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

A new surgical approach for the treatment of a refractory foveal microaneurysm: A case report

Purpose

To report a case of a refractory foveal microaneurysm (MA) that was successfully treated by use of a new surgical procedure.

Observations

This study involved a 79-year-old female with an active foveal MA associated with branch retinal vein occlusion in her left eye. Despite anti-vascular endothelial growth factor treatments, the MA remained active without closure, and best-corrected visual acuity (VA) gradually decreased from 20/20 to 20/200. After our new surgical procedure was explained in detail to the patient, written informed consent was obtained from the patient and the surgery was performed. Briefly, following pars plana vitrectomy, the internal limiting membrane in her left eye was peeled and the retina of the external wall of the MA was then gently incised. The exposed MA was then directly grabbed and pulled up onto the retina using 27-gauge microforceps, and photocoagulation was performed. At 3-months postoperative, closure of the MA and improvement in the retinal findings were observed, and best-corrected VA improved to 20/67.

Conclusions and importance

We report a case of a refractory foveal MA that was successfully treated with a novel surgical technique that closed the MA, avoided thermal damage to the surrounding tissue, and resulted in improved postoperative VA.

Retinal hemorrhages and damages from tractional forces associated with infantile abusive head trauma evaluated by wide-field fundus photography

We evaluated the distribution and types of retinal hemorrhages (RHs) and other damages in eyes with abusive head trauma (AHT). This retrospective, consecutive case series of AHT and non-AHT conditions involved 54 children with AHT, 43 children with head bruises, and 49 children with blunt eye trauma, each of non-AHT supported by reliable witness accounts. RHs and other damage were evaluated using ophthalmoscopy and wide-field fundus photography. A variety of RH types and other damage were identified in the AHT group but not in the non-AHT group. RHs in AHT extended from the posterior pole to the far periphery in 77% of eyes and on/near the veins in 86% and arteries in 85%, most of which were in the far periphery. Retinoschisis, white-dot lesions, and retinal folds were seen even in the far periphery. RHs on/near the veins and arteries, retinoschisis, and retinal folds suggest a traumatic mechanism of the tractional force of the vitreous that is attached to the entire retinal surface. Identifying the distribution and arterio and venous origins of RHs is a key factor in determining the association with trauma. Thus, wide-field fundus photography is useful to record and evaluate the origin of the RHs and other retinal damage.

Bilateral Subinternal Limiting Membrane Crystalline Deposits Secondary to Terson Syndrome

Background

We report the case of bilateral, subinternal limiting membrane crystalline deposits in a patient with Terson syndrome, describe the possible pathogenesis, and highlight management. Case Presentation. A 24-year-old male with a history of traumatic massive parenchymal and subdural frontal hemorrhage presented to our clinic seven months after a motor vehicle accident, prolonged hospitalization, and rehabilitation, complaining of decreased vision in both eyes. The Snellen visual acuity was 1/60 in the right eye, and 6/60 in the left eye. Fundus examination showed an organized white vitreous hemorrhage in both eyes with almost no view of the retina. The anterior segments were normal. He underwent a 25-gauge pars plana vitrectomy in both eyes. During the surgery, golden crescent-shaped sediment consisting of small crystals was observed under the internal limiting membrane in both eyes: anterior to the inferior temporal vascular arcade in the right eye and posterior to it in the left eye. Internal limiting membrane (ILM) peeling after staining with ILM-blue dye was performed in the left eye, where the finding involved the macula. One year after the surgery, visual acuity significantly improved to 6/8.5 on the right and 6/6 on the left. Epiretinal membrane formation was observed in the right eye, where ILM peeling was not performed.

Conclusion

Subinternal limiting membrane crystalline deposit finding is a rare condition. Consider performing internal limiting membrane peeling and sediment removal in cases with macular involvement. In cases where crystals are concentrated outside of the macula, follow-up may be considered.

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.

Optical coherence tomography findings after surgery for sub-inner limiting membrane hemorrhage due to ruptured retinal arterial macroaneurysm

Ruptured retinal arterial macroaneurysm (RAM) can cause sub-inner limiting membrane (ILM) hemorrhage, leading to acute vision loss in the elderly. Vitrectomy has been established as an effective treatment to remove hemorrhage and facilitate visual recovery. Although optical coherence tomography (OCT) is useful for the diagnosis of sub-ILM hemorrhage before surgery, little is known about the postoperative OCT findings. Here, we retrospectively investigated the records of nine eyes of nine patients who underwent surgery for sub-ILM hemorrhage due to RAM rupture. On postoperative OCT, hyperreflectivity throughout the full thickness of the central fovea was observed in eight eyes (88.9%), and disruption of the ellipsoid/interdigitation zone (EZ/IZ) was observed in seven out of eight eyes (87.5%). The widths of the hyperreflectivity and EZ disruption gradually decreased. Visual recovery was least favorable in two eyes, in which the EZ line continuation did not recover until the final follow-up. The OCT findings corresponded to the hemorrhagic staining identified on fundus photographs in at least four eyes; as per the fundus photographs the findings persisted even after the hemorrhage was absorbed. In contrast, the OCT findings resembled the appearance before the development of a full-thickness macular hole, suggesting fragility caused by the RAM rupture.

