Massive hemorrhagic retinal detachment during radial optic neurotomy

BACKGROUND

We encountered obvious arterial bleeding from the incision site during radial optic neurotomy (RON) in a 55-year-old woman with central retinal vein occlusion (CRVO) and report the findings herein.

CASE REPORT

The patient initially demonstrated a retinal hemorrhage and macular edema due to a left CRVO. Her corrected visual acuity was 0.5 OS. Since her symptoms did not improve and were aggravated, even though she received an oral anticoagulant drug orally, RON was performed 2 months after the onset of symptoms. During surgery, obvious arterial bleeding started from the RON incision site and it was not arrested although the infusion bottle was fully elevated. However, a subsequent infusion of liquid perfluoro-carbon successfully stopped the bleeding by direct pressure. Hemorrhagic retinal detachment occurred in the nasal quadrant and postoperative vitreous hemorrhage was treated surgically. The hemorrhagic retinal detachment was gradually absorbed and replaced by fibrous scar tissue. Two years after the surgery, no expansion of retinal detachment has been observed and corrected visual acuity is being maintained at 0.2 OS.

CONCLUSION

We conclude that RON for CRVO carries a risk of arterial bleeding and that infusion of liquid perfluoro-carbon seems to be effective to arrest arterial bleeding from the RON site.

Ocular manifestations in Dengue fever

PURPOSE

To report a case of Dengue fever resulting in permanent visual loss in both eyes due to retinal capillary occlusion.

METHODS

Case report.

RESULTS

Severe permanent visual loss occurred in a patient with Dengue fever. Dilated fundus exam showed vascular sheathing with associated retinal hemorrhages at the equator and cotton wool spots in the maculae of both eyes. Fluorescein angiography revealed areas of capillary nonperfusion at the equator and in the macula. The diagnosis of Dengue fever was confirmed by serology detecting IgM antibodies to the Dengue virus.

CONCLUSION

Ocular abnormalities may be seen in patients with Dengue fever, therefore ophthalmoscopy should be performed in patients presenting with severe forms of the disease.

Results of intravitreal tissue plasminogen activator and expansile gas injection for submacular haemorrhage in Thais

PURPOSE

To study the results of intravitreal tissue plasminogen activator (tPA) and expansile gas injection for submacular haemorrhage in Thai patients.

METHODS

The medical records of Thai patients who presented with submacular haemorrhage between January 1998 and December 2002 were reviewed. The inclusion criteria were acute onset of bleeding (<1 month), treatment with intravitreal injection of tPA solution (50-100 mug in 0.1 ml) and expansile gas (0.3-0.4 ml of 100% perfluoropropane or sulphur hexafluoride), and at least 6 months of follow-up. Our main outcome measures were best final postoperative visual acuity and surgical complications.

RESULTS

A total of 19 eyes of 19 patients completed the inclusion criteria with a mean duration of 13.1 days. The causes of haemorrhage were age-related macular degeneration in 15 eyes (78.9%), idiopathic choroidal neovascularization in two eyes (10.5%), and traumatic, and valsalva retinopathy in one eye each (5.2%). After a mean follow-up of 13 months (range 6-39 months), postoperative visual acuity improved two lines or greater in 12 eyes (63.2%), stabilized in six eyes (31.6%) and worsened in one (5.2%). The final visual acuity measured 20/63 or better in 10 eyes (52.6%). The surgical complications were breakthrough vitreous haemorrhage (three eyes) and cataracts (three eyes), and two had retinal detachments.

CONCLUSION

The treatment of submacular haemorrhage with intravitreal injection of tPA and expansile gas improved visual acuity in more than half of the patients. In all, 10 in 19 eyes demonstrated final visual acuity at a functional level.

Macular Hole in Behcet's Disease

Behcet's disease is an inflammatory disorder of unknown cause, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Ocular involvement occurs in 60-80% of patients with Behcet's disease and presents as panuveitis in most cases. Posterior segment involvement may lead to irreversible alterations and significant vision loss. The development of a partial or full-thickness macular hole, though rarely reported, may cause serious vision loss. In this report, we present two cases of macular hole in the worse eye of bilateral cases of Behcet's disease, and discuss the possible mechanisms and management in such cases.

Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings

Inflicted childhood neurotrauma (shaken baby syndrome) is the term used for violent, nonaccidental, repetitive, unrestrained acceleration-deceleration head and neck movements, with or without blunt head trauma, combined with a unique, age-related biomechanical sensitivity in children typically younger than 3 years. This syndrome is typically characterized by a combination of fractures, intracranial hemorrhages, and intraocular hemorrhages. Retinal hemorrhage is the most common ophthalmic finding, and usually occurs at all levels of the retina. In recent years, increasing pressure has been placed on ophthalmologists to render diagnostic interpretations of the retinal findings in children suspected to be victims, which may have great forensic implications in criminal proceedings. New research has increased our understanding of the pathophysiology of retinal hemorrhages, the importance of specifically characterizing the types, patterns, and extent of these retinal hemorrhages, and the differential diagnosis.

[Ocular onset in general serious diseases]

The paper intends to show the possibility to establish the diagnosis of some severe general diseases beginnning with ocular onset. Thus, we present tow clinical cases in which the association of careful complete clinical examination and paraclinical investigations, during the hospitalization for ophthalmological therapy, leaded to unexpected findings of vital risk diseases, without any other sign at that time.

[Retinal arterial macroaneurysm: spontaneous occlusion after rupture. In connection with a case]

INTRODUCTION

Retinal arterial macroaneurysms are ectatic modifications of the arterial wall. They are a relatively uncommon condition wich can threaten visual function by pre- or subretinal hemorrhage in case of rupture or by massive macular exudation.

OBSERVATION

We report a case of a 50 years old patient, without cardio-vascular history, who presented an arterial macroaneurysm complicated by premacular hemorrhage. Spontaneous evolution was aneurysm occlusion with complete hemorrhage regression and visual recovery.

COMMENTS AND CONCLUSION

Retinal macro-aneurysms are acquired malformations, often isolated and located in a temporal artery. Their evolution is unpredictable either towards spontaneous occlusion, occurrence of chronic exsudative retinopathy or hemorrhagic complications by fissuration or rupture of arterial wall. Through this observation, the authors discuss the evolution and therapeutic modalities of this affection.

From minimal background diabetic retinopathy to profuse sight threatening vitreoretinal haemorrhage: management issues in a case of pregestational diabetes and pregnancy

Deterioration of retinopathy is a recognized complication of pregnancy in Type 1 diabetes. We discuss management issues relating to a case of rapid sight-threatening progression of retinopathy in pregnancy complicated by pregestational diabetes.

[Retinal vein occlusions]

There are still gaps in understanding the etiology and pathogenesis of circulatory disorders of the central retinal vein. Although various new therapeutic approaches have been developed in the past few years, existing therapy forms are subject to controversy and available data are to some extent inconsistent. This discussion in the German-language literature is associated with varied and nonuniform terminology, which should do justice in particular to concepts of pathomechanism and degree of specificity. The general designation, "occlusion" seems to be the most suitable of all available terms since this implies no conclusions on possible etiological factors. Retinal vein occlusions develop at different sites and to varying extents. Depending on t he location of the occlusion, they can be classified into occlusions of the central vein, hemicentral vein, major branch vein, and macular branch vein. This overview provides information on the current knowledge of the pathogenesis and both established approaches and those in ongoing clinical trials for the treatment of central venous and branch vein occlusions.

[Intravitreal injection of rt-PA and gas in the management of minor submacular haemorrhages secondary to age-related macular degeneration]

BACKGROUND

Subfoveal haemorrhage is a serious complication of choroidal neovascularization in age-related macular degeneration (ARMD). Recent studies have demonstrated that intravitreal injections of the fibrinolytic agent recombinant tissue plasminogen activator (rt-PA) and expansile gas may be effective in displacing submacular blood and facilitating visual improvement. However, in most of these studies, this technique has been used for the management of major haemorrhages. The purpose of our study was to investigate the efficacy of treating minor subfoveal haemorrhages with intravitreal rt-PA and pneumatic displacement.

PATIENTS AND METHODS

In a prospective study, 25 consecutive eyes of 25 patients with recent (</= 28 days) subfoveal haemorrhage secondary to ARMD and severe visual loss were treated with intravitreous injections of rt-PA (50 micro g) and sulfur hexafluoride (0,5 ml). The extent of the haemorrhage ranged from R to 2 disc areas. Patient follow-up ranged between 4 and 18 months.

