Vitrectomy for premacular hemorrhagic cyst in children and young adults

Characterization of retinal hemorrhages delimited by the internal limiting membrane

Clinically, hemorrhages at the vitreoretinal interface have been termed as 'pre-retinal' in location. However, there is a careful distinction to be made between sub-hyaloid and sub-internal limiting membrane (ILM) planes of blood collection. In the past half-century, a body of literature has accrued on sub-internal limiting membrane hemorrhage. We characterize the etiopathological, clinical, anatomical, and imaging characteristics of this entity (often misconstrued as sub-hyaloid hemorrhage). Management decisions are briefly described, and a unifying term of sub-internal limiting membrane macular hemorrhage is proposed to aid in further research.

VALSALVA RETINOPATHY: Clinical Features and Treatment Outcomes

PURPOSE

To report the clinical presentation and outcomes in patients with Valsalva retinopathy.

METHODS

This was a retrospective case series of patients diagnosed with Valsalva retinopathy between June 1, 2010, and May 31, 2020. Clinical notes, operative reports, fundus photography, and optical coherence tomography images were reviewed.

RESULTS

This study comprised 58 eyes of 58 patients. The most common causes were lifting (34.4%), vomiting (20.6%), straining (20.6%), and coughing (17.2%). Mean best-corrected visual acuity at diagnosis was 20/163. The most frequently involved vitreoretinal compartment was the subhyaloid space (42.3%) followed by the intraretinal (32.7%), intravitreal (23.1%), and subretinal (13.4%) spaces. Mean best-corrected visual acuity of all patients was 20/59 at 3 months, 20/48 at 6 months, and 20/22 at 1 year. Mean time to clearance of hemorrhage on clinical examination was 99.0 ± 18.7 days in patients who underwent observation and 4.5 ± 3.5 days after surgery in patients who received pars plana vitrectomy.

CONCLUSION

Valsalva retinopathy is generally associated with a favorable visual prognosis. Most eyes perform well with observation although pars plana vitrectomy may be indicated in patients requiring rapid resolution of hemorrhage.

Visual and Anatomic Outcomes of Premacular Hemorrhage in Non-Accidental Trauma Infants Managed With Observation or Vitrectomy

BACKGROUND AND OBJECTIVE

The management of premacular hemorrhage secondary to non-accidental trauma (NAT) is unclear. The authors describe the outcomes of NAT infants referred for surgical evaluation of premacular hemorrhage.

PATIENTS AND METHODS

Retrospective institutional review board-approved case series between 2000 and 2019 of vision-threatening premacular hemorrhage (sub-hyaloid or sub-internal limiting membrane hemorrhage without vitreous hemorrhage) in NAT infants. Time to hemorrhage resolution, vision, and comorbidities were collected.

RESULTS

Thirty-six patients (62 eyes) with mean age of 5.4 months (range: 2-10 months) were included. Nine eyes (14.5%) underwent vitrectomy. Median time to hemorrhage resolution by observation was 75 days (interquartile range [IQR]: 60-120 days), and time to vitrectomy was 54.5 days (IQR: 47.8-58.5 days). Eight eyes (12.9%) had amblyopia, which was not significantly different between groups. Despite hemorrhage clearance, a higher proportion of eyes in the vitrectomy group had pigmentary changes (P = .04) and strabismus (P = .002) at follow-up.

CONCLUSIONS

Most cases of NAT-related premacular hemorrhage resolve within 3 months without surgical intervention. Comorbidities may limit visual prognosis. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:715-722.].

Long-term evaluation of pars plana vitrectomy in children with Abusive head trauma

PURPOSE

To determine the efficacy of pars plana vitrectomy (PPV) in children with intraocular hemorrhage (IOH) secondary to Abusive head trauma (AHT).

METHODS

A long-term retrospective analysis evaluating epidemiology, management, safety, anatomical and functional results of PPV for IOH in children with AHT at tertiary referral center for children in the Czech Republic from 2004 to 2017.

RESULTS

18 children were identified with IOH due to AHT during observation period of 14 years. Overall incidence of IOH related to AHT was 29.6/100 000, in children under 1 year 22.2/100 000, in children 1 to 5 years 7.4/100 000. Mean age at the time of diagnosis was 13.7 (SD±20.53) months, median 5 months. IOH resolved in 56% of children, 64% eyes, spontaneously. 44% children, 36% eyes, underwent PPV. PPV was performed 30.5 (SD±16.98) days after established diagnosis on average. Postoperatively, 80% of eyes had anatomical improvement, 20% eyes had preexisting irreversible changes in the posterior pole. Vision of 50% eyes improved after surgery, vision of 20% eyes remained poor, 30% of eyes was not possible to test due to severe neurological impairment. Mean observational period was 33.4 (SD±38.21) months. Mortality rate of AHT in our group was 17%, all victims were younger 4 months.

