Submacular hemorrhage removal

PURPOSE

To determine whether pars plana vitrectomy combined with tissue plasminogen activator for evacuation of submacular hemorrhage results in improved visual acuity.

METHODS

Retrospective review of 18 patients who received a subretinal injection of tissue plasminogen activator during a pars plana vitrectomy to evacuate dense submacular hemorrhages.

RESULTS

Diagnoses included age-related macular degeneration (16 patients), ruptured macroaneurysm (1 patient), and penetrating ocular trauma (1 patient). Preoperative visual acuity ranged from 20/200 to counting fingers (median visual acuity, counting fingers). Follow-up ranged from 10 to 104 weeks (median, 33 weeks). Best postoperative visual acuity ranged from 20/30 to counting fingers (median, 20/300). Best postoperative visual acuity improved two or more lines in 11 (61%) of 18 eyes, remained unchanged in 4 (22%) of 18 eyes, and decreased two or more lines in 3 (17%) of 18 eyes (P = 0.10, Wilcoxon sign-rank test). Final visual acuity ranged from 20/40 to light perception (median, counting fingers). Final visual acuity improved two or more lines in 5 (28%) of 18 eyes, remained unchanged in 6 (33%) of 18 eyes, and decreased two or more lines in 7 (39%) of 18 eyes (P = 0.53, Wilcoxon sign-rank test).

CONCLUSIONS

Pars plana vitrectomy to evacuate massive subretinal hemorrhage can improve visual acuity, but final visual acuity is limited by the underlying disease.

Intraoperative fibrinolysis of submacular hemorrhage with tissue plasminogen activator and surgical drainage

PURPOSE

This pilot study determined the safety and efficacy of intraoperative pharmacologic lysis of recent submacular hemorrhage with tissue plasminogen activator followed by surgical drainage of the unclotted blood in patients with age-related macular degeneration.

METHODS

In a prospective study, 24 consecutive eyes with recent (< 14 days old) submacular hemorrhage secondary to age-related macular degeneration and good visual acuity before development of submacular hemorrhage were treated with vitrectomy, subretinal injection of tissue plasminogen activator, and removal of the liquefied blood. Patients were followed up for at least six months (mean, 14 months).

RESULTS

Twenty eyes (83%) had improved visual acuity after surgery, and eight eyes (33%) attained visual acuity of 20/200 or better. In a subset of 16 eyes with submacular hemorrhage of seven days duration or less, eight (50%) attained visual acuity of 20/200 or better. Factors associated with poor visual outcome included submacular hemorrhage with duration greater than seven days (P < .001), the presence of hemorrhagic pigment epithelial detachment (P = .04), and massive subretinal hemorrhage (P = .04).

CONCLUSIONS

Tissue plasminogen activator thrombolysis may be a valuable adjunct to the surgical treatment of select patients with submacular hemorrhages secondary to age-related macular degeneration.

[Acute retinal necrosis syndrome. Lausanne cases, review of the literature and new physiopathogenetic hypothesis]

PURPOSE

The purpose of this study was to analyse our ARN-patients, perform an extensive review of the literature, suggest a physiopathogenic hypothesis for the disease that should influence the therapeutical approach of these cases.

PATIENTS AND METHODS

From 1985 to 1993, 15 HIV-negative cases of ARN were seen in our clinic. Eleven cases were analysed prospectively: the herpetic agent involved in each case was searched for by the determination of intraocular specific antibody production and a complete immunological work-up was performed.

RESULTS

Our collective included 4 cases of bilateral ARN (BARN). In 9 cases the clinical presentation was that of a typical ARN, in 3 cases ARN was of the "mild-type" and in 3 cases lesions were multifocal involving initially the posterior pole resembling the clinical picture of PORN (progressive outer retinal necrosis). The viral agent was varicella-zoster virus in 7 cases, herpes simplex virus in 3 cases, cytomegalovirus in 1 case and was not determined in 4 cases. In the 216 published cases a state of immunodepression was found in 15.7%. In our group with systematic immunological work-up this rate was 46%.

CONCLUSION

This is in support of the thesis that an immune dysfunction is probably at the origin of ARN. We therefore suggest to avoid to add systemic steroids to the specific antiviral therapy but to treat inflammation by periocular steroids.