RESULTS

Best postoperative visual acuity compared with preoperative visual acuity was improved by two or more Snellen lines in 11 of 25 eyes (44 %). Seven eyes (28 %) maintained this level at the final visit. Duration of haemorrhage was associated with a better gain of lines of vision. In a subgroup of 9 eyes with duration of haemorrhage </= 14 days, 7 (78 %) improved by two or more Snellen visual acuity lines, whereas only 4 of 16 eyes (25 %) with duration of haemorrhage > 14 days showed a comparable outcome (p = 0.017). There were no side effects or complications.

CONCLUSIONS

Our findings suggest that intravitreous injections of rt-PA and sulfur hexafluoride are of value for an improved and accelerated visual recovery in ARMD patients with minor subfoveal haemorrhages. Duration of haemorrhage </= 14 is associated with a better gain of lines of vision. Final visual outcome, however, is limited by the underlying ARMD. In addition, a rapid displacement of subfoveal haemorrhages may reveal discrete choroidal neovascular membranes amenable to further treatment. The complication rate of this therapeutic approach appears to be low.

[Management in preretinal macular hemorrhage. Case report]

The report presents a method of management in case of clotted premacular haemorrhage in a 46 year-old woman. The used method of treatment proceeded in 2 stages: 1) pars plana, intravitreal injection of 50 mg tissue plasminogen activator (tPA-Actilise), 2) after 24 hours intravitreal 0.5 cc SF6 with air mixture (1:5). Fibrinolytic tPA action and mechanic action of expanding gas caused after argon laser puncture intravitreal haemorrhage dislocation and following its resorption. The almost full visual acuity persisted for over 2 years.

[Eales]

Eales' disease, first described by Eales Henry in 1880, is an idiopathic obliterative vasculopathy that primarily affects the peripheral retina of adults. From nosologic point of view, we could distinguish the "true Eales disease" affecting males in India and portions of the Middle East and the "Eales' like disease" with no geographical or sex predisposition. Vascular sheathing, peripheral retinal nonperfusion and neovascularization are the principal clinical and angiographic findings. It remains a diagnostic by exclusion and retinal diseases with other causes of inflammation or neovascularization must be excluded. In the absence of a specific treatment, retinal photocoagulation to the nonperfused retina and vitrectomy for recurrent vitreal hemorrhage could be proposed.

Acute angle-closure glaucoma resulting from spontaneous hemorrhagic retinal detachment in age-related macular degeneration: case reports and literature review

PURPOSE

Acute angle-closure glaucoma resulting from massive subretinal hemorrhage is a rare and catastrophic complication in age-related macular degeneration. Anticoagulant usage had been strongly correlated with this complication in previously reported cases.

METHODS

Four patients (4 eyes), 3 men and 1 woman, developed angle-closure glaucoma with diffuse subretinal hemorrhage and total hemorrhagic retinal detachment.

RESULTS

Serial funduscopic examinations and echographic studies in 2 eyes showed that the blood gradually accumulated in the subretinal space. It took more than 10 days for the bleeding to build up to bullous hemorrhagic retinal detachment and secondary glaucoma. Anti-glaucomatous agents were given and sclerotomy was performed in 3 of the 4 patients. Phthisical changes were observed subsequently in these 3 eyes. The eye that received early drainage of blood was an exception, and a small degree of residual acuity was retained. Three of the 4 patients had diabetes mellitus, and hypertension and vascular diseases were also present in the same 3 patients.

CONCLUSIONS

Diabetes mellitus might be a predisposing factor for the impaired hemostasis. Anti-glaucomatous agents were of no effect in the management of intraocular pressure. Sclerotomy and drainage of blood help control intraocular pressure and relieve ocular pain. Poor final visual acuity is inevitable. However, phthisical changes might be prevented with early sclerotomy and drainage of blood.

Relationship between the severity of retinopathy and progression to photocoagulation in patients with Type 2 diabetes mellitus in the UKPDS (UKPDS 52)

AIM

to establish the degree to which the severity of retinopathy determines the risk for the need for subsequent photocoagulation in those with newly diagnosed Type 2 diabetes mellitus.

