Visual Outcome of Non-traumatic Dense Vitreous Hemorrhage in Patients without Diabetes: Single Center Case Series

Purpose

Dense vitreous hemorrhage is a vision-threatening disease with varied clinical manifestations. Herein, we aimed to evaluate its causes and outcomes in patients without diabetes.

Methods

A retrospective cohort including 60 eyes from 60 patients with an initial diagnosis of non-traumatic fundus-obscuring dense vitreous hemorrhages and without diabetes was recruited. The relevant medical records from January 2013 to December 2019 were reviewed and analyzed. We classified patients into the following four groups, depending on the underlying cause of dense vitreous hemorrhage: eight cases in the age-related macular degeneration (AMD) group, four cases in the posterior vitreous detachment group, 20 cases in the Tear group, and 28 cases in the Vascular group.

Results

The most common cause of dense vitreous hemorrhage was retinal vascular obstructive disease (46.7%); the AMD group showed the worst prognosis. The extent of best corrected visual acuity change was significantly better in patients who underwent vitrectomy compared to those receiving conservative treatment; best corrected visual acuity change (logMAR) was 1.62±0.57 and 1.06±0.88 in the surgical and non-surgical groups, respectively (p=0.007, Student t-test).

Conclusions

Retinal vascular disease is the most common cause of vitreous hemorrhages, and surgical treatments have a better visual outcome than non-surgical treatments.

Traumatic terson syndrome with a peculiar mass lesion and tractional retinal detachment: a case report

BACKGROUND

To report a case with bilateral Terson syndrome presented with a unique mushroom-like mass lesion on the optic disc along with proliferative vitreoretinopathy and tractional retinal detachment.

CASE PRESENTATION

A 33-year-old man was injured during a traffic accident and had diffuse brain swelling and intraocular hemorrhage. Poor vision in both eyes was noted after the patient regained consciousness. B-scan ultrasonography showed extensive vitreous opacity with a posterior vitreous detachment and without obvious retinal detachment. Vitrectomy was performed in both eyes five months after the accident. After clearing up the vitreous opacity, a peculiar pigmented mushroom-like mass lesion was noted in the posterior pole and had severe adhesion to the underneath optic disc. Extensive multilayered peripapillary epiretinal membrane was found covering the posterior pole and led to tractional retinal detachment around the macula. The mass was presumed to be an organized vitreous hemorrhage originated from the optic disc. The extensive and adherent epiretinal membrane together with the mass lesion were removed as much as possible and silicon oil was injected for tamponade. However, in the right eye, the retina redetached under silicon oil, whereas in the left eye, his vision improved to 20/100.

CONCLUSIONS

Terson syndrome usually has a favorable prognosis but may be complicated by proliferative vitreoretinopathy and tractional retinal detachment. Careful monitoring is warranted and early vitrectomy should be considered in cases suspecting additional pathologies.

Bilateral vitrectomy in patients with proliferative diabetic retinopathy-characteristics and surgical outcomes

PURPOSE

Comparing characteristics and outcomes of patients with bilateral proliferative diabetic retinopathy (PDR) undergoing concurrent and sequential vitrectomy.

METHODS

Patients having bilateral vitrectomy were classified into concurrent (requiring bilateral surgery simultaneously) and sequential (indicating vitrectomy in one eye later) groups. Clinical characteristics and outcomes were compared, and correlation between the first and second-operated eyes was analyzed.

RESULTS

One hundred eight and 126 eyes were in the concurrent and sequential groups, respectively. The sequential group was older (50 vs. 45 years, P = 0.017), had less retinal detachment (54 vs. 77%, P < 0.001), and better visual outcomes (0.79 vs. 1.30, P = 0.021), especially the second-operated eyes. The concurrent group had weaker correlations of disease severity (phi coefficient: 0.36 vs. 0.61) and post-operative visual acuity (r: 0.12 vs. 0.34) between the first- and second-operated eyes than the sequential group. Prior intravitreal injection of anti-vascular endothelial growth factor (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.15-0.86, P = 0.025) predicted better outcomes, while post-operative neovascular glaucoma predicted worse outcomes (OR 6.5, 95% CI 1.7-27.9, P = 0.008).

CONCLUSIONS

PDR patients requiring surgery concurrently were younger and had more severe diseases and worse outcomes. However, poor outcomes in the first eye did not predict similar outcomes in the second eye.

Retinal vasculitis following intravitreal pegcetacoplan administration

Purpose

To describe a case of retinal vaso-occlusive vasculitis with associated lid edema and conjunctivitis following intravitreal pegcetacoplan administration in a patient with geographic atrophy (GA).