Efficiency and Complication of 577-nm Laser Membranotomy for the Treatment of Retinal Sub-Inner Limiting Membrane Hemorrhage

Objective

We investigated the clinical efficiency and complications of treatment of retinal sub-inner limiting membrane (sub-ILM) hemorrhage by 577-nm semiconductive laser membranotomy.

Methods

The clinical features, ocular fundus photography, and SD-OCT image of patients who received 577-nm laser membranotomy for sub-ILM hemorrhage were assessed from January 2017 to April 2022 in this retrospective case-series study.

Results

A total of 19 patients (19 eyes) were treated for sub-ILM hemorrhage of the macula, in which eight were women and 11 were men. The age was 15-83 years (with an average age of 49.05 ± 19.41 years old). The right eye was affected in 12 patients, the left eye in seven patients. The follow-up period after laser treatment was from 0.5 to 9 months (with an average follow-up time of 3.25 ± 2.45 months). Treatment was not successful in one patient, and 577-nm laser membranotomy was successful in 18 patients (equaling a success rate of 94.74%). The best corrected visual acuity (BCVA) before laser treatment was from figure count to 40/200, and the BCVA after laser treatment was from 20/2000 to 20/20. Complications after laser treatment comprised macular hole (one patient), macular epi-membrane (one patient), vitreous hemorrhage without absorption (two patients), and sub-ILM cavity (12 patients).

Conclusions

The 577-nm laser is effective in treating sub-ILM hemorrhage and has a high success rate. Posttreatment complications should be monitored, and vitrectomy was needed with long-lasting vitreous hemorrhage and macular hole.

Terson's syndrome, the current concepts and management strategies: A review of literature

Terson's Syndrome describes intraocular hemorrhage secondary to an acutely raised intracranial pressure (ICP). Although Terson's Syndrome is common amongst patients with subarachnoid hemorrhage (SAH), it is underdiagnosed and often overlooked. This review discusses the current understanding of the etiopathogenesis, clinical features, and management of Terson's Syndrome and highlights the visual and prognostic implications to stress the importance of timely diagnosis and management. The origin of intraocular hemorrhage in Terson's Syndrome has been debated. A recognized theory suggests that an acutely raised ICP induces effusion of cerebrospinal fluid into the optic nerve sheath which dilates the retrobulbar aspect of the sheath in the orbit. Dilatation mechanically compresses the central retinal vein and retinochoroidal veins resulting in venous hypertension and rupture of thin retinal vessels. A commonly reported clinical feature is decreased visual acuity and blurred vision. These may be accompanied by symptoms of increased ICP including loss of consciousness and headache. Diagnosis is established using evidence from the clinical presentation, ophthalmoscopy, and, when required, imaging including B-mode ultrasound, CT, MRI, and fluorescein angiography. Terson's Syndrome is managed conservatively by observation for mild cases and with vitrectomy for bilateral cases and for patients whose hemorrhage has not spontaneously resolved after an observational period. Terson's Syndrome can be used as a prognostic indicator of morbidity and mortality in underlying pathology like SAH. Fundoscopy of patients with SAH, acutely raised ICP or visual disturbance with unknown etiology can help establish a timely Terson's Syndrome diagnosis. This may avoid the risk of permanent visual impairment.

Sub-internal limiting membrane hemorrhage as an unusual presentation of polypoidal choroidal vasculopathy

We report the two cases who presented with sudden decreased vision and sub-internal limiting membrane (ILM) hemorrhage without a history of Valsalva maneuver, trauma, or hematological disorders. Multimodal imaging revealed the features suggestive of polypoidal choroidal vasculopathy (PCV) in addition to the sub-ILM hemorrhage. A provisional diagnosis of sub-ILM hemorrhage secondary to PCV was made and was treated with intravitreal Bevacizumab injection. Treatment resulted in the improved visual acuity along with the resolution of the sub-ILM hemorrhage. These cases highlight the possibility of isolated sub-ILM hemorrhage as a presenting fundus finding in PCV, which is previously unreported. This report also highlights the importance of multimodal imaging in diagnosing chorioretinal disorders with unusual presentation.