Tissue plasminogen activator in the surgical management of subretinal haemorrhage

We report three cases of the use of tissue plasminogen activator (TPA) to aid the surgical removal of subretinal haemorrhage. All patients had choroidal neovascular membranes secondary to age-related macular degeneration. The technique involved infusing a sterile solution of TPA through a small retinotomy and irrigating out the dissolved clot. The visual acuity improved in the first patient from a preoperative 6/36 to 6/18 five weeks after surgery, but subsequently deteriorated to 6/60 after six months from a new choroidal neovascular membrane (CNVM), remaining 6/60 at nine months after surgery. The second patient's visual acuity improved from count fingers to 6/24 three weeks after surgery, but subsequently deteriorated to 6/60 after four months from a new CNVM, remaining 6/60 at nine months after surgery. The third patient's visual acuity improved from count fingers to 6/36 and remains stable at 6/36, eight months after surgery. Although long-term prognosis remains guarded, these early results suggest that TPA may have a role in the management of subretinal haemorrhage.

A simple technique for controlled subretinal injections

Recently developed vitrectomy techniques for management of choroidal neovascular membranes and subretinal hemorrhages often involve the subretinal injection of fluid materials. A simple, inexpensive infusion system that allows for the controlled injection of fluid, allowing use of a minimal amount of fluid and maximizing surgeon control, is described.

Tissue plasminogen activator irrigation to facilitate removal of subretinal hemorrhage during vitrectomy

I report removing a large submacular hemorrhage by means of vitrectomy combined with use of tissue plasminogen activator (tPA) to facilitate clot removal. Four months postoperatively, the vision was 20/100 and the retina was flat, with a very thin layer of residual hemorrhage and pigmentary alteration in the macula. Although the long-term prognosis is guarded, this case does suggest that tPA may be a useful adjunct in managing selected cases of subretinal hemorrhage associated with macular degeneration.

Tissue plasminogen activating factor assisted removal of subretinal hemorrhage

We used tissue plasminogen activator (tPA) to aid in the surgical evacuation of subretinal hemorrhages. Subretinal hemorrhage secondary to a ruptured retinal macroaneurysm was treated in two patients. The surgical technique involved using a micropipette to fashion a small retinotomy through which tPA was injected into the subretinal space and through which the dissolved clot was removed. Visual acuity improved from counts fingers to 20/50 in one patient and from counts fingers to 20/70 in the other. Three additional patients, with massive subretinal hemorrhages secondary to age-related macular degeneration, were similarly treated. In one, visual acuity improved from counts fingers to 20/400; in two others, visual acuity was stabilized; in the first patient, at 20/300, and in the second patient at 20/400. The use of tPA minimizes surgical manipulation of the sensory retina and greatly reduces the size of the retinotomy required for evacuation of subretinal blood.

[Hemorrhage in the premacular bursa treated with the Q-switched Nd-YAG laser]

Hemorrhages in the premacular bursa may cause an important loss of the visual acuity due to their localization. Several treatments, going from a conservative attitude to prompt vitrectomy, have been proposed. Three cases of premacular hemorrhage, treated by Nd-YAG laser puncture, are reported. One or two impacts are sufficient to empty the blood collection into another vitreous compartment. The blood is dispersed through the vitreous on the second day after treatment and is resorbed within the ten to fifteen following days. With the help of ultrasound, the blood volume was estimated to be equal to or less than 10 microliters in the three cases. In all cases the YAG laser puncture allows a faster recovery of the visual acuity as compared to the conservatively treated cases. In no instance a recurrence, macular degeneration or preretinal proliferation was observed. The new concepts of vitreo-macular relations and vitreous anatomy are well illustrated by this therapeutic indication. Although the precise localization of a blood collection in the premacular area remains controversial, we consider it of no consequence to the outcome of the treatment.

[Fluorescein angiography in the diagnosis of injuries of internal ocular membranes]

Fluorescent angiography was used to examine changes in the retina and vascular coating in traumatic and posttraumatic conditions of the eyes in 55 patients aged 12-66 who had traumas 3 days--4 years before. 36 patients had blunt injuries and 16 penetrating wounds of the eyeball. The type of posttraumatic changes in the fundus oculi was examined, and classification of these changes with consideration of their clinical and angiographic signs developed. Fluorescent angiography yields additional data on the process severity and dissemination, its data are prognostically important, it helps define the indications for laser and drug therapy and surgery.

Intraoperative control of hemorrhage in penetrating ocular injuries

Control of intraoperative hemorrhage is critical during vitreoretinal surgery for penetrating ocular injuries. Methods to control bleeding include: (1) raising the intraocular pressure, (2) intraocular diathermy, (3) fluid/gas exchange, (4) choice of irrigating solution, (5) addition of thrombin to the infusion solution, (6) endophotocoagulation, (7) silicone oil injection, (8) sodium hyaluronate injection. A combination of these various methods will almost always control bleeding in each case.

