Under pressure: Foveal mountain peak sign and macular hole after ruptured RAM

To describe a case of a macular hole (MH) secondary to a submacular hemorrhage caused by a ruptured retinal arterial macroaneursym (RAM). An individual case and its observations were examined. Initial examination revealed no visible MH due to the hemorrhagic clot. Two weeks later, a full-thickness MH measuring 340 μm was detected. Pneumatic displacement with sulfur hexafluoride (SF6) was performed to reduce hemorrhagic toxicity and potentially promote spontaneous closure. However, after three months, the MH persisted with no evidence of closure, and visual acuity remained reduced (20/150). The Foveal mountain peak sign (FMP) was identified as a useful predictive indicator of MH formation. MHs secondary to ruptured RAMs and submacular hemorrhages may be initially obscured by hemorrhagic clots, complicating early diagnosis. The FMP sign can aid in predicting MH development. Given the risk of persistent MH and visual impairment, especially when the RAM rupture is close to the fovea (<1500 μm), early surgical intervention should be considered.