Bilateral preretinal hemorrhage associated with Kikuchi-Fujimoto disease

Purpose

To present a case of a patient with human immunodeficiency virus (HIV) disease and Kikuchi-Fujimoto disease (KFD) who presented with a unique pattern of retinopathy.

Observations

A 7-year-old Taiwanese girl with HIV disease who was recently diagnosed with KFD had a sudden onset of blurry vision in both eyes one month after her KFD systemic symptoms had relatively resolved. Ophthalmic examination showed decreased visual acuity in both eyes (OU). On fundus examination, she had bilateral preretinal, subhyaloid, and vitreous hemorrhage that was more severe than anemic retinopathy.

Conclusion

Ocular manifestations in Kikuchi-Fujimoto disease are rare; however, if they occur, presentations may vary. The exact etiology of the disease has remained elusive and controversial. This case is the first report of a patient with HIV disease and KFD presenting with ocular involvement. Furthermore, bilateral preretinal, subhyaloid, and vitreous hemorrhage, which was beyond anemic retinopathy, is an unprecedented manifestation of KFD that has not been previously reported. This case highlights the necessity for clinicians to consider all possible differential diagnoses when evaluating patients with similar findings to identify the best therapeutic approach and avoid unnecessary treatment.

Nd:YAG membranotomy for sub-inner limiting membrane hemorrhage: a case report

Case Description: A 16-year-old male patient presented with a 12-days sudden painless loss of vision in his left eye after diving in a lake. Best corrected visual acuity (BCVA) in the left eye was counting fingers. Anterior segment was unremarkable. Fundoscopy in the left eye revealed a pre-retinal hemorrhage in the macular region and swept-source ocular coherence tomography (SS-OCT) confirmed the location in the sub-inner limiting membrane (ILM) space. An Neodymium:YAG (Nd:YAG) laser membranotomy was performed the next day in order to drain the hemorrhage into the vitreous cavity. A couple of days after, the BCVA in the left eye improved to 20/ 25, at fundoscopy the blood being almost reabsorbed and the SS-OCT showing a resolution of the sub-ILM hemorrhage.

Discussion: Due to Valsalva retinopathy, sub-ILM hemorrhage may lead to a sudden painless vision loss. Spontaneous resolution of the hemorrhage is possible but absorption may take a long time. During this period, intraretinal tissue migration and proliferation may lead to permanent structural damage. Posterior vitrectomy is a treatment option but the fact that it is an invasive procedure fuels the search for less invasive treatment methods and Nd:YAG laser membranotomy fits this place.

Conclusion: Given the excellent results and low complication rates, Nd:YAG laser membranotomy is highly recommended to treat this condition as it offers a simple, relatively safe and a non-invasive treatment option for drainage of sub-ILM hemorrhages.

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.

"Arcus retinalis": A novel clinical marker of sub-internal limiting membrane hemorrhage

INTRODUCTION

Preretinal hemorrhages can be located in subhyaloid or sub-internal limiting membrane (ILM) space. Though optical coherence tomography (OCT) may help to distinguish the exact location of hemorrhage in selected cases, it is often difficult to discern clinically. The purpose is to describe a novel clinical sign named "arcus retinalis" as a clinical marker of sub-ILM hemorrhage.

METHODS

Retrospective observational case series. Ophthalmic records of 31 eyes with sub-ILM hemorrhage were analyzed. The sub-ILM nature of the hemorrhage was confirmed either by the presence of two distinct layers (ILM and posterior hyaloid) on OCT or on intraoperative sub-ILM localization of the hemorrhage during vitrectomy.

RESULTS

15 out of 31 eyes with sub-ILM hemorrhage demonstrated a retinal yellowish-white arc corresponding to the outer margin of the sub-ILM hemorrhage. A complete circle was not seen in most of the cases. This arc corresponded to a vertical peg-like structure in the outer retina on OCT and had a tendency to fade away over months. In 10 eyes, it was visible at presentation and in five eyes it could only be seen after clearing of the hemorrhage.

CONCLUSION

Retinal yellowish-white arc ("arcus retinalis") is a useful clinical marker of sub-ILM hemorrhage with distinct OCT features that tends to disappear with time.

Spontaneous Resolution of Foveal Sub-internal Limiting Membrane Hemorrhage with Excellent Visual and Anatomical Outcome in a Patient with Acute Myeloid Leukemia

Sub-internal limiting membrane (sub-ILM) hemorrhage is a distinct type of retinal hemorrhage in which the blood accumulates between ILM and nerve fiber layer. Little is known about visual prognosis as well as ideal management of foveal sub-ILM hemorrhage in patients with acute leukemia. Herein, we presented a case of acute myeloid leukemia with foveal sub-ILM hemorrhage. Observation alone resulted in complete resolution of hemorrhage with good visual and anatomical outcome.