METHODS

Of 5102 patients entered into the UK Prospective Diabetes Study (UKPDS), 3709 had good quality retinal photographs that could be graded at entry. They were followed until the end of the study or until lost to follow-up, or until they received photocoagulation. Retinopathy severity was categorized as no retinopathy, microaneurysms (MA) only in one eye, MA in both eyes or more severe retinopathy features. The risk of photocoagulation was assessed in relation to severity of retinopathy at baseline, 3 and 6 years.

RESULTS

Of the 3709 patients assessed at entry to the UKPDS, 2316 had no retinopathy. Of these 0.2% needed photocoagulation at 3 years, 1.1% at 6 years and 2.6% at 9 years. Those with MA in one eye only (n = 708) were similar, with 0%, 1.9% and 4.7% needing photocoagulation by 3, 6 and 9 years, respectively. Amongst those who had more retinopathy features at entry (n = 509), 15.3% required photocoagulation by 3 years, and 31.9% by 9 years. When those without retinopathy at 6 years (n = 1579) were examined 3 and 6 years later (9 and 12 years after diagnosis), 0.1% and 1.8% required photocoagulation. Those with more severe retinopathy (n = 775) needed earlier treatment, 6.6% after 3 years and 13.3% after 9 years. The commonest indication for laser therapy was maculopathy, but those with more severe retinopathy were more likely to be treated for proliferative retinopathy and to need both eyes treated.

CONCLUSION

Few type 2 diabetic patients without retinopathy progress to photocoagulation in the following 3-6 years, while patients with more severe retinopathy lesions need to be monitored closely.

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid-gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration

PURPOSE

To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration.

METHODS

Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 microg), and fluid-gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity.

RESULTS

In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P =.004) but not between preoperative and final visual acuity (P =.16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye.

CONCLUSIONS

This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

Pneumatic displacement of submacular hemorrhage

Patients with thick submacular hemorrhage complicating age-related macular degeneration and other disorders typically have a poor visual prognosis. A new outpatient procedure, consisting of intravitreal injection of tissue plasminogen activator and gas followed by brief prone positioning, is effective in displacing thick submacular blood and facilitating visual improvement in most patients. Injection of gas alone also appears to be effective in many eyes. The procedure is technically simple and the rate of serious complications appears to be acceptably low. Although the final visual outcome is often limited by progression of age-related macular degeneration, significant and stable visual recovery is possible in selected eyes. Prospective clinical trials are needed to clarify the role for intravitreal tissue plasminogen activator and to provide definitive outcome comparisons with other management approaches.

Nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms

OBJECTIVE

To report visual acuity outcomes of nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms.

METHODS

Forty-one patients at multiple centers with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone were reviewed. Time to clearance of macular hemorrhage, visual acuity at final follow-up, and presence or absence of macular pigmentary changes after absorption of the hemorrhage were recorded for each patient.

RESULTS

On initial examination, visual acuity was 20/200 or worse in all except 4 patients (3 with 20/70, 1 with 20/80). At an average follow-up of 15. 7 months, a final visual acuity of 20/40 or better was achieved in 15 eyes (37%), between 20/50 and 20/100 in 12 (29%), and 20/200 or worse in 14 (34%). Macular pigmentary abnormalities were noted after clearance of the hemorrhage in 23 (56%) of 41 cases, and these eyes generally had worse visual acuity outcomes.

CONCLUSIONS

In eyes with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone, good visual acuity outcomes can often be achieved. Poorer visual acuity outcomes are associated with macular pigmentary changes after resorption of blood. Arch Ophthalmol. 2000;118:780-785

[Clinical results of intravitreal administration of tissue-type plasminogen activator (tPA) and gas for removal of subretinal hemorrhage in senile macular degeneration]

BACKGROUND

Subretinal hemorrhage in age related macular degeneration (AMD) usually causes acute visual loss and is associated with poor visual prognosis. In order to prevent retinal damage and to perform laser treatment of the underlying choroidal neovascularization (CNV) the subretinal hemorrhage has to be removed from the macular region. This could be achieved by intravitreal injection of tissue plasminogen activator (tPA) and gas.

PATIENTS AND METHODS

In 8 consecutive patients, suffering from a massive macular hemorrhage (duration of visual problems: mean 9 days), tissue plasminogen activator (tPA) (40 micrograms in 400 microliters BSS) and SF6-gas (0.75 ml) was transsclerally injected into the vitreous cavity to achieve liquification and displacement of the hemorrhage.

