Abstract

     This is a report of a patient with Valsalva Retinopathy induced premacular subhyaloid hemorrhage, which was managed successfully and cleared quickly by Q-switched Nd: YAG: laser posterior hyaloidotomy, and protecting him from major vitreous surgery.
Key Words: YAG Lasers, Macula, Hemorrhage, Visual acuity

Introduction

          Premacular hemorrhage occurs as a result of Valsalva retinopathy, proliferative diabetic retinopathy, and retinal artery macroaneurysm and may cause sudden, profound visual loss. Currently, it is managed with observation or vitrectomy. An alternative method of treatment is by Nd: YAG laser or argon laser membranotomy(1). This report documents a clinical course of a successful drainage of premacular subhyaloid hemorrhage into the vitreous with an Nd: YAG laser and saving the patient from hazards of vitreous surgery.

Case Report

     Case Report: A 42-year-old, a previously healthy Asian man presented to the emergency ophthalmic room of Hamad General Hospital, Doha, Qatar, with a sudden visual failure in his right eye,that happened after a forceful straining 3 days prior to the attendance. There was no history of systemic or ophthalmic diseases, direct or surgical trauma.

      A thorough ophthalmic examination revealed, normal left eye with a visual acuity of 6/6 and right eye visual acuity of CCF (closed counting fingers), normal anterior segment, and multiple (4) different-sized pre-retinal subhyaloid hemorrhages, the crucial one; was premacular, well circumscribed, leveled, dome-shaped hemorrhage with a convex surface, extending between the temporal vascular arcades, it's size was estimated to be about 5 disc diameters horizontally and 3 disc diameters vertically (Figure 1).

     Normal optic disc, vessels, and peripheral retina. Q-switched neodymium: yttrium-aluminum-garnet (Nd: YAG) laser was done on the next day. Full pupillary dilatation was achieved with Tropicamide 1% and phenylephrine 10%. Using simple topical anesthesia (Benoxinate 0.4%), a fundus contact lens was used for focusing of the Nd: YAG laser aiming beam. The aiming beam was precisely focused on the surface of the posterior hyaloid membrane at the inferior edge of the subhyaloid hemorrhage (Figure 1), to facilitate the gravity-dependent spread of the blood into inferior vitreous cavity. The initial power was adjusted to 1 mJ with a single pulse mode. The energy was gradually amplified to 7 mJ to get a break of the posterior hyaloid. The rupture of the posterior hyaloid membrane was done at a location distant from the fovea, optic disc and retinal blood vessels, and within an area of an adequate thickness of blood, that was guessed clinically (Figure 1) and ultrasonographically (Figure 2),

Figure 2 . the upper picture is TRANSVERS AXIAL SCAN viewing premacular bleeding below optic nerve shadow . the lower one is L9 (lONGITUDINAL SCAN AT 9 O`CLOCK).

      in order to avoid retinal damage. Blood began to leak down into the vitreous cavity, but stopped after few seconds due to clotting, and with further lasering at the clot site (repeated twice), more subhyaloid blood was slipped down into the vitreous cavity .The total energy required was 170 mJ

Half- an hour later, a significant amount of the subhyaloid hemorrhage had been removed down into the vitreous cavity, and it's level reached down to the fovea, and the patient recovered a central vision of 6/36 and clearer inferior visual field. The next day, visual acuity improved to 6/12, and the major part of blood was cleared away from the macula (Figure3). Follow up, showed a visual acuity 6/6 after 4 months of laser treatment, complete clearance of subhyaloid blood, and a residual organized intragel hemorrhage at the bottom of vitreous cavity. No retinal damage or rebleeding occurred due to the laser treatment, and vitrectomy was not required.

Discussion

         Premacular Subhyaloid hemorrhage may occur in retinal vascular disorders as Proliferative diabetic retinopathy, branch retinal vein occlusion, macroaneurysm, and age related macular degeneration; in hematological disorders such as leukemia and chemotherapy- induced pancytopenia; following laser in situ keratomileusis (LASIK) or after vigorous physical exertion (Valsalva Retinopathy) (2).

       In the premacular retro-hyaloid space bleeding may cause an acute, dramatic loss of central vision, which may persist if left untreated, however, spontaneous re-absorption of the blood may occur within several months, and might cause permanent visual loss due to pigmentary macular changes or growth of epiretinal membranes and toxic injury to the retina due to prolonged contact with hemoglobin and Iron(2, 3,4).

