Vitrectomy for macular hemorrhage associated with retinal arterial macroaneurysm

Evaluation of a new Q-switched Nd:YAG laser on premacular hemorrhage

BACKGROUND

Premacular hemorrhage is among the causes of sudden deterioration of visual acuity. This study aimed to investigate the therapeutic outcomes of a new Q-switched Nd:YAG laser on premacular hemorrhage.

METHODS

Retrospective, case series study of 16 eyes from 16 patients diagnosed with premacular hemorrhage, including 3 cases of Valsalva retinopathy, 8 cases of retinal macroaneurysm, 3 cases of diabetic retinopathy, 1 case of trauma-related hemorrhage and 1 case with leukemia. A 1064nm Q-switched Nd:YAG laser was performed to puncture the posterior hyaloid and inner limiting membrane to drain the hemorrhage.

RESULTS

The success rate of 16 patients with premacular hemorrhage drainage was 100% in this study. Improved visual acuity was observed in each patient.

CONCLUSIONS

In this case series of 16 patients, the new Q-switched Nd:YAG laser was successful in draining premacular hemorrhage with no serious complications.

Multilayered Hemorrhage Secondary to Retinal Arterial Macroaneurysm Rupture: A Case Report and Review of Literature

Retinal arterial macroaneurysms represent an acquired vascular irregularity that is primarily observed in the elderly population. The high variability surrounding the clinical presentation of this condition makes the initial diagnosis challenging. Employing several diagnostic techniques including fundus fluorescence angiography, optical coherence tomography, and optical coherence tomography angiography ensures that any hemorrhages secondary to macroaneurysms rupture are identified promptly. This is crucial for appropriately managing the case and ensuring a good prognosis. Here, we present a case of a multilayered hemorrhage secondary to a ruptured retinal arterial macroaneurysm managed with a pars plana vitrectomy with gas tamponade and we aim to highlight the recent advancements in diagnosis and management of this condition.

Three-dimensional locations of ruptured retinal arterial macroaneurysms and their associations with the visual prognosis

The aim of this retrospective, observational study was to examine the intraretinal locations of ruptured retinal arterial macroaneurysms (RMAs) and investigate the associations with the visual prognosis. Fifty patients (50 eyes) with untreated RMA rupture who visited the Department of Ophthalmology at Kyoto University Hospital (April 2014–July 2019) were included. The intraretinal position of the ruptured RMAs relative to the affected retinal artery was examined using optical coherence tomography (OCT) and color fundus photography (CFP). The relative RMA positions were anterior to (anterior type, 44%), at the same level as (lateral type, 20%), or posterior to (posterior type, 34%) the affected artery. At the initial visit, the posterior type showed greater subretinal hemorrhage thickness than did the lateral and anterior types (P = 0.016 and 0.006, respectively), and poorer visual acuity (VA) than did the anterior type (P = 0.005). At the final visit, the length of the foveal ellipsoid zone band defect was longer (P = 0.005) and VA was poorer (P < 0.001) for the posterior type than for the anterior type. The intraretinal positions of ruptured RMAs vary, affect the thickness of foveal subretinal hemorrhage and predict future damage to the foveal photoreceptors. The visual prognosis may be poor for posteriorly ruptured RMAs.

Clinical variations and therapeutic challenges in the management of symptomatic retinal artery macroaneurysm: a tertiary center experience

PURPOSE

To find out clinical characteristics, therapeutic options, and visual outcome in symptomatic retinal artery macroaneurysm (RAMA) patients.

METHOD

Newly diagnosed cases of symptomatic RAMA from January 2015 to December 2019 were included. Fifteen eyes of 15 patients with mean age 62.46 years ± 14.89 (SD) fulfilled the inclusion criteria.