RESULTS

In all patients liquification and displacement of the hemorrhage out of the macular region was achieved during follow up. During the first week after operation a significant increase of visual acuity was noticed in all patients, however ophthalmoscopically there was just little reduction of the hemorrhage in the foveolar area. After successful removal of the blood the choroidal neovascularization was treated successfully by laser coagulation in one patient. No laser treatment was performed in the other patients because of the subfoveal location of the neovascularisation or because of disciform scar. Visual acuity increased 4 lines after surgery. In one case the procedure was complicated by a persistent vitreous hemorrhage and vitrectomy had to be performed in another patient due to an endophthalmitis.

CONCLUSION

Intravitreal injection of tPA assisted gas displacement of subretinal hemorrhage due to AMD leads to a significant increase of visual acuity during the first week after operation. Although a nearly complete removal of the hemorrhage out of the macular area could be achieved, it was difficult to differentiate this from the spontaneous course. Laser photocoagulation could be performed in only few cases.

[Intra-vitreal rt-PA and gas introduction in submacular hemorrhage]

Efficacy and complications of intravitreally injected tissue plasminogen activator (rt-PA) and sulfahexafluoride gas (SF6) in submacular hemorrhage are demonstrated.

PATIENTS AND METHODS

Fifty-three patients with submacular hemorrhage were treated (27 women, 26 men, mean age 79 +/- 1 years). Causes of hemorrhage were a choroidal neovascularization in 47 patients and macroaneurysm in 6 patients. After i.v. administration of 500 mg acetazolamide and disinfection of the conjunctiva, 50 micrograms rt-PA in 0.1 ml (BSS) and 0.5 ml SF6 were injected intravitreally. The patient was positioned prone for 24 h.

RESULTS

In 23 patients with choroidal neovascularization visual acuity improved by 2 lines and more; in 12 patients vision remained unchanged. In 12 patients visual acuity deteriorated. In 5 of 6 patients with a macroaneurysm vision improved from less than 0.1 to 0.1-0.5. Postoperative complications were four cases of vitreous hemorrhage and one case of endophthalmitis.

CONCLUSION

The intravitreal injection of rt-PA and SF6 is an alternative method for treatment of submacular hemorrhage.

[Management of submacular hemorrhage by tissue plasminogen activator and SF(6) gas injection]

The formation of platelet-fibrin clots causes degeneration of foveolar photoreceptors by subretinal hemorrhage.

PATIENTS

Twenty-two patients with submacular hemorrhages were treated by intravitreal injection of 50 microg tpa and 0.5 ml SF(6) gas within 1 h. Biomicroscopy, fundus photography and fluorescein angiography were performed pre- and postoperatively. Further multifocal electroretinograms were recorded.

RESULTS

The subfoveolar hemorrhages were dissoluted and displaced out of the macular region. The visual acuity increased in 18 cases and ranged from hand movement and 0.3 to values between 1/10 and 0.5.

CONCLUSIONS

Toxic and hypoxic damage of foveolar photoreceptors by subretinal hemorrhage can be prevented by early and minimal invasive fibrinolytic therapy. After localization of choroidal neovascularizations, treatment by focal laser coagulation is possible in some cases.

Preoperative use of tissue plasminogen activator for large submacular hemorrhage

BACKGROUND AND OBJECTIVE

Tissue Plasminogen Activator (TPA) has been used as an adjunct in the surgical removal of submacular hemorrhage. It is usually used intraoperatively, but may not provide enough time for effective fibrinolysis, especially for a large hemorrhage. The present study was conducted to evaluate the efficiency and safety of preoperative use of TPA for large submacular hemorrhages.

METHODS

Five eyes with large submacular hemorrhage secondary to age-related macular degeneration underwent subretinal injection of TPA in the office 24 hours before surgery. All hemorrhages were less than seven days old and at least 3 mm thick.

RESULTS

Preoperative visual acuity ranged from counting fingers to hand motion (HM). Patient follow-up ranged from 3 months to 24 months (mean, 11 months). Final visual acuity ranged from 20/30 to HM. Four of the five eyes (80%) showed improved visual acuity after surgery and 3/5 (60%) attained visual acuity of 20/200 or better.

CONCLUSION

Preoperative use of TPA for drainage of large submacular hemorrhage appears to be safe and may result in efficient clot removal. The true efficacy of TPA in the treatment of submacular hemorrhage can only be proven by a prospective randomized trial.