Bilateral and multiple sub-internal limiting membrane hemorrhages in a familial retinal arteriolar tortuosity patient by Valsalva-like mechanism: an observational case report

Background

Bilateral and multiple Valsalva-related sub-internal limiting membrane (ILM) hemorrhages in a familial retinal arteriolar tortuosity (FRAT) patient is rare, and we treated this patient by both observation and Neodymium yttrium aluminum garnet (Nd: YAG) laser membranotomy methods.

Case presentation

A 13-year-old female student presented with sudden visual loss and central scotoma in both eyes after running 800 m at the school gym. The examination revealed six sub-ILM hemorrhages with the biggest hemorrhage measuring approximately 1.5-disc diameters (DD) in the right eye and two sub-ILM hemorrhages with the biggest one measuring 5.5 DD in the left eye. The patient was diagnosed as having Valsalva retinopathy associated with FRAT. Nd: YAG laser membranotomy was performed at the biggest hemorrhages and the rest hemorrhages were treated with observation in both eyes. The visual acuity recovered to 20/16 in the right eye and 20/20 in the left eye. Epiretinal membrane (ERM) formation was observed in the left eye.

Conclusions

Nd: YAG laser could be considered for treating premacular hemorrhage in FRAT patient especially when a quick vision recovery was needed. This is the first reported case of a FRAT patient suffering from bilateral and multiple Valsalva-related sub-ILM hemorrhages which were treated by both observation and Nd: YAG laser treatment.

Different approaches in the management of macular hemorrhage: Case reports and a literature review

Introduction

Macular hemorrhages result in a sudden and profound loss of vision. The primary treatment modalities include observation, intravitreal injection of antiangiogenic drugs, neodymium-doped yttrium aluminum garnet hialoidotomy, intravitreal injection of gas with or without tissue plasminogen activator, as monotherapy or combined with surgery. In this paper, we report four cases of macular hemorrhages of different causes treated with different approaches, and we review the literature in this regard.

Case presentation

All four patients presented different causes of macular hemorrhage. The first case had a preretinal hemorrhage due to a Valsalva retinopathy and was treated with surgery. Case 2 had a multilevel macular hemorrhage due to a rupture of a retinal arteriolar macroaneurysm and was treated with pneumatic displacement, laser, and intravitreal ranibizumab. Case 3 presented an extensive subretinal hemorrhage due to a choroidal rupture after high-energy ocular trauma that was also successfully treated with surgery. The last case was a preretinal hemorrhage due to diabetic retinopathy managed with neodymium-doped yttrium aluminum garnet laser. Different treatment approaches were successfully performed in all cases with good outcomes.

Conclusion

There is an extensive range of options available for the management of macular hemorrhages, and the best option depends on the characteristics of each particular case. Proper and timely management of these diseases can achieve an excellent visual outcome, especially if the location of the hemorrhage is preretinal.

Sub-internal limiting membrane hemorrhage associated with Weil's disease

Purpose

Leptospirosis is a rare, typically tropical disease associated with water sources infected with rat urine. Symptoms can range from asymptomatic to a severe, deadly form known as Weil's disease, and ocular manifestations can arise. As global temperatures continue to rise, leptospirosis will become a larger problem worldwide. Here we describe the first case to our knowledge of foveal sub-internal limiting membrane (sub-ILM) hemorrhage due to Weil's disease.

Observations

A 56-year-old female presented with floaters and decreased vision to 20/200 in the right eye after being hospitalized for Weil's disease. Funduscopic examination and optical coherence tomography (OCT) demonstrated a foveal sub-ILM hemorrhage in the right eye. The patient was treated with pars-plana vitrectomy with internal limiting membrane removal and blood aspiration, and her best corrected visual acuity improved to 20/60.

Conclusions and Importance

Here we report the first case of sub-ILM hemorrhage following Weil's disease. Patients with leptospirosis and Weil's disease can develop retinal complications and therefore should be followed with fundoscopic eye examination after resolution of systemic symptoms. For those with retinal hemorrhages, OCT evaluation should be used to differentiate sub-hyaloid and sub-ILM hemorrhages.

Histopathological Changes and Clinical Outcomes following Intervention for Sub-Internal Limiting Membrane Haemorrhage

INTRODUCTION

Haemorrhage confined to the sub-internal limiting membrane (ILM) space can be associated with good visual recovery. There is controversy as to the best management of purely sub-ILM haemorrhage, which ranges from observation to immediate surgical intervention.

METHODS

We studied a retrospective case series of patients with sub-ILM haemorrhage who underwent vitrectomy with subsequent histological analysis of the removed ILM.