RESULT

Hypertension was present in 66.6% of the patients, and the commonest site was superotemporal (12 eyes, 80%). The most commonly employed treatment was Nd: Yag laser hyaloidotomy in 4 eyes (26.6%). Other treatments were intravitreal bevacizumab in 3 eyes (20%), focal laser with intravitreal bevacizumab in 3 eyes (20%), PPV with focal laser (13.3%) in 2, focal laser only in one (6.6%), PPV with focal and intravitreal bevacizumab in one (6.6%). The mean best-corrected visual acuity (BCVA) at baseline was 1.35 ± 0.84 LogMAR, which improved to 0.39 ± 0.53 LogMAR at the last follow-up. Presenting VA 0.77 (±0.40) improved to 0.20 (±0.17) p value (0.180) in intravitreal bevacizumab only group, 1.29 (±0.35) to 0.75 (±0.15) p value 0.66 in Nd: Yag laser group, 2.67 (±0.58) to 0.46 (±0.28) p value 0.019 in PPV group and did not improve in combined anti-VEGF and focal laser group due to dense hard exudates at the fovea in one and persistent cystoid macular edema in another case.

CONCLUSION

With regard to its presentation, which can vary tremendously, there are no approved guidelines for its treatment. The present study reinforces the need for a treatment guideline development. Customization of treatment should be considered depending on the clinical presentation of each case.

Clinical characteristics of retinal arterial macroaneurysms and prognosis of different interventions

PURPOSE

To estimate the clinical characteristics of retinal arterial macroaneurysms (RAM) and evaluate the prognosis of different interventions.

METHODS

This study is a meta-analysis. The databases PubMed, EMBASE, and Ovid from inception to January 2021 were searched to identify the relevant studies. R software version 3.6.3 was used to perform the statistical analyses. Results in proportion with 95% confidence interval were calculated by means of Freeman-Tukey variant of arcsine square transformation.

RESULTS

Sixty-nine studies involving 1332 patients were finally included. The pooling results indicated that 91% (95% CI [88 ~ 94%]) of the RAM patients were over sixty, 73% (95% CI [68 ~ 77%]) were female, and 73% (95% CI [66 ~ 79%]) have hypertension. By observation, the RAM closure rate was 64% (95% CI [39 ~ 86%]), the visual acuity (VA) improved in 55% (95% CI [40 ~ 71%]) of the patients, and the VA of 64% (95% CI [54 ~ 74%]) hemorrhagic versus 27% (95% CI [15 ~ 41%]) exudative patients improved significantly. By laser, the closure rate was 96% (95% CI [87 ~ 100%]), the VA improved in 73% (95% CI [65 ~ 80%]) of the patients, and the VA of 66% (95% CI [47 ~ 84%]) hemorrhagic versus 35% (95% CI [23 ~ 47%]) exudative patients improved significantly. By anti-VEGF, the closure rate was 98% (95% CI [93 ~ 100%]), the VA improved in 90% (95% CI [74 ~ 100%]) of the patients, and the VA of 58% (95% CI [18 ~ 94%]) hemorrhagic versus 67% (95% CI [31 ~ 96%]) exudative patients improved significantly.

CONCLUSION

RAM are most commonly seen in the elderly with a marked female predominance and a strong association with hypertension. Patients receiving laser or anti-VEGF treatments get higher closure rate and better visual prognosis than those with observation alone. Hemorrhagic RAM have a better visual prognosis by observation or laser treatment, while exudative RAM have a better visual prognosis by anti-VEGF treatment.

Combined Intravitreal Bevacizumab and Laser Photocoagulation to Treat Retinal Arterial Macroaneurysms

