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Introduction: Blunt ocular trauma may be associated with a variety of complications, including traumatic macular holes (TMH) and uveitis. Concerning the TMH, there is no standard treatment protocol. There have been reports of spontaneous closure and of the use of certain medications and surgical techniques. Our purpose is to present a case of bilateral blunt ocular trauma with TMH in the right (OD) and uveitis in the left eye (OS) in a 24-year-old Caucasian man.
Case presentation: The patient had complaints of decreased vision in OD and redness and discomfort in OS. Three days previously, he had sustained trauma to both eyes with an exercise resistance band. The diagnosis was made with a thorough ophthalmic exam and optical coherence tomography (OCT). The best-corrected visual acuity (BCVA) of OD was 20/40 and of OS – 20/20. The intraocular pressure was within normal limits. There was a TMH in OD and iridocyclitis in OS. The therapy included prednisolone with an initial dose of 60 mg q.d. PO, a lutein/zeaxanthin supplement, and additional topical treatment for OS – dexamethasone and cyclopentolate. The TMH in OD had improved significantly within 6 days. BCVA of OD recovered to 20/20 in a month.
Conclusion: We observed closure of the TMH with complete recovery of vision in the affected eye, most likely spontaneous, and with full resolution of the uveitis in the other, in the setting of short-term prednisolone therapy. The uveitis in OS was also treated with topical dexamethasone and cyclopentolate.