Spontaneous full thickness macular hole development and closure in a patient with nucleus dislocation due to hypermature cataract: a case report

Spontaneous posterior capsule rupture with lens-nucleus dislocation is a very rare entity, as is the development and spontaneous closure of a full thickness macular hole (FTMH) after vitrectomy. The occurrence of these two entities in one eye has not been previously described. A 79-year-old woman was referred because of the right eye intermittent pain and progressive visual loss. Best corrected visual acuity (BCVA) with correction for aphakia was 20/20. Intraocular pressure was normal with therapy. The cornea, anterior chamber, and vitreous were clear. Gonioscopy was normal. The capsular bag was clear, with rolled-up anterior and posterior lens capsule, and the nucleus dislocated in the vitreous. As surgery waiting time was prolonged due to administrative problems, the patient’s intraocular pressure (IOP) increased and cystoid macular edema (CME) with lamellar macular hole developed. The patient underwent pars plana vitrectomy with endophacofragmentation and epiretinal membrane peeling. Postoperative optical coherence tomography was normal, BCVA was 20/40, and IOP was normal with topical therapy. One month after surgery, the eye was without signs of inflammation and IOP started rising in spite of maximum therapy. CME reoccurred and progressed to a FTMH, which started closing spontaneously in one month. One year after surgery, IOP normalized and FTMH closed completely. A dislocated crystalline lens in a quiet eye with normal BCVA, which rapidly developed into intractable glaucoma and FTMH, is an unusual finding. The deterioration was followed by spontaneous IOP normalization and macular hole closure. Such unexpected disease course, suggesting a possible autoimmune reaction, has not yet been described.