CONCLUSIONS

PPV is a safe and effective procedure to clear IOH in children with AHT. Ophthalmology outcomes are strongly associated with degree of neurological impairment. Best outcomes were achieved with PPV performed between 2 and 5 weeks after trauma. Opportunity to plan surgery within this time frame indicates a good neurological prospect and prevents deprivation amblyopia.

Valsalva retinopathy: Long-term results and management strategies

PURPOSE

To investigate the long-term results and efficacy of the treatment modalities for preretinal hemorrhage due to valsalva retinopathy.

METHODS

Retrospective review was conducted on 24 eyes of 24 patients with valsalva retinopathy who were treated between 2004 and 2019. These patients were treated with Nd:YAG laser, argon laser and vitrectomy or were only observed. Nd:YAG laser hyaloidotomy was performed in 10 eyes, argon laser was applied to two of those following failed Nd:YAG laser, and vitrectomy was performed in one eye. A conservative approach was adopted in 13 eyes.

RESULTS

There were 15 females and nine males with mean age of 41.08 ± 12.72 (21-65) years. Mean follow-up period was 42.83 ± 23.78 (range: 12-116) months. Patients with hemorrhage size smaller than or equal to 4-disc diameter were observed for spontaneous resorption and achieved 20/20 visual acuity within 6 months. Visual acuity of all patients treated with Nd:YAG and/or argon laser, increased within the first week after the treatment. Vitrectomy was performed in only one patient with hemorrhage located away from macula. The good visual outcomes were achieved in all treatment modalities.

CONCLUSIONS

Observation, Nd:YAG laser and argon laser seem to be safe and effective approaches for eyes with valsalva retinopathy. The size, volume and duration of hemorrhage are the most crucial factors for treatment choice, success and complications.

A white membrane beneath the inner limiting membrane of the retina in a 4-year-old child with ultrastructural evidence: a case report

Background

Epiretinal membranes (ERMs), secondary to retinal cell proliferation on the retinal surface, usually affect patients over 50 years of age but occur rarely in children. Here we report the case of a 4-year-old patient with a unilateral sub-inner limiting membrane (sub-ILM) membrane mimicking epiretinal membrane with notable ultrastructural features indicating its possible origin from old sub-ILM hemorrhage.

Case presentation

A 4-year-old boy was admitted with the complaint of poor vision in his right eye, which had been detected at school vision screening performed 6 months earlier. Fundal examination showed a feather-shaped white membrane in the macula of the right eye, and optical coherence tomography (OCT) revealed a thickened retina with a hyper-reflective band on the retinal nerve fiber layer. We suspected epiretinal membrane in the right eye, and pars plana vitrectomy with membrane peeling was performed to improve the patient’s vision. Surprisingly, the membrane was found intraoperatively to be located beneath the intact ILM; it was lifted carefully from the underlying retina as it was strongly adhered to a retinal artery of the superotemporal arcade. Postoperative scanning electron microscopy showed that the membrane consisted of hemosiderin, collagenous fibre and fibrinoid deposits. At follow-up visits, fundal examination and OCT revealed improvement in the retinal structure with disappearance of the hyper-reflective band and reduced retinal thickness. The patient’s visual acuity in the right eye was stable at 20/100 at 1 year post operation.

Conclusions

The white membrane presented here was found to lie between the intact ILM and the rest of the retina, adhering firmly to the superotemporal vessel arch. Given the ultrastructural findings of the membrane and the medical history, we speculate that the sub-ILM membrane probably developed secondary to a sub-ILM hemorrhage.

Successful Resolution of Preretinal Haemorrhage with Intravitreal Ranibizumab

We would like to report two cases of preretinal haemorrhage from two different aetiology courses of bleeding being treated with intravitreal ranibizumab and its outcome. Our first case was a 39-year-old man with a diagnosis of severe aplastic anaemia that presented with bilateral premacular haemorrhages in both eyes. His right eye vision was 6/45 and it was counting finger in the left eye. He was treated with intravitreal ranibizumab once to the right eye and twice to the left eye. Right eye showed complete resolution of premacular haemorrhage and minimal residual premacular haemorrhage in the left eye at 3 months after initial presentation. Our second case was a 32-year-old healthy teacher that presented with preretinal haemorrhage at superotemporal region extending to macular area in left eye secondary to valsalva retinopathy. Her left vision was counting finger. She was treated with single intravitreal ranibizumab to the left eye. There was significant reduction of premacular haemorrhage and her left eye vision improved to 6/6 at 10 weeks after injection. Both cases had favourable outcome with intravitreal ranibizumab and can be considered as nonsurgical treatment option in treating premacular haemorrhage.