Purpose: To investigate the effects of intravitreal bevacizumab injection combined with laser photocoagulation in patients with retinal microaneurysms.Methods: We retrospectively reviewed the medical records of 21 eyes of 21 patients who underwent intravitreal bevacizumab injection and/or laser photocoagulation to treat retinal macroaneurysms. Eleven eyes received the combination therapy (CT) and 10 eyes monotherapy (MT) (either bevacizumab injection or laser photocoagulation). Changes in visual acuity, central macular thickness, macroaneurysm size and location, blood pressure, and the lipid level were compared between the two groups.Results: The mean patient age was 74.0 ± 10.5 years and the mean study period 7.0 ± 5.3 months. The mean macroaneurysm diameter of the CT group was 480.00 ± 292.30 μm and that of the MT group 328.75 ± 87.09 μm. The diameter was significantly larger in the CT group (p = 0.002). The initial visual acuities were 0.91 ± 0.66 and 0.88 ± 0.83 in the CT and MT groups, respectively. At the 4-month follow-up, the visual acuities were 0.33 ± 0.26 and 0.17 ± 0.29 in the CT and MT groups, respectively, and had significantly improved only in the CT group (p = 0.042). The initial central macular thicknesses were 441.82 ± 226.81 and 541.63 ± 401.97 μm in the CT and MT groups, respectively. At the 4-month follow-up, the figures were 293.60 ± 46.10 and 269.00 ± 48.34 μm in the CT and MT groups, respectively, and had significantly decreased only in the CT group (p = 0.043). Compared to the initial findings, the proportion of patients whose final visual acuities improved by more than two lines were 73% and 40%, respectively, thus significantly higher in the CT group (p < 0.001).Conclusions: Combined intravitreal bevacizumab injection and laser photocoagulation treatment of retinal macroaneurysms improve visual acuity and decrease macular thickness.

Retinal arterial macroaneurysm in leukemia

INTRODUCTION

Retinal arterial macroaneurysm (RAM) is an acquired vascular dilatation usually seen at the site of arterial bifurcation or arterial-vein crossing. It's often seen in the first three branches of the central retinal artery.

CASE DESCRIPTION

A 15-year-old male patient was admitted to the outpatient clinic with complaints of weakness, headache, and bruising on the body for a few weeks. During the physical examination, a hepatomegaly and a common patchy ecchymosis in the body were detected at the abdominal examination. Hemoglobin was 6.6 g/dl, white blood cells were 40,000/mm³, platelet was 24,000/mm³ at the whole blood count done. The 70% blast was detected in peripheral spread. Bone marrow aspiration evaluation was consistent with pre-B cell acute lymphoblastic leukemia. There was two macroaneurysms in the inferior arcuate of the left eye. The patient was examined on a weekly basis. During control examinations, retinal macroaneurysms in left eye and the hemorrhages significantly regressed.

CONCLUSION AND IMPORTANCE

The fact that RAM is not often seen in the pediatric age group, indicates the importance of this phenomenon. It should be remembered that a complete ophthalmic examination should be performed on leukemia patients.

Intraoperative optical coherence tomography-guided subretinal cocktail injection in a case of ruptured retinal artery macro-aneurysm with multilevel bleed

Submacular hemorrhage (SMH) following ruptured retinal artery macro aneurysm (RRAM) has better prognosis as compared to other etiologies. Timely intervention from as early as 24 h to less than 7 days is known to provide better visual outcomes in such cases. A variety of surgical techniques have been described in the treatment of RRAM. In this case report, we describe the advantages of intraoperative optical coherence tomography-guided sub-retinal injection of a cocktail mixture consisting of recombinant tissue plasminogen activator, bevacizumab, and air. Faster visual recovery with an immediate displacement of sub-macular bleed can be achieved with this technique in cases of RRAM-associated SMH.

ADVERSE EFFECT OF MACULAR INTRARETINAL HEMORRHAGE ON THE PROGNOSIS OF SUBMACULAR HEMORRHAGE DUE TO RETINAL ARTERIAL MACROANEURYSM RUPTURE

PURPOSE

To investigate the clinical course of submacular hemorrhage associated with ruptured retinal arterial macroaneurysm using swept-source optical coherence tomography.

METHODS

This study included 23 eyes of 23 consecutive patients diagnosed with submacular hemorrhage associated with ruptured retinal arterial macroaneurysm. Cases underwent displacement of submacular hemorrhage (vitrectomy + subretinal injection of tissue plasminogen activator + air tamponade) and were followed up for 6 months after surgery. Localization of the preoperative hemorrhage and its effect on preoperative and postoperative best-corrected visual acuity, central retinal thickness, and continuity of the ellipsoid zone were measured.

