Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage

PURPOSE

To describe the clinical features and to present results of new diagnostic methods to help define the cause of the clinical syndrome of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH).

DESIGN

Retrospective review of patients with IHAPSH at presentation seen in 3 centers in Hawaii and Japan.

METHODS

We analyzed data including patient demographics, presenting symptoms, initial and final visual acuities, biomicroscopic findings, fundus photographs, and results of available ancillary testing, including fluorescein angiography, B-scan ultrasonography, and optical coherence tomography.

RESULTS

There were 10 eyes of 9 patients (7 female and 2 male, 8 Asian and 1 white) aged 14 to 79 years. All patients experienced an acute onset of visual symptoms. Eight eyes had mild to severe myopia (-2.50 diopters [D] to -9.50 D), and 8 eyes had a tilted disc. Hemorrhage within the disc and adjacent subretinal hemorrhage were located nasally in 6 eyes, superiorly in 2 eyes, and temporally in 2 eyes. Vitreous hemorrhage was noted in 6 of 10 eyes. Posterior vitreous evaluation by biomicroscopy (10 eyes), by B-scan ultrasonography (4 eyes), and by optical coherence tomography (2 eyes) revealed no evidence of vitreopapillary traction, except for a follow-up optical coherence tomography in 1 eye showing localized vitreoretinal separation with residual attachment to the optic disc 10 months after presentation. Fluorescein angiography showed mild disc staining in 4 of 8 eyes. Hemorrhage spontaneously resolved within 1 to 7 months, and there were no recurrent hemorrhages with an average follow-up of 13.5 months (range, 2-31 months). Visual acuities maintained or improved to 20/25 or better in 8 eyes. The other 2 eyes had unrelated poor vision.

CONCLUSIONS

Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage is more common in myopic eyes and spontaneously resolves without treatment. The unique structural architecture of the elevated nasal edge of the myopic tilted disc and the choroidal blood supply of the prelaminar optic nerve may predispose patients to bleeding from the optic discs, which may be spontaneous or may be precipitated by acute disc edema, Valsalva maneuver, or vitreopapillary traction.

Lens-sparing vitreous surgery for infantile amblyogenic vitreous hemorrhage

PURPOSE

To report on a series of infants with amblyogenic vitreous and/or subinternal limiting membrane hemorrhage managed by lens-sparing vitrectomy.

DESIGN

Retrospective case series studying retinal attachment status and visual acuity.

RESULTS

Eleven eyes sustained vitreous hemorrhage as a consequence of shaken baby syndrome, 1 due to hyaloidal canal hemorrhage extending into the vitreous, 1 due to Terson syndrome, 1 due to birth trauma, and 2 due to a presumed coagulation disorder. Age of the patients at the time of surgery ranged from 2 to 23 months (age adjusted for prematurity). Follow-up ranged from 7 to 81 months (mean, 28 months). Ten eyes had visual improvement. Two infants with shaken baby syndrome had bilateral nonrecordable flash visual evoked potential before surgery; one eye of one infant had a better than expected visual outcome after surgery. One eye sustained a retinal tear without detachment. One eye in an infant with severe shaken baby syndrome and traumatic retinopathy developed a total rhegmatogenous retinal detachment with proliferative vitreoretinopathy.

CONCLUSIONS

Infantile amblyogenic vitreous hemorrhage may be effectively managed by lens-sparing vitreous surgery. Visual outcome of shaken baby syndrome may be limited as a consequence of structural damage to the retina, optic nerve, or posterior visual pathways.

Microvascular Remodeling after Occlusion-Recanalization of a Branch Retinal Vein in Rats

PURPOSE

To describe the time course of microvascular changes after transient branch retinal vein occlusion (BRVO) in rats.

METHODS

BRVO was induced in pigmented rats by focal laser photocoagulation. The subsequent changes in the retinal angiogram were followed up, both in vivo by confocal scanning laser ophthalmoscopy and ex vivo by confocal microscopy.

RESULTS

At day 1, capillary closure affected the three microvessel layer differentially, the intermediary layer being the most affected. Collateral veins, which were initiated by the dilation of deep-layer venules, pursued their course below adjacent arteries. These microvascular changes peaked between days 1 and 3. After recanalization at day 3, microvascular changes regressed gradually but incompletely, and at day 30 capillary closure and venule dilation persisted.