RESULTS

Sixteen patients underwent vitrectomy for sub-ILM haemorrhage. Five patients had underlying Terson syndrome, 6 had ruptured macro-aneurysms, and 5 had Valsalva retinopathy. Seven patients demonstrated cellular proliferation on the retinal surface of the ILM with staining for glial fibrillary acidic protein and cytokeratin 7, as well as CD68pg and Prussian blue. All but 1 of these cases were isolated from patients undergoing surgery >4 weeks following initial symptoms, the other presented at >2 weeks. Serial optical coherence tomography (OCT) was available in 8 patients; serial OCT in patients with delayed intervention demonstrated persistent inner retinal layer hyper-reflectance. Fourteen of 15 patients demonstrated symptomatic recovery and showed visual improvement with acuity ranging from -0.1 to 1.8 (mean 0.43) within 3 months of intervention (1 was lost to follow-up). The post-operative vision was 0.11 logMAR (mean; range -0.1 to 0.4) at 3 months in the group with intervention within 2 weeks of symptoms, and 0.9 logMAR (mean; range 0.0 to HM) in the group with delayed surgery.

CONCLUSIONS

Early surgical intervention for sub-ILM haemorrhage resulted in good visual outcomes; delayed surgery may lead to proliferative vitreoretinopathy-like changes on the inner retinal surface of the ILM, and untreated cases may demonstrate persistent inner retinal changes potentially limiting visual prognosis despite subsequent surgical intervention.

Pars plana vitrectomy with intraoperative optical coherence tomography for sub-internal limiting membrane fibrosis excision in a child with Terson syndrome: Surgical and pathological correlation

Purpose

To report the intraoperative optical coherence tomography (OCT)-guided surgery of a consolidated sub-internal limiting membrane (ILM) hemorrhage that developed into a sub-ILM fibrotic membrane in a child with a history of Terson syndrome.

Observations

A one year-old boy with a history of Terson syndrome due to a motor vehicle accident presented three months after trauma with a white feather-shaped membrane in the left macula. Preoperative OCT showed a preretinal hyperreflective tissue at the foveal center. The patient underwent pars plana vitrectomy. After separation of the posterior hyaloid, intraoperative OCT did not show any change in structural components. After peeling the ILM, the fibrotic membrane persisted. A bent 30-gauged needle was used to create a plane of dissection in the adherent sub-ILM membrane, which was then peeled with ILM forceps without complication. Post-operative OCT confirmed complete excision without evidence of macular edema. Pathology results indicated presence of fibrocellular tissue that contained hemosiderin, consistent with old organized hemorrhage as a component of the membrane.

Conclusion and importance

Sub-ILM hemorrhage may persist as a tautly adherent fibrotic membrane that can mimic the appearance of an epiretinal membrane or a chronic subhyaloidal hemorrhage during examination, especially in young children. Intraoperative OCT may aid in select complex macular surgery cases to better delineate the planes of dissection during sub-ILM fibrosis excision.

Recurrent pre-retinal haemorrhages associated with coagulation factor VII deficiency

The case concerns a 20 year-old woman with a sudden visual loss in her left eye. In the fundus examination, a focal pre-retinal haemorrhage was observed in the superior temporal vascular branch with accompanying vitreous haemorrhage. There was a favourable spontaneous outcome. Eighteen months later, she presented with a new visual loss in the same eye, showing a sub-hyaloid pre-macular haemorrhage that was satisfactorily drained by hyaloidotomy using a Nd-YAG laser. The patient had also presented with an upper digestive tract haemorrhage and menorrhagia. A haemostasis study was performed that showed a coagulation factor VII deficiency. This is a very uncommon disorder that has not been previously described in association with the appearance of pre-retinal haemorrhages.

Subinternal limiting membrane hemorrhage post-Ahmed glaucoma valve in vitrectomized eye

Glaucoma drainage devices are mostly used for refractory glaucoma. Early postoperative complications include flat anterior chamber, choroidal effusion, and suprachoroidal hemorrhage. An 8-year-old male patient with a prior history of vitreous surgery for traumatic vitreous hemorrhage, presented to us with angle recession glaucoma in his right eye. His intraocular pressure (IOP) was 44 mmHg despite maximum antiglaucoma medication. Ahmed glaucoma valve (AGV) surgery was performed to control his IOP. In the early postoperative period, the patient developed premacular subinternal limiting membrane (ILM) hemorrhage, which did not resolve even after 4 weeks. Vitreoretinal intervention involving removal of the thickened ILM and sub-ILM bleed had to be performed. To the best of our knowledge, no case has been reported with sub-ILM bleed post aqueous humor shunts. Here, we report a case of premacular sub-ILM bleed following AGV in vitrectomized eye.