RESULTS

Macular intraretinal hemorrhage (IRH) was observed in 17 eyes (73.9%, IRH [+] group) and was not observed in 6 eyes (26.1%, IRH [-] group). The IRH (+) group showed worse postoperative best-corrected visual acuity values compared with the IRH (-) group (0.89 ± 0.47 in logarithm of the minimal angle of resolution units, Snellen equivalent 20/155 and 0.16 ± 0.23, 20/29, respectively; P < 0.01), smaller central retinal thickness values (97.7 ± 53.5 μm, 173.0 ± 32.3 μm, respectively; P < 0.01), and a higher rate of ellipsoid zone disruption (100%, 33.3%, respectively; P < 0.01).

CONCLUSION

Patients with preoperative macular IRH showed lower postoperative visual acuity and worse macular contour after submacular hemorrhage displacement compared with patients without macular IRH.

Retinal vascular disease in hypertension

In a previous article (July 2004, page 57), Dr Colucciello reviewed nonproliferative and proliferative diabetic retinopathy. In this article, he discusses retinal vascular disease associated with hypertension, which is especially likely to occur in persons with vasculopathic risk factors. Retinal vein occlusion, retinal arterial macroaneurysm, retinal artery occlusion, and carotid artery disease are predictive of progressive systemic vascular disease. Modification of risk factors and prompt identification of retinal vascular disease optimize vision outcomes and preserve quality of life.

Long-term, therapy-related visual outcome of 49 cases with retinal arterial macroaneurysm: a case series and literature review

PURPOSE

Retinal arterial macroaneurysms (RAMAs) are acquired dilations of branches of the central retinal artery. Treatment depends on vision-limiting complications. We compare the long-term visual acuity (VA) in three groups according to treatment.

METHODS

49 charts of patients with RAMA were reviewed. 16 remained untreated, 15 received photocoagulation and 18 vitrectomy. Patients underwent full ophthalmological examinations and up-to-date imaging. We evaluated chosen therapy, complications and final VA at the last visit.

RESULTS

65% of the cohort was female, aged 75±11 years (mean±SD). Follow-up was 34±23 months. These parameters did not differ significantly between the three groups. In the observed group, initial VA was 0.48 (mean log MAR) vs 0.35 at the final visit, in the photocoagulation group 0.55 vs 0.59, and in the vitrectomy group 1.8 vs 0.77. VA was significantly worse at enrolment in the vitrectomy group, while all other VA differences were not significant.

CONCLUSIONS

The overall visual prognosis of RAMA was good, even after macular complications. VA remained unchanged in the observed and the laser groups and was comparable in all groups after 3 years. Based on an individual treatment decision, all therapies were effective and efficient. If subfoveal haemorrhage caused a macular hole, the VA outcome was limited.

Subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage associated with ruptured retinal arterial macroaneurysm

PURPOSE

To evaluate the surgical outcomes of small-gauge vitrectomy with subretinal injection of recombinant tissue plasminogen activator (rt-PA) for a submacular hemorrhage caused by a ruptured retinal arterial macroaneurysm (RAM).

METHODS

Non-comparative, consecutive case-series performed at two ophthalmological institutions. We examined 22 eyes of 22 patients with a submacular hemorrhage associated with a RAM but without a preretinal or sub-internal limiting membrane hemorrhage at the fovea. During 25-gauge vitrectomy, approximately 4000-8000 IU of rt-PA was injected subretinally, followed by the injection of air or 10 % sulfur hexafluoride as a tamponade. The patients maintained an upright position for 1 hour, then turned to a facedown position for 1 to 3 days. The best-corrected visual acuity (BCVA) and postoperative complications were evaluated.

RESULTS

The average interval from the onset of symptoms to surgery was 8.4 ± 7.6 days, and the average size of the subretinal hemorrhage was 3.4 ± 1.0 disc diameters. The submacular hemorrhage was displaced from the foveal area in all eyes after 1 week. The mean baseline BCVA was 1.41 ± 0.41 logMAR units, and it improved to 0.91 ± 0.43 at 1 month and to 0.64 ± 0.45 at the final visit (P = 0.0001, P < 0.0001 respectively). A macular hole was detected intraoperatively in two eyes and postoperatively in two eyes, and both were closed by internal limiting membrane peeling or a second vitrectomy.