      Different techniques have been used for treatment of premacular subhyaloid hemorrhage; these include prompt vitrectomy(5), Pneumatic displacement of hemorrhage by Intravitreal injection of gas and tissue plasminogen activator(6), and posterior hyaloidotomy green laser(7,8). Since subhyaloid hemorrhage may be associated with permanent macular changes before it spontaneously resolves and adequate treatment of the underlying cause of the hemorrhage may be delayed with potential risks for further damage to ocular structures, early intervention seems to be crucial.

     Vitrectomy is associated with numerous complications; the progression of lens nuclear sclerosis, even after uneventful vitrectomy, is a well known complication which occurs in almost all patients, Intraoperative retinal breaks and postoperative Proliferative vitreoretinopathy(5) are other complications. Perforating the posterior hyaloid face or internal limiting membrane by use of a pulsed Nd: YAG laser has been described as a practical substitution to vitrectomy for rapid clearing of premacular hemorrhage(2,7,8,9,10). The posterior vitreous boundary layer may be lacerated by argon laser coagulation in such a way that the blood floats into the vitreous body, where it is absorbed within a few weeks. Older premacular hemorrhages under an intact vitreous boundary layer, typically green white in color, should be treated by more invasive vitreo-surgical procedures.(8) In comparison with vitrectomy, The Nd: YAG laser is the ambulatory and painless procedure, not exciting proliferative vitreoretinopathy. It will also not change the outcome of a deferred vitrectomy.(8).

       Complications including macular holes and retinal detachment from a retinal break have been reported in a patient with myopia(8), however this is uncommon because the premacular blood shields the underlying retina from laser-induced damage(7). This case demonstrates the successful treatment with rapid recovery of a subhyaloid premacular hemorrhage by Nd: YAG laser posterior hyaloidotomy. In previous reports, the subhyaloid hemorrhage was usually left to be absorbed in the next few weeks after YAG hyaloidotomy, and necessitated further lasering in several cases afterwards. In this case we preferred to evacuate most of the bleeding in the same session in order to minimize retinal side effects of laser (especially since the hemorrhage thickness decreased in subsequent sessions), to protect the macula from the potential toxicity of blood as early as possible, and to decrease the number of patient's visits and treatment cost. No side effects were described, quite the opposite to the possible hazards of pars plana vitrectomy. Nd: YAG laser hyaloidotomy, being a simple, safe and effective procedure, producing quick clearing of premacular subhyaloid hemorrhage and avoiding the risk and cost of Vitreoretinal surgery, is a practical option for patients with fresh bleeding in selected cases    

Acknowledgment
     The author thanks Dr. Mohammed Farouk for his assistance and comments on fundus photos and ultrasound.

References

1. Puthalath S, Chirayath A and et al. Frequency-doubled Nd: YAG laser treatment for premacular hemorrhage Ophthalmic Surg Lasers Imaging. 2003 Jul-Aug; 34(4): 284-90.

2. Rennei CA, Newman DK, Snead MP, Flanagan DW. Nd-YAG laser treatment for premacular subhyaloid hemorrhage. Eye.2001; 15:519-524.

3. O' Hanley GP, Canny CLB. Diabetic dense premacular hemorrhage. Ophthalmology1985;4:507-511.

4. Gass JDM. Stereoscopic atlas of macular diseases: diagnosis and treatment. 3rd ed. St Louis: Mosby; 1987:361-367; 560-564.

5. O`Hanley GP, Canny CL. Diabetic dense premacular hemorrhage .A possible indication for prompt vitrectomy. Ophthalmlogy.1989; 92:507-511.

6. Schmitz K, Kreutzer B, Hitzer S, Behrens-Bauman W. Therapy of subhyaloidal hemorrhage by intravitreal application of rtPA and SF6 gas. Br J Ophthalmol 2000; 84:1324-1325.

7. Gabel VP, Birngruber R, Gunther-Koszka H, et al. Nd: YAG laser photodisruption of hemorrhagic detachment of the internal limiting membrane. Am J Ophthalmol 1989; 107:33-37

8. Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Longterm results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd: YAG Laser. Arch Ophthalmol 1998; 116:1465-1469

9. GabelVP, Bringruber R, Gunther-Koszka H, Puliafito CA. Nd: YAG laser photodisruption of hemorrhagic detachment of internal limiting membrane .Am J Ophthalmol.1989; 107:33-37

10. Raymond LA.Neodymium: YAG laser treatment for hemorrhage under the internal limiting membrane and posterior hyaloid face in the macula. Ophthalmology .1995; 102:406-411.

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