Supplementary Material for: Acute macular hole formation after posterior vitreous detachment induction in epiretinal membrane surgery: A Case Report

Introduction: We report a case of acute macular hole formation that occurred immediately following posterior vitreous detachment (PVD) induction during epiretinal membrane (ERM) surgery, and to highlight the significance of intraoperative foveal hemorrhage as an early indicator of this complication. Case Presentation: A 47-year-old Asian female presented with blurred vision in the left eye. Preoperative examination revealed an ERM with associated macular distortion. The patient underwent cataract surgery combined with pars plana vitrectomy, including induction of PVD, ERM and internal limiting membrane peeling. A small foveal hemorrhage was noted immediately after PVD induction. On postoperative day 1, OCT revealed a full-thickness macular hole (MH) with foveal hyperreflective lesion and posterior shadowing, consistent with foveal hemorrhage. Despite in-office intravitreal gas injection, the MH persisted and required a second vitrectomy with additional gas tamponade. Follow-up OCT confirmed successful closure of the MH, with gradual restoration of the photoreceptor and outer plexiform layers. Conclusion: Acute macular hole formation can occur immediately after PVD induction during ERM surgery, even in the absence of overt vitreomacular traction or direct macular trauma. Intraoperative foveal hemorrhage should alert the surgeon to the possibility of impending macular hole formation.