CONCLUSIONS

Small-gauge vitrectomy with subretinal rt-PA injection and gas tamponade were effective in displacing a submacular hemorrhage associated with a RAM.

Ruptured retinal arterial macroaneurysm: diagnosis and management

Retinal arterial macroaneurysm is an acquired, focal dilation of a retinal artery, typically occurring within the first three bifurcations of the central retinal artery. The clinical presentation of a retinal arterial macroaneurysm is highly variable, making initial diagnosis difficult and differentials many. Identification of retinal arterial macroaneurysms is crucial to appropriately co-manage with the primary care physician for hypertension control. Prognosis is generally good and observation is often an adequate treatment. However, in cases of macular threat or involvement, some treatment options are available and referral to a retinal specialist is indicated.

Retinal arterial macroaneurysms

Retinal arterial macroaneurysms are acquired saccular or fusiform dilatations of the large arterioles of the retina, usually within the first three orders of bifurcation. They are associated with systemic vascular conditions such as hypertension and arteriosclerotic disease occurring most commonly in elderly women. The primary reported symptom is a sudden loss of vision due to haemorrhage or oedema affecting the macula. Most of macroaneurysms regress without treatment and without causing decreased visual acuity. Poor visual outcome may occur secondary to foveal exudates and subfoveal haemorrhage.

Nd:YAG membranotomy for preretinal hemorrhage secondary to valsalva retinopathy

PURPOSE

To report four cases of premacular hemorrhage secondary to valsalva retinopathy treated with Nd:YAG membranotomy and discuss techniques as well as the literature.

DESIGN

Retrospective case series.

METHODS

A retrospective review was conducted for four patients with vision obstructing hemorrhage secondary to valsalva retinopathy. These patients were all treated with Nd:YAG membranotomy.

RESULTS

Four patients with premacular hemorrhage secondary to valsalva retinopathy were treated with Nd:YAG laser creating a membranotomy to drain the hemorrhage. Power settings ranged from 1.7 to 3.8 mJ. Visual acuity at presentation ranged from 20/400 (1 patient) to count fingers (3 patients). Visual acuity improved in three out of four patients after laser treatment. Final visual acuity ranged from 20/20 to 20/30 in these three patients. One patient was lost to follow up after performing laser membranotomy and therefore visual acuity after treatment was not obtained. No complications were noted.

CONCLUSION

Nd:YAG membranotomy is a non-invasive, office-based treatment option that may be successfully used to treat premacular hemorrhage secondary to valsalva retinopathy.

Intravitreal bevacizumab for symptomatic retinal arterial macroaneurysm

PURPOSE

To evaluate the therapeutic effect of intravitreal bevacizumab injection for symptomatic retinal arterial macroaneurysm.

DESIGN

Retrospective interventional case series.

METHODS

The study included 23 patients (23 eyes) with symptomatic retinal arterial macroaneurysm. They were categorized according to treatment method into 2 groups: an intravitreal bevacizumab-treated group (11 eyes) and an untreated group (12 eyes). Bevacizumab was injected at the initial visit, followed by as-needed monthly reinjection. Best-corrected visual acuity (BCVA) and central macular thickness were documented and analyzed between groups.

RESULTS

The mean follow-up period for all subjects was 10.83 ± 4.6 months. The mean number of injections for the treated group was 1.42 ± 0.69. The mean logarithm of the minimal angle of resolution (logMAR) of BCVA improved from baseline at the last follow-up by 0.26 in the bevacizumab-treated group (P = .02) and by 0.34 in the untreated group (P = .005). Average central macular thickness decreased from 384.4 ± 150.1 μm to 265 ± 112.5 μm in the bevacizumab-treated group (P = .0002) and from 413.2 ± 155.2 μm to 236.3 ± 103.5 μm in the untreated group (P = .008). The BCVA was significantly improved from baseline after 1 month in the bevacizumab-treated group (P = .02) and after 3 months in the untreated group (P = .01). However, there was no statistically significant difference in BCVA improvement or central macular thickness improvement achieved at the final visit.

