a 17-year - old boy sustained blunt trauma from a tennis ball to his left eye , 5 h before examination . only hand movements were perceivable and projection of light rays was accurate .
clinically , a full - thickness mh , sized 415 m , with coexistent macular detachment of height 458 m on optical coherence tomography ( oct ) examination ( stratus oct , carl zeiss meditec inc . ,
usa ) , was detected along with commotio retinae and widespread subretinal hemorrhages of the posterior pole and inferior retina [ fig .
examination by microperimetry ( mp-1 , nidek technologies srl , italy ) demonstrated reduced sensitivity of the macula to high - intensity light stimuli [ fig .
surgical intervention was contemplated . however , follow - up examination 3 days later surprisingly revealed that the mh had reduced in size to 218 m .
careful serial follow - up found complete closure of the mh and near complete resolution of the macular detachment 7 days after presentation [ fig . 2a and b ] .
three weeks posttrauma , the chorioretinal scarring and pigmentary changes at the macula were very prominent [ fig .
2d ] . significant atrophy and thinning of all the retinal layers was evident on oct examination ; the foveal thickness was 82 m [ fig .
large atrophic holes were noticed at this time in the inferior retina and were delimited by laser photocoagulation [ fig .
microperimetry , done with four - cross target because of poor fixation , reveals loss of perceived stimuli at the macula ( c ) .
the macular hole is smaller and the detachment shallower after 3 days ( d and e ) .
microperimetry shows absolute scotoma ( f ) seven days later , the macular hole is closed and the subretinal fluid nearly completely absorbed ( a and b ) .
three weeks later , the chorioretinal scarring is very prominent ( d and e ) .
two considerations relevant to the management of the present subject are , first , the mechanisms involved in the formation and closure of the traumatic mh and detachment , and second , whether a waiting period is advisable before undertaking any surgical repair . with respect to the first issue , the most important fact to understand is that the vitreous is very tightly adherent to the macula in young normal eyes , putting considerable stress upon this region when compression  expansion of the globe occurs in a concussion injury .
most eyes with a traumatic mh have an attached vitreous.[68 ] oct imaging corroborates this finding lending credence to the belief that the pathogenesis of mh is independent of the occurrence of a posterior vitreous detachment ( pvd ) and occurs likely as an immediate mechanical disruption in a coup contrecoup injury .
delayed mh may however develop if pvd is incomplete , causing continued foveal traction , or due to contusion necrosis , or consequent to the formation and rupture of a foveal cyst.[57 ] a pvd was absent in our case and we believe that the hole occurred due to mechanical disruption as an immediate effect of concussion [ supplementary figs . 1 and 2 ] . a rd may occur due to the mechanical distortion that occurs between the retina and the vitreous ; loss of the retinal pigment epithelial ( rpe ) function and the hyperpermeability of retinal vessels consequent to the retinochoroidal concussion injury may be the important contributing factors .
vertical scan through the macula on optical coherence tomography at presentation showing discontinuous retinal pigment epithelium and a full - thickness macular hole - associated retinal detachment horizontal scan through the macula on optical coherence tomography at presentation showing discontinuous retinal pigment epithelium and a full - thickness macular hole - associated retinal detachment the mechanisms responsible for the spontaneous closure of a traumatic mh include proliferating glial cells and rpe cells from the edges that fill the hole ; formation of an epiretinal membrane that constricts the hole ; and reattachment of the operculum to the mh .
there was no operculum or membrane formation in our case but we expect the proliferating potential of the recovering glial and rpe cells to be high in our patient , considering his young age , which eventually led to the closure of the mh .
this mechanism is consistent with the histopathologic study of a surgically treated mh which was closed by bridging glial tissue .
a quick recovery of the rpe function in young eyes also ensures the rapid absorption of the subretinal fluid .
the resolution of the rd , simultaneous to the closure of the mh seems necessary for the successful resolution of both pathologies .
we observed these processes occurring concurrently in our patient , leaving anatomically resolved rd and mh within 7 days of presentation .
the time and need of surgical intervention is an open question with no available answer ; mhs and rds rarely arise simultaneously after trauma and therefore specific management guidelines are lacking .
traumatic mhs are known to close spontaneously and a period of observation till 6 months has been advised before undertaking a surgical repair .
chen et al . achieved retinal reattachment with the vitrectomy procedure and gas tamponade in seven patients out of eight who had traumatic mh - related rds .
recently , spontaneous resolution of a traumatic mh - related macular detachment , which occurred within 3 weeks , has been described in a young patient .
our patient experienced a complete closure of the mh and resolution of the macular detachment 1 week after the incident of trauma , young age and a relatively small size of the hole apparently being the factors responsible for a better anatomical outcome .
however , functional visual improvement failed to occur despite anatomical reattachment of the retina because of irreversible changes at the macula .
one must understand that functional and anatomical results may not correlate depending on the severity of the trauma ; the final va depends upon the degree of photoreceptor and rpe cell disruption .
immediate visual loss after injury due to retinal dehiscence is followed by a delayed visual loss due to secondary changes in the retinochoroidal layer [ supplementary fig .
besides this , our case illustrates that the spontaneous reattachment of a traumatic mh - related macular detachment is possible and a clear evidence of progressive clinical improvement entails a waiting period in the expectation of a spontaneous recovery .
fast macular thickness scan showed marked atrophy and thinning of the retina at the macula at 4 months following trauma
 the association of macular detachment with posttraumatic macular hole is a known but rare occurrence . spontaneously occurring resolution of the detachment and closure of the macular hole 
 has been reported only once in the literature . 
 we describe a similar rare event in a young male , the documentation of which was done serially by microperimetry ( mp ) and optical coherence tomography ( oct ) . a 17-year - old male presented with a decrease in vision following a closed globe injury to the left eye . 
 a coexisting macular hole and macular detachment were detected in the affected eye . 
 serial follow - up with oct and mp documented complete resolution of the macular hole and the macular detachment within 1 week of presentation . 
 the case highlights that spontaneous resolution of traumatic macular hole and related macular detachment may occur and a waiting period is advisable before undertaking any corrective surgical procedure . 
 the pathophysiologic mechanisms of causation and the resolution of posttraumatic macular hole - related retinal detachment are discussed . 
Case Report
Discussion