Source:American Journal of Ophthalmology Case Reports 42 (2026) 102589
Authors: Angelica Aja Dangca Alcoreza, Junyeop Lee
Executive Summary & Clinical Context
Full-thickness macular holes (FTMHs) in highly myopic eyes represent a challenging surgical subcategory. Driven by complex tractional forces—including anteroposterior vitreomacular traction (VMT), tangential traction from epiretinal membranes (ERMs) or rigid internal limiting membranes (ILM), and posterior staphyloma/scleral ectasia—myopic FTMHs traditionally yield lower primary closure rates and poorer visual outcomes than idiopathic FTMHs. While spontaneous closure of idiopathic FTMHs is well-recognized (typically occurring via vitreous release or bridging glial proliferation), spontaneous closure of an acute myopic FTMH with photoreceptor recovery is exceptionally rare. This case report documents a 68-year-old highly myopic female with an incidental FTMH in the left eye that underwent spontaneous anatomical closure within 3 months of observation, resulting in sustained photoreceptor realignment, restoration of ellipsoid zone (EZ) integrity, and functional microperimetric improvement.
Patient Baseline Characteristics & Diagnostic Workup
Demographics & Ocular History
- Age/Gender: 68-year-old female.
- Systemic History: Type 2 Diabetes Mellitus, Hypertension.
- Refractive Status & Axial Length:
- Pseudophakic bilaterally (PCIOL implanted 10 years prior).
- Pre-op Refraction: -20.00 DS (OD), -21.00 DS (OS).
- Post-op Refraction: -5.00 DS +2.00 DC × 118° (OD), -6.00 DS +2.50 DC × 60° (OS).
- Axial Length (IOLMaster): 30.96 mm (OD), 30.44 mm (OS).
- Baseline BCVA: 0.5 Snellen equivalent (~20/40) in both eyes.
Multimodal Imaging at Presentation
+———————————————————————————————————————-
| BASELINE OCT (LEFT EYE)
------------------------------------------------------------------------------------------------------------------------
| Minimum Linear Diameter (MLD): 204 µm
| Base Diameter: 550 µm
| Features:
| - Acute cuff of intraretinal cystic spaces along hole margins
| - Epiretinal membrane (ERM) extending along temporal margin
| - Incomplete PVD with residual posterior hyaloid cortex
------------------------------------------------------------------------------------------------------------------------ Right Eye OCT: Thin ERM with subtle foveal contour changes suggestive of an impending macular hole.
- Left Eye OCT: Full-thickness macular hole with:
- Minimum linear diameter (MLD): 204 µm.
- Base diameter: 550 µm.
- Intraretinal cystic space edema at hole edges (signaling acute formation).
- Persistent ERM attached to the temporal margin.
- Incomplete posterior vitreous detachment (PVD) with posterior hyaloid attachment.
Longitudinal Course & Findings
Given the patient’s stable baseline BCVA (20/40) and absence of subjective visual symptoms (e.g., metamorphopsia, central scotoma), a joint decision was made to pursue conservative observation with close serial OCT monitoring rather than primary pars plana vitrectomy (PPV).
Baseline Month 3 Month 5
+-----------------------+ +-----------------------+ +-----------------------+
| FTMH (MLD: 204 µm) | -> | Spontaneous Closure | -> | Sustained Closure |
| Cystic Edema Margins | | Foveal Reconstruction | | EZ/ELM Alignment |
| BCVA: 20/40 | | BCVA: 20/63 | | BCVA: 20/50 |
+-----------------------+ +-----------------------+ +-----------------------+1. Three-Month Follow-Up
- Anatomical Status: Repeat spectral-domain OCT demonstrated complete, spontaneous foveal closure with bridging of the inner/outer retinal layers.
- Membrane Dynamics: The temporal ERM remained in situ without separation or avulsion.
- Functional Metrics:
- BCVA: 0.32 Snellen (~20/63).
- Microperimetry (Centervue) & M-chart scores: 0.4 (vertical), 0.5 (horizontal).
2. Angiographic Workup
Because active vitreomacular traction was not explicitly evident, secondary vascular etiologies were investigated:
- Fluorescein Angiography (FA): Excluded macular vascular malformations, telangiectasia, diabetic macular edema, or CNV. Showed peripheral avascularity without active leakage.
- Indocyanine Green Angiography (ICGA): Demonstrated dilated choroidal vessels consistent with myopic choroidal remodeling.
3. Five-Month Follow-Up
- Anatomical Status: Sustained macular hole closure with progressive restoration of the ellipsoid zone (EZ) and external limiting membrane (ELM).
- Functional Metrics:
- BCVA improved to 0.4 Snellen (~20/50).
- M-chart scores normalized to 0 on both horizontal and vertical meridians.
- Microperimetry confirmed resolution of the relative central scotoma.
Comparative Analysis of Literature
Spontaneous closure of FTMH in high myopia is an exceptional event. Reviewing the limited published series highlights how this case differs structurally and functionally:
| Feature | Yu et al. (2014) | Li et al. (2014) | Present Case (2026) |
|---|---|---|---|
| Associated Pathology | Posterior staphyloma & RD | Myopic RD & Retinoschisis | Isolated FTMH + ERM |
| Structural Outcome | Hole closure with persistent outer layer defect | Hole closure; persistent retinoschisis/VMT | Complete closure with EZ/ELM restoration |
| Photoreceptor Recovery | Incomplete | Incomplete | Functional & Structural Improvement |
| Time to Closure | Long-term | Intermediate | Rapid (3 Months) |
Pathophysiologic Considerations
The mechanism of spontaneous closure in an eye with an axial length >30 mm remains speculative, but several complementary factors likely contributed:
- Alteration of Tangential Vectors: Partial PVD or subtle detachment of the posterior hyaloid along the nasal/peripheral retina likely relieved critical tangential vectors, even if the focal temporal ERM remained attached.
- Glial Cell Proliferation: Proliferation of Müller cells and astrocytes across the base of small-diameter (<250 µm) holes creates a tissue bridge that contracts, pulling the outer retina together.
- Small Initial Hole Size: An MLD of 204 µm significantly increased the probability of spontaneous bridge formation compared to large myopic holes (>400 µm).
Strategic Takeaways for Surgical Retina Practice
- Role of Initial Observation in Asymptomatic Small Myopic FTMHs: In highly myopic patients who present with small FTMHs (<250 µm MLD), preserved visual acuity, and absence of active anteroposterior traction or foveal-off detachment, a period of close observation with monthly/bimonthly OCT can be considered.
- Avoid Immediate Surgery in Asymptomatic Patients: Primary vitrectomy in high myopia carries inherent risks (e.g., retinal tears, posterior polar breaks, poor ILM peeling ergonomics, secondary CNV). Identifying candidate eyes for conservative observation may prevent unnecessary surgical morbidity.
- Prompt Surgical Conversion: Surgical intervention (PPV with ILM peeling/inverted flap and gas/oil tamponade) remains mandatory if serial OCT demonstrates hole enlargement, worsening retinoschisis, detachment, or visual decline.