Acute angle-closure glaucoma from spontaneous massive hemorrhagic retinal or choroidal detachment. An updated diagnostic and therapeutic approach

Acute angle-closure glaucoma from a spontaneous massive hemorrhagic retinal or choroidal detachment occurred in five eyes. The source of the hemorrhagic detachment was a disciform macular lesion in all instances. The mechanism for the angle closure is the abrupt forward displacement of the lens-iris diaphragm resulting from the massively detached choroid and retina. Four of the five patients had either systemic hypertension or a primary or anticoagulant-induced clotting disorder. All patients underwent ultrasonographic studies, and one patient had magnetic resonance imaging (MRI) to rule out melanoma. Only one eye required enucleation for pain relief. Glaucoma medication, cyclophotocoagulation, or retrobulbar alcohol controlled the other four eyes. The clinical, ultrasonographic, MRI, and histopathologic features of this rare condition are described, and an updated therapeutic approach is discussed.

Nd:YAG laser photodisruption of hemorrhagic detachment of the internal limiting membrane

We used a Q-switched Nd:YAG laser to create an opening in the internal limiting membrane in three eyes with hemorrhagic detachment of the internal limiting membrane. In all instances, after membranotomy blood was rapidly cleared from the preretinal space resulting in prompt improvement in visual acuity. No retinal injury was observed. Nd:YAG laser photodisruption may be useful in the treatment of some cases of subinternal limiting hemorrhages.

Acute high-altitude illness

Acute high-altitude illness usually occurs at elevations of 8,000 ft or more, is more common than is generally appreciated and is often confused with other disorders. The acute forms of high-altitude illness include acute mountain sickness, high-altitude pulmonary edema, high-altitude cerebral edema and high-altitude retinal hemorrhage. These illnesses often occur simultaneously and in severe forms can be fatal. Gradual ascent and acetazolamide help prevent acute mountain sickness and high-altitude pulmonary edema. The definitive treatment for all forms of high-altitude illness is descent to a lower altitude.

Retinal tears with total vitreous hemorrhage

In ten cases of nontraumatic retinal tears with initial vitreous hemorrhages so dense that all retinal detail was obscured, medical management included hospitalization, sedation, and binocular patching. It took an average of 4.3 days for the vitreous to clear so that the tears could be examined. All the tears were on or anterior to the equator, and all were in the superior quadrants. Surgery was performed promptly once the tears were visible even though much of the retina was still covered with hemorrhage. After total clearing of the vitreous, no additional retinal tears were found in any of the ten cases. Postoperative complications included hemorrhages in three cases, macular pucker in one case, and a paramacular star in one case.

Peripheral exudative hemorrhagic chorioretinopathy

Images

Some observations on ocular manifestation of sickle cell disease

The ocular manifestations of 76 sickle cell disease patients are reported. Our findings indicate that any type of sickle cell oculopathy may appear in conjunction with any type of hemoglobinopathy and that no single ocular finding is specific to any one type of sickle cell anomaly. Sickle cell oculopathy, particularly retinopathy, is found to be a slowly progressive condition. Treatment of retinal and vitreal neovascularization with photocoagulation seems to be indicated to stop the disease process. Acute retinal vascular occlusion seems to respond favorably to the intravenous administration of low molecular weight dextran and papaverine hydrochloride. Sickle cell patients suffering from retinal detachment do not respond favorably to conventional retinal detachment surgery.

[Coats' disease: early detection and early treatment (author's transl)]

With regard to visual prognosis Coats disease can grossly be divided in 3 different stages: If the disease is confined to the periphery of the fundus, complete recovery can be achieved by appropriate treatment. If there is already a severe macular involvement central visual acuity hardly improves, but blindness can be prevented. In case of a widespread, exsudative retinal detachment, the prognosis is unfavourable. Early diagnosis and early treatment of Coats' disease are therefore very important.

Acute vitreous haemorrhage: a clinical report

In the first hours after a vitreous haemorrhage dense enough to obscure the reina, the blood is usually confined to the posthyaloid space in an aqueous phase. Binocular occlusion and elevation provides sufficient immobilization of the eyes in nine out of 10 patients for the blood cells to settle to the bottom of the space and make the retina available for examination and repair. Blood enters the vitreous gel through holes that develop in the posterior hyaloid membrane. Blood in the gel does not settle and requires months to clear.