Pneumatic displacement of subretinal hemorrhage without tissue plasminogen activator

OBJECTIVE

To assess the efficacy and complications of intravitreal injection of perfluoropropane gas for displacement of subretinal hemorrhage (SRH), without the use of tissue plasminogen activator.

PATIENTS AND METHODS

Pure perfluoropropane gas (0.4-0.5 mL) was injected into the vitreous cavity in 5 patients with SRH involving the fovea because of age-related macular degeneration (4 eyes) or ruptured retinal arterial macroaneurysm (1 eye). The patients were instructed to maintain a prone position.

RESULTS

Visual acuity ranged from 20/300 to 20/2000 before gas injection. On the day after gas injection, SRH was dramatically displaced in 3 eyes and slightly displaced with a reduction in the thickness of subfoveal hemorrhage in the remaining 2 eyes. Final visual acuity improved in all cases, ranging from 20/15 to 20/220. Three eyes had a final visual acuity of 20/50 or better. Vitreous hemorrhage caused by migration of SRH into the vitreous cavity and retinal detachment each occurred in 1 eye, and both complications were successfully treated by vitrectomy.

CONCLUSIONS

Gas injected into the vitreous cavity can displace SRH without the use of tissue plasminogen activator in some cases. Visual acuity after gas injection may be improved, making this treatment an alternative to evacuation of SRH with vitrectomy.

Peripheral retinal hemorrhages: a literature review and report on thirty-three patients

BACKGROUND

Peripheral retinal hemorrhages are often asymptomatic and are detected during routine dilation. The incidence of peripheral retinal hemorrhages is unknown and there is a paucity of information on the subject available in the literature.

METHODS

This article reports on 33 patients with peripheral retinal hemorrhage detected during routine fundus examination. The possible etiologies and pathophysiology of peripheral retinal hemorrhages are discussed and a management plan for the primary care clinician is presented. The ophthalmic literature was reviewed and reports of peripheral retinal hemorrhages were included. For each etiology, the ocular and systemic sequelae, symptoms, testing, treatment, and followup are delineated.

RESULTS

Various proposed etiologies of peripheral retinal hemorrhages include senescence, systemic and retinal vascular disease, hematologic disorders, infectious disease, hypoxia, and mechanical and iatrogenic causes.

CONCLUSION

Despite their asymptomatic nature, peripheral retinal hemorrhages have a variety of potential etiologies and risk factors. Causes associated with serious ocular or systemic complications must be identified so that appropriate treatment and followup can be instituted.

Subretinal fibrosis and nonrhegmatogenous retinal detachment associated with multifocal central serous chorioretinopathy

PURPOSE

To report the rare occurrence of subretinal fibrosis in patients with multifocal central serous chorioretinopathy and evaluate the role of systemic corticosteroids and the effects of laser photocoagulation on multifocal leaks.

METHODS

A total of 29 patients (mean age, 37.7 years; 89.7% male) treated for subretinal fibrosis and multifocal central serous chorioretinopathy from 1983-1995 were reviewed retrospectively. Mean follow up was 26 months (range, 6.8-81 months).

RESULTS

Retinal detachment involved the macula in 72.4% cases. Fluorescein angiography showed a mean of 6.7 (range, 2-22) central serous chorioretinopathy leaks and a mean of 1.8 (range, 1-5) retinal pigment epithelial detachments. The fundus pictures of 23 patients who were taking systemic corticosteroids showed no improvement. Following laser treatment, however, retinal reattachment was obtained in all eyes, and improvement in visual acuity of > 2 Snellen lines was noted in 68.9% of patients.

CONCLUSIONS

The presence of subretinal fibrosis with secondary retinal detachment in otherwise healthy young patients, particularly in men, should alert the physician to look for multifocal central serous retinopathy leaks. Systemic corticosteroids did not prove effective in treating these patients, although laser treatment is recommended for each leak identified on an angiogram.

Subretinal administration of tissue-type plasminogen activator to speed the drainage of subretinal hemorrhage

BACKGROUND

Bleeding into the subretinal space in the vicinity of the macula is associated with age-related macular degeneration or retinal arterial macroaneurysm. The prognosis for restoration of vision is poor in the presence of blood clots.

METHODS

Using a simple device composed of three disposable syringes we injected tissue-type plasminogen activator (tPA) into the subretinal space during conventional vitrectomy in six patients to assist the draining of subretinal clots.