[Laser membranotomy in the management of acute premacular hemorrhage : Case report and overview on the approach]

Acute premacular bleeding is often associated with vasoproliferative retinal changes, vascular anomalies or a Valsalva maneuver. The diagnosis is made during the funduscopic examination and can if necessary be confirmed with optical coherence tomography (OCT). This article presents a case example with a sub-inner limiting membrane (ILM)/sub-hyaloidal bleeding. Furthermore, we present various treatment options and give an overview on the use of the Nd:YAG laser for laser membranotomy as a minimally invasive treatment option with a low complication profile.

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.

Sub-inner limiting membrane hemorrhage in a patient with Terson syndrome

PURPOSE

To report a case of bilateral Terson Syndrome with sub inner limiting membrane hemorrhage associated with a rare finding: perimacular fold.

METHODS

The patient, a 34 years old female with aneurysmal subarachnoid hemorrhage and bilateral Terson syndrome was admitted to the Ophthalmology department, complaining of blurred vision. Core vitrectomy, hyaloid detachment, peeling of the ILM and aspiration of the sub inner limiting membrane hemorrhage was performed. Once the inner limiting membrane of the left eye was peeled off, we noticed a particular aspect: the perimacular fold.

RESULT

Although our patient suffered from a massive vitreous haemorrhage the postoperative outcome was favorable with a final best corrected visual acuity of 20/30.

CONCLUSIONS

In patients with billateral Terson syndrome we recommend early surgery, especially if the neurological status allows it, a good visual acuity being helpful for the neurophysical rehabilitation of the patient.

Valsalva Retinopathy in Twin-Pregnancy: A Case Report and Literature Review

Patient: Female, 21

Final Diagnosis: Valsalva retinopathy

Symptoms: Sudden visual loss due to twin-pregnancy

Medication: None

Clinical Procedure: Conservative treatment of valsalva retinopathy with good and careful prognosis

Specialty: Ophthalmology

Evolution of Leukemic Retinal Hemorrhages Documented by Spectral-Domain OCT and Color Fundus Photography

PURPOSE

Retinal hemorrhages are observed frequently in patients with leukemia. However, little is known about the impact and natural history of these hemorrhages. The purpose of this study was to describe leukemic retinal hemorrhages using multimodal imaging and to monitor their evolution longitudinally.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 11 eyes of 7 symptomatic leukemic patients with posterior segment hemorrhages.

METHODS

Single-center study performed at the Johns Hopkins Hospital. Symptomatic leukemic patients with posterior segment hemorrhages underwent serial dilated fundus examinations. The hemorrhages were documented longitudinally with color fundus photographs and spectral-domain (SD) OCT.

MAIN OUTCOMES MEASURES

Microanatomic locations of leukemic retinal hemorrhages and their impact on vision and evolution over time.

RESULTS

A total of 7 patients (71.4% men; 57.1% white, 28.6% black, and 14.3% Hispanic) were included, with 11 eyes showing posterior segment hemorrhages. The median age at presentation was 49.8 years. All patients had intraretinal hemorrhages; these involved the vitreous and sub-internal limiting membrane (ILM) space in 1 and 3 patients, respectively. The median total follow-up duration was 4.0 months. At the final follow-up visits, 4 of 6 patients showed complete resolution of hemorrhages on examination and color fundus photographs. The final SD-OCT images of all patients did not show any retinal thinning, disruption of the ellipsoid zone, disorganization of the retinal layers, intraretinal fluid, or subretinal fluid.

CONCLUSIONS

Symptomatic leukemic retinal hemorrhages are associated with anemia and thrombocytopenia. These hemorrhages, including visually significant central sub-ILM hemorrhages, tend to be self-limiting and resolve within a few months with treatment of the underlying disease.

A unique case of valsalva retinopathy in a conch blower

Purpose

Valsalva hemorrhagic retinopathy is a form of preretinal hemorrhage that develops after a valsalva maneuver, leading to rupture of the superficial retinal capillaries. Here, we report a case of valsalva retinopathy secondary to blowing a conch, the first case report of its kind. The patient blew conch, which was part of his daily ritual to pray to God as he was a Hindu priest.

Observations

A 58-year-man developed an acute decrease in vision to 5/60 in his right eye after blowing the conch while performing “Puja,” which is the act of praying to God in Hindu culture. Ophthalmoscopy showed a fresh preretinal hemorrhage over the macula in his right eye. YAG laser membranotomy was performed, and his vision returned to 6/6.

Conclusions and importance

Conch “Shankha” is a religious instrument used routinely in Hindu culture. Its mechanism is very much similar to that of a wind instrument. This is the first case report of valsalva retinopathy caused by conch blowing.