Spontaneous absorption of extensive subinternal limiting membrane hemorrhage in shaken baby syndrome

The Shaken Baby Syndrome (SBS) is characterized by subdural hematomas (SH), retinal hemorrhages (RH), and multiple fractures of long bones without external evidence of head trauma. Subinternal limiting membrane (ILM) hemorrhage, also known as macular schisis, is a characteristic finding of this entity. There is no guideline on the right time to indicate surgical treatment. This report describes an abused child with massive sub-ILM hemorrhage, which showed spontaneous absorption after less than two months of follow-up. Due to the possible spontaneous resolution, we suggest an initial conservative treatment in cases of sub-ILM hemorrhage related to SBS.

[Spontaneous macula hemorrhage. Subhyaloid/sub-inner limiting membrane (ILM)]

This case study describes the clinical findings of two patients with spontaneous subhyaloid and sub-inner limiting membrane preretinal macular hemorrhage including ophthalmoscopy, optical coherence tomography (OCT) and fluorescein angiography (FAG), which are typical for a Valsalva retinopathy. The improvement of the decreased visual acuity was achieved in one case by spontaneous resorption and in the other case by pars plana vitrectomy. The etiology, diagnostic criteria and therapeutic options are discussed.

Non-vitrectomizing vitreous surgery for premacular haemorrhage

PURPOSE

We report three cases illustrating an alternative treatment option for premacular haemorrhage.

METHODS

This retrospective interventional case study included three eyes in three patients with premacular haemorrhage caused by idiopathic thrombocytopenic purpura in the first case, trauma in the second case and retinal arterial macroaneurysm in the third case. All patients underwent non-vitrectomizing vitreous surgery. Visual acuity as well as slit-lamp and indirect ophthalmoscopic examinations were performed pre- and postoperatively to evaluate the resolution of premacular haemorrhage and changes in lenticular opacity.

RESULTS

At postoperative day 1, visual acuity had improved from counting fingers (CF) to 6/12 in case 1, from CF to 6/20 in case 2 and from CF to 3/60 in case 3. Examination of the fundus showed resolution of the premacular haemorrhage with mild vitreous haemorrhage in all cases. Final best corrected visual acuities were 6/6, 6/7.5 and 6/15, respectively. The lens remained clear in two of two phakic eyes at the last follow-up visit.

CONCLUSIONS

In these selected cases, non-vitrectomizing vitreous surgery was a useful and safe alternative for the treatment of premacular haemorrhage.

Subhyaloidal and macular haemorrhage: localisation and treatment strategies

Deterioration of visual acuity as a result of haemorrhage

Sub-inner limiting membrane haemorrhage: causes and treatment with vitrectomy

BACKGROUND

Preretinal haemorrhages usually occur at the interface between the posterior hyaloid and inner limiting membrane (ILM). Less frequently, they are located between the ILM and the retinal nerve fibre layer. Sub-ILM haemorrhages have been described in a variety of clinical settings and often lead to severe visual impairment because of their predilection for the macular region.

METHODS

A consecutive series of five cases in which sub-ILM haemorrhages were clinically suspected and confirmed during early vitrectomy with ILM peeling were reviewed.

RESULTS

Sub-ILM haemorrhages were clinically suspected in five patients (median age 32 years) based on the fundoscopic appearance and clinical setting of Terson's syndrome (n = 1), Valsalva retinopathy (n = 2), blood dyscrasia (n = 1) and blunt facial trauma (n = 1). Vision was severely impaired in all patients (to hand movements in four of five) because of a premacular location of the haemorrhage. All patients were treated with early pars plana vitrectomy because of insufficient spontaneous visual recovery after a median of 6 weeks. The sub-ILM location of the haemorrhage could be confirmed intraoperatively in all patients by biostaining of the membrane overlying the haemorrhage. ILM peeling and aspiration of the haemorrhage resulted in excellent visual recovery in all patients. No procedure-related complications were observed.

CONCLUSIONS

Sub-ILM haemorrhages often occur in a specific clinical context and can lead to severe visual impairment in young patients. Given the excellent results and low complication rates, timely surgical intervention is justified when spontaneous resorption is insufficient.