CONCLUSIONS

Transient occlusion of a retinal vein in rats leads to short- and long-term microvascular remodeling upstream of the occlusion site. This study describes a model for the tridimensional arrangement of retinal microvessel that accounts for the topography of the early capillary closure and collateral vessel formation that occur after BRVO. In the long term, these changes regressed incompletely, with recanalization of the occluded vein, suggesting that after a short period of occlusion, microvascular changes may become at least partially independent of flow. Despite the intrinsically limited applicability of this model to human vein occlusion, the results suggest that even if therapeutic decompression of an occluded vein is performed early, it may not reverse capillary dropout completely.

Going to High Altitude with Preexisting Ocular Conditions

The goal of this paper is to review how preexisting ocular conditions may be affected by altitude exposure. Such preexisting conditions include dry eye problems, monocular visual loss, and potential problems following refractive surgery procedures, as well as the possible changes associated with some forms of retinal and optic nerve diseases. Although most such altitude-related visual difficulties are relatively minor, some have resulted in serious morbidity or even death at high altitude. This review will give the reader background regarding these potentially debilitating conditions in order to better prepare for exposure to high altitude environments.

Optical coherence tomography characteristics of a hemorrhagic detachment of the retinal pigment epithelium after blunt trauma

PURPOSE

To report traumatic, hemorrhagic detachment of the retinal pigment epithelium that was detected by optical coherence tomography.

DESIGN

Observational case report.

METHODS

A 17-year-old boy with hemorrhagic fundus lesions caused by blunt ocular trauma was examined by optical coherence tomography and angiography.

RESULTS

Initially, two dark red, mounded lesions were seen, with one in the macula and the other adjacent to the optic disk. The lesions blocked the fluorescence on fluorescein and indocyanine green angiography. Optical coherence tomography demonstrated dome-shaped elevations of the retinal pigment epithelium at each lesion. Four months later, the retinal pigment epithelium detachments disappeared in the tomography images, and no scarring was evident ophthalmoscopically. Small choroidal ruptures were detected in each lesion by angiography.

CONCLUSIONS

Optical coherence tomography was useful in evaluating the site of the hemorrhage in the chorioretinal layers caused by blunt ocular trauma.

Frequency-doubled Nd:YAG laser treatment for premacular hemorrhage

BACKGROUND AND OBJECTIVE

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. This study investigates the efficacy of frequency-doubled Nd:YAG laser membranotomy.

PATIENTS AND METHODS

Twelve patients had frequency-doubled Nd:YAG laser membranotomy as a two-step procedure to drain premacular hemorrhage: two stretch burns to make the membrane stable and taut and then placement of penetration burns between stretch burns. The follow-up period was 18 months.

RESULTS

Ten eyes had marked clearing of hemorrhage and immediate improvement of vision following the laser treatment. One eye with retinal macroaneurysm and another with proliferative diabetic retinopathy did not show marked improvement immediately following membranotomy.

CONCLUSION

Frequency-doubled Nd:YAG membranotomy is a safe, simple, and noninvasive alternative to conservative treatment or vitrectomy and allows faster resolution of premacular hemorrhage.

Characteristics of visual field progression in patients with normal-tension glaucoma with optic disk hemorrhages

PURPOSE

To study the characteristics of visual field progression in patients with normal-tension glaucoma (NTG) with optic disk hemorrhages.

DESIGN

Observational study.

METHODS

Fifty-eight eyes of 58 untreated patients with NTG who had at least five reliable visual fields of the Humphrey Field Analyzer (central 30-2) within the follow-up period of more than 24 months were enrolled. Of these, 27 eyes had optic disk hemorrhages in their clinical courses. Pointwise linear regression analysis was done using total deviation values of the fields at each of 74 test locations in each patient. Progression was defined as the points of negative slopes with P <.01. A whole visual field was concentrically divided into three clusters: the areas within 10 degrees, 10 to 20 degrees, and 20 to 30 degrees. Percentages of the progressed points of the three clusters and a whole field were compared between the groups with and without optic disk hemorrhages.

RESULTS

No significant differences were found in patients' backgrounds, including initial mean deviation values, follow-up periods, and the number of visual field examinations between the 27 patients with optic disk hemorrhages and the 31 without. The group with optic disk hemorrhages showed significantly higher percentages of progressed points within the 10-degree area compared with the group without optic disk hemorrhages (mean +/- SD: 13.1 +/- 13.7%; 5.1 +/- 8.5%, respectively; P =.0086, Student t test), whereas no significant differences were found in the other two clusters or in a whole field.

