema with a peribulbar triamcinolone acetonide injection led to vision improvement and FTMH closure. 4 Another study implicating macular edema in FTMH pathogenesis demonstrated an increased risk of FTMH reopening in patients undergoing cataract extraction. The risk was 7-fold higher in patients with clinically apparent cystoid macular edema. 5 One study done prior to routine use of OCT indicated that approximately 8% of patients with FTMHs have spontaneous regression. 6 It could be argued that the initial closure of the FTMH in our patient was spontaneous and coincided with the NSAID treatment. However, reopening when the NSAID was discontinued and reclosure when the NSAID was restarted make a strong case that the NSAID directly contributed to the closure of this FTMH. This case demonstrates a probable role for topical NSAID treatment in a patient with an FTMH. 1. Tornambe PE. Macular hole genesis: the hydration theory. Retina. 2003;23(3): 421-424. 2. Weisz JM, Bressler NM, Bressler SB, Schachat AP. Ketorolac treatment of pseudophakic cystoid macular edema identified more than 24 months after cataract extraction.
doi:10.1001/archophthalmol.2009.319 pmid:20008731 fatcat:r3pv2cffpjbv3a7jqo6yhm5vny