CONCLUSIONS

Intravitreal bevacizumab injection likely hastens resolution of macular edema and hemorrhage secondary to retinal arterial macroaneurysm. Intravitreal bevacizumab injection could be an effective treatment option for symptomatic retinal arterial macroaneurysm.

Treatment of multilevel macular hemorrhage secondary to retinal arterial macroaneurysm with submacular tissue plasminogen activator

Purpose.

To evaluate the efficacy of pars plana vitrectomy (PPV) followed by internal limiting membrane (ILM) removal and injection of subretinal recombinant tissue plasminogen activator (rtPA)–assisted pneumatic displacement in eyes with massive multilevel macular hemorrhage caused by ruptured retinal arterial macroaneurysm (RAMA).

Methods.

Four eyes of 4 patients treated with PPV for recent (≤7 days) macular hemorrhage at both beneath the ILM and subretinal space involving the center of the fovea caused by RAMA were included in the study. In each case, following PPV, ILM removal, subretinal injection of rtPA (12.5 µg/0.1 mL), and fluid-air exchange with postoperative prone positioning was performed. Optical coherence tomography (OCT) examination was performed at the initial and the follow-up visits.

Results.

Duration of symptoms ranged from 3 to 7 days (average, 4.5±1.9 days). Preoperative visual acuity ranged from hand motions to 20/800. Follow-up ranged from 6 to 18 months (average, 13±5.2 months). The postoperative visual acuity improved in all eyes and ranged from 20/100 to 20/30 (mean, 20/50). At the final visit, OCT examination revealed well-preserved foveal structure in all eyes. Mild nuclear sclerosis developed in one eye.

Conclusions.

Pars plana vitrectomy followed by ILM removal and injection of subretinal rtPA-assisted pneumatic displacement appears to be effective in both improving visual acuity and preserving the foveal structure in eyes with recent massive multilevel macular hemorrhage secondary to RAMA.

[Clinical and progressive features of macular hemorrhage secondary to retinal artery macroaneurysms]

INTRODUCTION

Retinal arterial macroaneurysm (RAM) is an acquired vascular retinal abnormality that has developed from a retinal arterial branch located in the macular area. It is responsible for decreased visual acuity when complications such as bleeding or retinal exudation occur. A ruptured RAM leads to severe premacular, submacular, or vitreous hemorrhage. The progression can be spontaneously favorable depending on the severity and the location of the hemorrhage. A poor visual prognosis is usually reported in subretinal hemorrhage. We reported the observation of four patients with macular hemorrhage secondary to ruptured RAM.

PATIENTS AND METHODS

Four patients--two males and two females, aged from 39 to 65 years, presented with sudden unilateral decreased visual acuity. An ophthalmologic exam with visual acuity measurement, anterior segment exam, ocular tonometry, and funduscopy was performed, completed with fluorescein retinal angiography. A Nd:Yag laser hyaloidotomy was done in two cases of premacular hemorrhage 1 week after its occurrence. Submacular hemorrhages were only observed using visual acuity measurement and ophthalmoscopic examination. The follow-up is 3-4 months.

RESULTS

Initial visual acuity varied from light perception to 2/10. The fundus examination showed a macular hemorrhage: subretinal in one case, preretinal in two cases, and in the last case the hemorrhage was both preretinal and subretinal. The diagnosis of MAR was confirmed by fluorescein angiography, which showed a hyperfluorescent arterial dilatation temporal to the macula. In the cases of submacular hemorrhage, the hemorrhage reduced spontaneously after simple monitoring. Final visual acuity was 4/10 and 5/10. For premacular subhyaloid hemorrhage treated with laser Nd:Yag drainage, the final visual acuity was 5/10 and 7/10.

CONCLUSION

Visual prognosis in premacular hemorrhage is improved by Nd:Yag laser treatment. Subretinal hemorrhage can have a spontaneous favorable outcome. Surgery should not be systematic. Comparative studies are necessary to apply indications.