CONCLUSIONS

Patients with NTG with optic disk hemorrhages tend to show visual field progression in areas within 10 degrees.

Resolution of leukemic retinopathy following treatment with imatinib mesylate for chronic myelogenous leukemia

PURPOSE

To report a case of leukemic retinopathy before and after treatment with imatinib mesylate (formerly STI-571) for chronic myelogenous leukemia (CML).

DESIGN

Interventional case report.

METHODS

A 58-year-old man diagnosed with stable phase CML (SP-CML) presented with blurry vision. Fundoscopy revealed several flame-shaped hemorrhages in the macular region in both eyes. One month after this initial visit, imatinib therapy was initiated.

RESULTS

: The patient noticed improvement in his visual as well as his medical symptoms; on repeat examination 6 months after the initial visit, the retinal hemorrhages had resolved and remained so after 18 months.

CONCLUSIONS

Imatinib appears to be an effective treatment for SP-CML, and the improvement in visual and medical symptoms in our case report correlates with this.

Ipsilateral globe penetration and transient contralateral amaurosis following retrobulbar anesthesia

PURPOSE

To report a rare complication of retrobulbar anesthesia with ipsilateral globe penetration and transient contralateral amaurosis.

DESIGN

Interventional case report.

METHODS

A 63-year-old woman complained of vision loss in the right eye immediately following cataract surgery on the left eye.

RESULTS

Right eye vision decreased to no light perception with clear media and normal fundus. The vision recovered to baseline in 12 hours. Left eye vision was checked and demonstrated only light perception. Fundus examination disclosed preretinal and vitreous hemorrhage. During vitrectomy of the left eye, a penetrating wound below the optic disk with retinal detachment was found.

CONCLUSION

The ipsilateral globe penetration wound depicts the mechanism of contralateral amaurosis following retrobulbar anesthesia of the case.

Scanning laser polarimetry and detection of progression after optic disc hemorrhage in patients with glaucoma

OBJECTIVE

To examine retinal nerve fiber layer changes with scanning laser polarimetry (SLP) in the eyes of patients with glaucoma and optic disc hemorrhage.

METHODS

Automated perimetry and SLP were performed in 17 eyes of 17 patients identified prospectively with optic disc hemorrhage. Criteria for visual field progression were based on decreased sensitivity seen at 3 adjacent points on the total deviation plot. Progression on SLP images was defined as a 15% or more decrease in the average thickness of the affected quadrant (superior or inferior), a 25% or more reduction in the affected quadrant ratio, an increase in the nerve fiber analyzer number of 10 or more (GDx Nerve Fiber Analyzer; Laser Diagnostic Technologies), or any change on Serial Analysis of the SLP images.

MAIN OUTCOME MEASURES

Visual field progression and SLP image progression.

RESULTS

The mean follow-up was 31 months (minimum, 12 months). Of the 17 eyes, 10 (59%) had visual field progression. No significant change was seen on SLP images for either the total group or the group with visual field progression. Five eyes (29%) showed progression on SLP images, 3 of which also showed visual field progression. Ten eyes showed progression on SLP images that was not confirmed on subsequent imaging.

CONCLUSIONS

In eyes with visual field progression after optic disc hemorrhage, a significant change in the SLP image was not seen. Fluctuation of SLP results in patients with glaucoma necessitates confirmation of progression seen on SLP images.

Retinal change induced in the primate (Macaca mulatta) by oxygen nuclei radiation

Retinas of primates (Macaca mulatta) were exposed to oxygen nuclei at the Bevatron, Berkeley, California. Color fundus photographs and fluorescein angiograms were taken of the retinas prior to irradiation and up to 5 weeks post exposure. Animals were sacrificed at post exposure intervals for histopathologic examination of the retinas. A series of animals were exposed to 200 kVp X-ray and examined on the same regime as the first series. The results showed a low rad equivalent dose for retinal damage as compared with the X-ray series, i.e., a high quality factor, and a marked compression of the latency between exposure and onset of the retinal pathology.