Bilateral Prefoveal Sub-Internal Limiting Membrane Hemorrhage in Autoimmune Hemolytic Anemia

Severe anemia can cause multilayered retinal hemorrhages. A 65-year-old woman noted "red spheres" in the central vision of both eyes during a hospital admission for autoimmune hemolytic anemia. Examination revealed extensive multilayered retinal hemorrhages, including bilateral foveal preretinal hemorrhage. Spectral-domain optical coherence tomography localized the preretinal blood to the sub-internal limiting membrane (ILM) space. Various options are available for management of such hemorrhage, including observation for spontaneous resolution, YAG laser membranotomy, or pars plana vitrectomy with ILM peeling. In the authors' patient, the size of the sub-ILM hemorrhage spontaneously improved during the course of 1 month, with both subjective and objective visual improvement. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1151-1153.].

CHEMOTHERAPEUTIC NADIR-ASSOCIATED RETINOPATHY

PURPOSE

To describe subinternal limiting membrane hemorrhage as a retinal complication of chemotherapy nadir in a patient with leukemia.

METHODS

Case report.

RESULTS

A 23-year-old man presented with bilateral subinternal limiting membrane hemorrhages in both eyes as a manifestation of thrombocytopenia secondary to chemotherapy treatment for acute myeloid leukemia.

CONCLUSION

Chemotherapeutic nadir-associated retinopathy may present with sub-internal limiting membrane hemorrhages most probably secondary to thrombocytopenia.

THE "DOUBLE-RING SIGN" IN ANEMIC RETINOPATHY EVALUATED BY SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To describe three cases of anemic retinopathy who demonstrated premacular hemorrhage with a "double-ring sign."

METHODS

Three patients with anemia were found to have a premacular hemorrhage and a double-ring sign either at presentation or after laser membranotomy. Spectral domain optical coherence tomography was performed to ascertain the level of the hemorrhage.

RESULTS

To the best of the author's knowledge, there is no report of a double-ring sign in anemic retinopathy. In two eyes, spectral domain optical coherence tomography revealed that the double-ring sign consisted of an outer subhyaloid and inner sub-internal limiting membrane hemorrhage. However, in the third case, spectral domain optical coherence tomography confirmed that the double-ring sign consisted of a sub-internal limiting membrane hemorrhage only.

CONCLUSION

Spectral domain optical coherence tomography evaluation is essential to determine the level of hemorrhage in premacular hemorrhage with a double-ring sign. It may not always indicate concurrent occurrence of a subhyaloid and sub-internal limiting membrane hemorrhage, as was previously believed.

YAG Laser Membranotomy for Subinternal Limiting Membrane Hemorrhage

PURPOSE

To report the use of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser internal limiting membranotomy to successfully treat the first reported case of subinternal limiting membrane (sub-ILM) hemorrhage that developed after coil embolization of a cerebral aneurysm.

CASE REPORT

A 59-year-old Korean woman visited our clinic complaining of central scotoma in her left eye, which developed shortly after stent-assisted coil embolization of an unruptured internal carotid artery aneurysm. Fundus examination revealed a sub-ILM hemorrhage in her left eye, and after 2 days, a Nd:YAG laser membranotomy was performed with a single 4.5-mJ burst. There was a marked reduction in the sub-ILM hemorrhage 1 day after Nd:YAG laser membranotomy, and after 1 month, her best-corrected visual acuity improved to 20/20, with complete resolution of the sub-ILM hemorrhage.

CONCLUSIONS

Sub-ILM hemorrhage can develop after coil embolization of a cerebral aneurysm, and Nd:YAG laser internal limiting membranotomy can be a useful noninvasive treatment alternative to surgical intervention.

Prevalence of Diabetic Retinopathy and Vision Loss in the Beijing Eye Study: the Potential Role of the Cerebrospinal Fluid Pressure

In the Beijing Eye Study, a population-based study carried out in 2001, 2006, and 2011, prevalence of diabetic retinopathy (DR) was 2.9 ± 0.3 % (95 % confidence interval 2.3, 3.5) per individual in 2011. Correspondingly, only 1.1 % of blindness and 0.8 % of visual impairment were caused by DR in East Asia. As in other populations, prevalence, severity, and 10-year incidence of DR were associated with higher levels of HbA1c, higher blood glucose concentration, longer known duration of diabetes, lower educational level, and higher blood pressure. Interestingly, the presence, severity, and 10-year incidence of DR were additionally correlated with higher estimated cerebrospinal fluid pressure and shorter ocular length. Higher cerebrospinal fluid pressure may lead to higher retinal vein pressure and subsequently higher retinal capillary blood pressure increasing fluid and blood extravasation. Shorter axial length or hyperopia may be associated with higher intraocular concentration of cytokines. Aging of the society, improvements in medical infrastructure, and lifestyle changes may profoundly increase prevalence of, and burden by, DR in China in the future.