Case of recurrent macular haemorrhage after removal of a sub-internal limiting membrane haematoma secondary to retinal artery macroaneurysm

The authors report the case of an 80-year-old man with sub-internal limiting membrane haematoma secondary to retinal artery macroaneurysm in the right eye. Corrected visual acuity was 6/60 in the right eye. Vitreous surgery was performed. The internal limiting membrane over the haematoma was removed by pulling with a soft-tipped extrusion cannula, and then the haematoma was removed with a vitreous cutter. One month post surgery vision had improved to 6/9. Two months post surgery, however, the same macroaneurysm ruptured again, and vision decreased to 6/60. Clinicians should be aware that recurrent macular haemorrhage may occur after removal of sub-internal limiting membrane haematoma secondary to macroaneurysm.

Intravitreal Tissue Plasminogen Activator and Pneumatic Displacement of Submacular Hemorrhage Secondary to Retinal Artery Macroaneurysm

PURPOSE

To assess the efficacy of treating submacular hemorrhages secondary to retinal arterial macroaneurysm with intravitreous tissue plasminogen activator (tPA) and gas.

PATIENTS AND METHODS

Six consecutive patients (6 eyes) with submacular hemorrhage secondary to retinal arterial macroaneurysm were included in this study. Tissue plasminogen activator, at a dose of 50 microg/0.1 mL, was injected through the pars plana into the vitreous cavity. Gas (0.3-0.5 mL of perfluoropropane) instillation followed tPA injection, either immediately after injection or sometime during the next day.

RESULTS

Best postoperative visual acuity improved in 5 of 6 eyes (83%) and was unchanged in 1 of 6 (17%) eyes. In 5 of 6 (83%) eyes, the procedure resulted in complete or partial displacement of submacular hemorrhage out of the foveal area.

CONCLUSIONS

Intravitreous injection of tPA and gas, followed by prone positioning of the patient, is an effective and simple treatment of submacular hemorrhage secondary to retinal arterial macroaneurysm. No complication occurred in this series.

Macular hole formation following ruptured retinal arterial macroaneurysm

PURPOSE

To report four cases of macular hole formation following ruptured retinal arterial macroaneurysm.

DESIGN

Case-control study.

METHODS

Review of clinical records of 75 consecutive eyes (73 patients) with macroaneurysm. Macroaneurysms were confirmed using either fluorescein angiography or indocyanine green angiography or both that indicated a telangiectatic retinal vascular change. Clinical data of patients with macroaneurysm with and without macular hole (MH) formation were compared retrospectively.

RESULTS

Of 75 eyes, four (5.3%; four patients) with macroaneurysm had a macular hole. In one of the four eyes, a macular hole was detected 2 days after the rupture. The distance from the macroaneurysm to the center of the fovea was significantly closer in the four eyes with a macular hole (MH group, 1.1 +/- 0.4 (mean +/- standard deviation [SD]) disk diameter) than in the 71 eyes without a macular hole (non-MH group, 1.9 +/- 0.9 disk diameter) (P =.0196). The incidence of subretinal hemorrhage in the macula was significantly greater in the MH group (100%) than in the non-MH group (35.2%) (P =.0195).

CONCLUSIONS

Macular hole formation associated with ruptured macroaneurysm is not as uncommon as previously thought. We suggest that there might be early onset of macular hole formation following ruptured macroaneurysm. Macroaneurysms with early-onset macular hole are present near the center of the macula and are accompanied by subretinal hemorrhage in the macula.

Valsalva retinopathy induced by labour

PURPOSE

To describe a patient with Valsalva retinopathy induced by labour.

METHODS

Case report.

RESULTS

A 29-year-old woman at her second pregnancy complained of a sudden loss of vision in her left eye during spontaneous labour. Visual acuity was reduced to counting fingers. Funduscopy revealed a large preretinal hemorrhage at the macula in the left eye. Three weeks after delivery, the hematoma was treated with Nd:YAG laser. Two weeks after treatment, visual acuity was 20/20 and the premacular hemorrhage had resolved.

CONCLUSIONS

A rise in intra-abdominal pressure during labour may result in Valsalva retinopathy. Nd:YAG laser may be useful in treating such hemorrhage.