RESULTS

Four of six patients recovered their visual acuity postoperatively, while visual acuity in the other patients was stabilized.

CONCLUSION

Early drainage of subretinal hemorrhage assisted by the introduction of tPA into the subretinal space led to uncomplicated surgery and favorable postoperative results.

Experimental studies with perfluoro-octane for hemostasis during vitreoretinal surgery

PURPOSE

To investigate the effect of perfluoro-octane on coagulation studies and on intraoperative hemostasis during vitreoretinal surgery in an animal model.

METHODS

In vitro study--comparison of coagulation profiles (bleeding time, whole blood clotting time, partial thromboplastin time, and one-stage prothrombin time) of blood taken from healthy volunteers with and without the addition of perfluoro-octane. In vivo study--comparison of times taken to achieve hemostasis in a rabbit model with large retinal arterial bleeding in vitrectomized and aphakic eyes with and without intraocular injection of perfluoro-octane.

RESULTS

In vitro study--perfluoro-octane had no significant effect on coagulation profiles. In vivo study--intraocular perfluoro-octane significantly reduced the time to achieve hemostasis (P < 0.01) at all infusion bottle heights in vitrectomized and aphakic rabbit eyes.

CONCLUSIONS

Perfluoro-octane may be used to control bleeding during vitreoretinal surgery. A direct effect on the clotting cascade could not be demonstrated.

Pathophysiology and management of subretinal hemorrhage

Subretinal hemorrhage can arise from the retinal and/or choroidal circulation. Significant subretinal hemorrhage occurs in several conditions, but most commonly is associated with age-related macular degeneration, presumed ocular histoplasmosis, high myopia, retinal arterial macroaneurysm, and trauma. Released toxins, outer retinal shear forces, and a diffusion barrier created by subretinal hemorrhage all contribute to photoreceptor damage and visual loss. The use of tissue plasminogen activator and improvements in surgical instrumentation have facilitated surgical drainage and have made it a useful option in the management of selected cases. Mechanisms of subretinal hemorrhage formation, underlying etiologies, diagnostic evaluation, and the histopathology of damage are summarized. Published surgical series are reviewed and surgical advances are summarized. The value of surgically removing subretinal hemorrhages to improve visual outcome remains unestablished, because definitive studies have not been performed. Guidelines for selecting candidates for surgical intervention are proposed.

Retinopathy secondary to anemia from myeloid metaplasia in polycythemia vera

BACKGROUND

Polycythemia vera is a chronic clonal disorder associated with excessive proliferation of erythrocytes, leukocytes, and thrombocytes, as well as an accompanying splenomegaly. Ocular manifestations of polycythemia vera include occipital cortex transient ischemic attacks, transient monocular blindness, vaso-occlusive disease, and retinal hemorrhages.

CASE REPORT

A 56-year old man with longstanding polycythemia vera sought treatment for a chief symptom of blurred vision in the left eye and a red tinge to things first noticed on awakening that morning. He had preretinal and intraretinal hemorrhages and was subsequently found to be severely anemic as a result of postpolycythemic myeloid metaplasia after years of phlebotomy. Splenectomy controlled his anemia and thrombocytopenia, allowing transient improvement of the retinal hemorrhages. Acute leukemia subsequently developed and the patient died 7 weeks after initial examination.

CONCLUSION

In this case, preretinal and intraretinal hemorrhages were found in a patient with longstanding polycythemia vera. The exact origin of these hemorrhages is uncertain. They are probably secondary to anemia, but the possibility that they are sites of extramedullary hematopoiesis must be considered. The appearance of retinal hemorrhages warrants careful investigation to rule out diabetes, hypertension, and anemia, as well as the various other blood dyscrasias.

High-altitude retinopathy

PURPOSE

To report a patient with high-altitude retinopathy.

METHODS

A 30-year-old man with high-altitude retinopathy was examined and treated.

RESULTS

After spending 2 weeks at an altitude of 7,000 meters and then descending to sea level, the patient's visual acuity was RE, 20/20 and LE, 20/50. Intraretinal hemorrhages in both eyes and a scotoma in the left eye were found. Blood cell count was normal, but hematocrit had increased to 53%. The patient was treated with isovolemic hemodilution, pentoxifylline, and aspirin, which reduced hematocrit to 41%. Visual acuity and visual field returned to normal, and intraretinal hemorrhages resolved.