[Myelinated nerve fibers associated with juxtapapillary haemorrhages]

The myelinated nerve fibers (MNF) are o congenital anomaly characterized by the extension of the myelinisation process anterior from the lamina cribosa. The incidence of myelinated nerve fibers is 0.3-0.6% in patients and 0.54% in eyes from autopsies. Although these represent benign lesion, rarely are associated with retinal abnormalities: vascular abnormality (retinal telangiectasis, cranial-facial lesions, coloboma of the iris, keratoconus, myopia/strabismus, amblyopia). Myelinated nerve fibers asSociated with juxtapapillary haemorrhages was not reported in the available literature. We describe the clinical findings and diagnostic particularities of myelinated retinal nerve fibers associated with juxtapapillary haemorrhages in a personal case. An 40-year-old woman was referred for unilateral papillary abnormalities. The diagnosis was myelinated retinal nerve fibers as white striated patches with feathery edges, associated with two juxtapapillary haemorrhages. The clinical and pathogenic features are discussed. Based on the association between the myelinated nerve fibers, the juxtapapillary haemorrhages there is a possible pathogenic correlation between these elements. The action of the myelinated nerve fibers can be explained by a mechanical compression, with the disruption of the retinal artery, a structural vulnerable artery.

Polypoidal choroidal vasculopathy: natural history

PURPOSE

The present study was performed to clarify the long-term natural history of polypoidal choroidal vasculopathy (PCV).

DESIGN

Prospective, consecutive observational case series.

METHODS

Fourteen eyes of 12 consecutive patients with PCV were prospectively followed in our clinic for at least 2 years without any treatment after a first visit to the clinic between February 1996 and November 1998. All patients underwent complete ophthalmologic examination, color fundus photography, and fluorescein and indocyanine green (ICG) angiography at regular intervals. Inclusion criteria were as follows: eyes had serous and/or hemorrhagic pigment epithelium detachment (PED) and retinal detachment in the posterior pole, and ICG angiography revealed a branching vascular network with polypoidal dilations at the terminals of the network. Exclusion criteria were as follows: other diseases such as exudative age-related macular degeneration, high myopia, angioid streaks, and presumed ocular histoplasmosis syndrome, and patients who previously underwent any ocular surgery.

RESULTS

Patients were followed for mean of 39.9 months (range, 24-54 months). PCV was present in 10 (83%) men and two women and in the elderly (mean age 68.1 years), usually unilateral (83%) with vascular lesions located at the macula (93%). The PCV manifested in two patterns, exudative and hemorrhagic. In the exudative pattern, serous PED and retinal detachment were predominant at the macula. The hemorrhagic pattern was characterized by hemorrhagic PED and subretinal hemorrhage at the macula. ICG angiography revealed polypoidal choroidal neovascularization that was changeable in appearance and repeatedly grew and spontaneously regressed, but the vascular network persisted. In some eyes, a collection of small aneurysmal dilations of vessels resembling a cluster of grapes appeared and all of them had marked bleeding and leakage and worse outcome.

CONCLUSION

Polypoidal choroidal vasculopathy is a long persistent chronic disease and the patients had a variable course. Fifty percent of the patients had a favorable course. In the remaining half of the patients, the disorder persisted for a long time with occasional repeated bleeding and leakage, resulting in macular degeneration and visual loss. Eyes with a cluster of grapes-like polypoidal dilatations of the vessels had a high risk for severe visual loss.

Persistent intraschisis hemorrhage simulating choroidal melanoma

BACKGROUND

Intraschisis hemorrhage of dark green color without accompanying vitreous hemorrhage is a rare complication of degenerative retinoschisis-detachment.

CASE

A 37-year-old male patient with unilateral intraschisis hemorrhage closely mimicking a choroidal melanoma is described.

OBSERVATIONS

Ultrasonography and intravenous fluorescein angiography suggested intraschisis hemorrhage. T(1)-weighted magnetic resonance imaging demonstrated a hyperintense lesion compared to the vitreous that did not enhance with contrast agent. Managed by observation, the color of the lesion started to change at the 6th month of follow-up. The hemorrhagic lesion regressed to half size in 40 months following the diagnosis, and disappeared in 62 months.

CONCLUSION

Very rarely may an intraschisis hemorrhage secondary to degenerative retinoschisis-detachment simulate a choroidal melanoma. In our patient, careful interpretation of the conventional methods was adequate for the differential diagnosis. The unusual feature of this patient was that the hemorrhage resolved in 5 years, much slower than expected.