Valsalva-Like Retinopathy Secondary to Pancytopenia following Induction of Etoposide and Ifosfamide

Etoposide and ifosfamide are chemotherapeutic agents used frequently in the treatment of sarcomas and hematologic malignancies. Ocular side effects are rarely reported. We describe a case of a patient on etoposide and ifosfamide who presented with unilateral vision loss, anemia, and thrombocytopenia. The patient was found to have a large subinternal limiting membrane hemorrhage in the right eye that is thought to be related to his anemia and thrombocytopenia. The hemorrhage resolved spontaneously after 10 days. This case illustrates how bone marrow suppression by chemotherapeutic agents may indirectly contribute to retinal hemorrhages resulting in at least transient vision loss.

Late spectral-domain optical coherence tomography findings in sub-internal limiting membrane hemorrhage

PURPOSE

To report spectral-domain optical coherence tomographic (OCT) findings during the natural history of a sub-internal limiting membrane (sub-ILM) hemorrhage.

METHODS

Observational case report of a 20-year-old man with myeloid acute leukemia who presented a spontaneous resolution of a premacular hemorrhage, which was demonstrated by OCT. During the 12-month follow-up, periodic ophthalmologic and OCT examinations were performed.

RESULTS

A premacular hemorrhage was revealed in fundus examination, and spectral-domain OCT demonstrated a highly hyperreflective band just above the premacular hemorrhage consistent with the ILM. At 6-month follow-up, the macula was free of blood. The OCT scans after spontaneous resolution of the hemorrhage showed a thickened hyperreflective membrane (ILM) and a prominent hyporeflective premacular cavity. Six months later, this premacular cavity had resolved.

CONCLUSION

These late OCT findings in sub-ILM hemorrhage have not been described in spontaneous evolution and confirm the sub-ILM location of a premacular hemorrhage.

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.

Sub-internal limiting membrane hemorrhage treated with intravitreal tissue plasminogen activator followed by octafluoropropane gas injection

Sub-internal limiting membrane (sub-ILM) hemorrhage is a relatively rare disease which is associated with different etiologies and often leads to loss of visual acuity. We report two cases of sub-ILM hemorrhage, both confirmed by optical coherence tomography (OCT) and treated with an intravitreal injection of tissue plasminogen activator (tPA) followed by an octafluoropropane (C₃F₈) pneumopexy and a strict postoperative prone positioning. The hemorrhage was totally resolved and complete visual recovery was achieved in both cases. We found tPA hemolysis with C₃F₈ pneumopexy to be a safe and effective method for treating sub-ILM hemorrhage.

[Premacular hemorrhage treatment with Nd:YAG laser: a clinical case]

INTRODUCTION

To report a case of premacular hemorrhage treated with Neodymium (Nd):YAG laser puncture.

CASE REPORT

A 54 year-old Caucasian female was seen in the emergency department with complaints of sudden loss of vision in her right eye (RE), detected on the previous day. The best-corrected visual acuity (BCVA) in the RE was reduced to light perception, and fundoscopy evidenced a large and dense premacular hemorrhage. An Nd:YAG laser puncture was performed that day to drain the hemorrhage into the vitreous cavity. The intravitreal hemorrhage cleared in about 1 month, and the BCVA of the RE was 20/25 after 3 months.

Macular hole secondary to Valsalva retinopathy after doing push-up exercise

Background

Valsalva retinopathy and traumatic macular hole are common conditions, but macular hole secondary to Valsalva retinopathy is rarely reported.

Case presentation

A 34-year-old healthy man suffered Valsalva retinopathy after doing push-up exercise. During his follow-up visits, the best-corrected visual acuity (BCVA) measurements, fundus examinations and spectral-domain optical coherence tomography (SD-OCT) tests were performed. Three months later, the premacular hemorrhage was noticeably absorbed with an improvement of visual acuity. SD-OCT showed a lamellar macular hole with intact but thickened internal limiting membrane (ILM) with vitreal tractions on surface of the macular. Nine months after the first visit, his vision acuity was 20/25. The fundus examination showed a complete absorption of the macular hemorrhage. SD-OCT showed that the lamellar macular hole has enlarged, with thickened ILM on the surface. Seventeen months after the onset, the BCVA, fundus examination results and OCT findings were stable.

Conclusions

Macular hole secondary to Valsalva retinopathy had been rarely reported and its mechanism needs further understanding. SD-OCT can be used to observe the evolvement of Valsalva retinopathy.