CONCLUSIONS

High-altitude hemoconcentration should be treated in patients with high-altitude retinopathy.

Antiphospholipid antibodies and retinal vascular disease

BACKGROUND

Antiphospholipid antibody retinopathy is a rare and poorly defined clinical entity in which the proper diagnosis has important ocular and systemic implications. The clinical course of five patients with antiphospholipid antibody retinopathy is described and the role of such antibodies in idiopathic retinal venous occlusive disease is investigated.

METHODS

Five case reports are presented highlighting the presentation, course, therapy, associations and outcomes of patients with antiphospholipid antibody retinopathy. In addition, twenty additional patients presenting with idiopathic retinal venous occlusive disease were tested for the presence of antiphospholipid antibodies.

RESULTS

All five patients with antiphospholipid antibody retinopathy had diffuse retinal vascular occlusion. All five patients presented with associated rheumatologic disease, including three with lupus or lupus-like disease. Antibodies to antiphospholipid were not detected in any of the twenty patients with idiopathic retinal venous occlusive disease. Prompt panretinal photocoagulation together with varying regimens of corticosteroids, immunosuppressives, or warfarin was partially successful in stabilizing the ocular and systemic disease.

CONCLUSION

The diagnosis of antiphospholipid antibody retinopathy should be suspected in patients with diffuse retinal vaso-occlusion, particularly when characterized by involvement of both arteries and veins, neovascularization at presentation, and symptoms of symptoms of systemic rheumatologic disease. Antiphospholipid antibodies do not appear to play an important role in idiopathic retinal vein occlusions.

Surgical removal of submacular hemorrhage using tissue plasminogen activator and perfluorocarbon liquid

PURPOSE

To assess the result of surgical removal of submacular hemorrhage by using tissue plasminogen activator and perfluorocarbon liquid.

METHODS

In 22 consecutive patients (22 eyes), subretinal hemorrhage associated with age-related macular degeneration, which involved the fovea and completely obscured the choroidal vascular pattern, was treated by pars plana vitrectomy. The hemorrhages were liquefied with tissue plasminogen activator, squeezed into the vitreous cavity with perfluorocarbon liquid, and then evacuated.

RESULTS

Efficacy of the procedure was judged by the best postoperative corrected visual acuity, which was 20/100 or better in 16 eyes (73%). Submacular hemorrhage recurred in four (18%) eyes, epiretinal membrane formed in three (14%) eyes, and retinal detachment occurred in three (14%) eyes. Best-corrected final visual acuity was improved postoperatively in 18 (82%) of the 22 eyes, unchanged in three (14%) eyes, and decreased in one (5%) eye, final visual acuity was 20/200 or better in 15 eyes (68%) and limited in other eyes by subretinal hemorrhage of greater than 30 days' duration or subfoveal neovascularizations.

CONCLUSIONS

Use of tissue plasminogen activator and perfluorocarbon liquid in surgical removal of submacular hemorrhage may improve the outcome of surgery by reducing surgically induced retinal damage.

Replacement therapy with a monoclonal antibody purified protein C concentrate in newborns with severe congenital protein C deficiency

Protein C replacement therapy with a monoclonal antibody purified, virus inactivated protein C concentrate was carried out in nine infants (three male, six female) with severe congenital protein C deficiency and life-threatening purpura fulminans and/or thrombosis associated with disseminated intravascular coagulation (DIC). Eight infants were homozygous for protein C deficiency; one was a compound heterozygote. The treatment period varied from 22 days to three years. The half-life of protein C was found to be as short as two to three hours during activation of the coagulation system, increasing to approximately ten hours after stabilization. During the acute phase, protein C levels of 0.10 to 0.25 IU/mL were associated with elevated markers of coagulation activation indicating DIC, while protein C levels greater than 0.25 were associated with normalization of coagulation markers. No product-related side effects were reported. Episodes of bleeding or purpura recurred in all patients who were switched to oral anticoagulant therapy, necessitating reinstatement of protein C replacement therapy, either as needed to control symptoms, or on a long-term prophylactic schedule, alone or in addition to oral anticoagulation. Home treatment with protein C concentrate allowed a near-normal life-style for patients who otherwise would be hospitalized for long periods of time.