Observation

A 78 year old Caucasian woman presented with complaints of lid edema, conjunctival injection, loss of vision, and mild ocular discomfort eleven days after receiving an intravitreal pegcetacoplan injection in the left eye for geographic atrophy. Visual acuity on presentation was decreased to 20/400 from 20/200 previously in that eye. Eyelid edema and conjunctival injection were present with minimal anterior chamber reaction. Dilated fundus examination revealed hemorrhages throughout the retina and signs of retinal vasculitis. The patient subsequently developed hyphema and vitreous hemorrhage. Laboratory evaluations for common infectious and inflammatory causes including aqueous and vitreous cultures for bacteria and Herpes simplex PCR were normal or negative. A delayed hypersensitivity to pegcetacoplan was suspected and was treated with topical, oral subconjunctival and intravitreal steroids.

Conclusion

This index report illustrates a case of retinal vaso-occlusive vasculitis associated with intravitreal pegcetacoplan associated with lid edema and conjunctival injection and subsequent hyphema and vitreous hemorrhage. Therapy with steroids topically, systemically, periocularly and intravitreally were used to treat the inflammatory process and prevent further visual loss.

Postoperative vision loss due to bilateral vitreous hemorrhage after robot-assisted laparoscopic hysterectomy: A case report

Purpose

To report a case of bilateral vitreous hemorrhage (VH) resulting in postoperative vision loss (POVL) after robot-assisted laparoscopic hysterectomy in a 71-year-old female patient.

Observations

At initial presentation, best-corrected visual acuity was hand motion at 20 cm in the right eye and 20/666 in the left eye. VH in both eyes and preretinal hemorrhage in the left eye was observed. As the hemorrhage gradually resolved, a full-thickness macular hole was discovered in the right eye, for which the patient did not agree with a surgical treatment.

Conclusions and importance

This report describes a rare incidence of bilateral VH as a cause of POVL after non-ophthalmic surgery, which may be related to Trendelenburg positioning, CO2 pneumoperitoneum, and a long surgical duration. Given that POVL can cause severe visual impairment, consultation with ophthalmologists is crucial.

Proliferative Sickle Cell Retinopathy: Outcomes of Vitreoretinal Surgery

PURPOSE

To report the clinical presentation and outcomes in patients who underwent surgery for proliferative sickle cell retinopathy (PSCR).

DESIGN

Retrospective, consecutive case series.

SUBJECTS

All patients who underwent vitreoretinal surgery for complications secondary to PSCR between January 1, 2014, and December 31, 2021, at a university referral center.

METHODS

Retrospective consecutive case series.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), single operation anatomic success rate.

RESULTS

The study included 65 eyes of 61 patients. Disease distribution included 24 (44.4%) eyes with hemoglobin SC disease, 14 (25.9%) with hemoglobin SS disease, 13 (24.1%) with sickle cell trait, and 3 (5.6%) with sickle cell-β thalassemia. Preoperative transfusion was not performed in any study patients. Regional anesthesia with monitored anesthesia care (RA-MAC) was utilized in 58 (89.2%) eyes and general anesthesia in 7 (10.8%). In eyes that underwent surgery for retinal detachment (RD; N = 52) the rate of single operation anatomic success was 72.4% with combined scleral buckling/pars plana vitrectomy (SB/PPV; N = 29) compared with 47.8% with PPV alone (N = 23; P = 0.07). Mean BCVA at the last follow-up examination was 1.27 (20/372) in the SB/PPV group and 1.05 (20/226) in the PPV group (P = 0.48). In all SB cases, an encircling band was utilized and there were no known cases of anterior segment ischemia. All eyes that had surgery for vitreous hemorrhage (N = 13) underwent PPV with endolaser and mean BCVA improved from 1.67 (20/944) preoperatively to 0.45 (20/56) at last follow-up examination (P < 0.001). Mean preoperative BCVA, indication for surgery, single operation success rate, and mean BCVA at last follow-up examination did not differ based on sickle cell disease type (P > 0.05).

CONCLUSIONS

In patients with RD, SB/PPV achieved slightly higher rates of single operation anatomic success compared with PPV alone. Visual acuity outcomes were similar in the 2 groups. The majority of patients received RA-MAC anesthesia and preoperative transfusions were not performed. There were no cases of postoperative anterior segment ischemia. Hemoglobin SC disease was the most common disease type in the current study and surgical outcomes did not differ between sickle cell disease types.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Proliferative diabetic retinopathy: Role of bevacizumab in decreasing the occurrence of vitreous hemorrhage after panretinal photocoagulation

PURPOSE

To investigate the beneficial effect of bevacizumab injection one week prior to panretinal photocoagulation (PRP) on the occurrence of vitreous hemorrhage (VH) following PRP in high-risk proliferative diabetic retinopathy (PDR).

METHODS

This was a case-control pilot study conducted on two groups: an anti-VEGF treatment group, treated with bevacizumab injection one week prior to the first PRP session, and a control group of treatment-naive PDR patients who underwent PRP treatment and were not given an intravitreal bevacizumab injection, consecutively recruited. In both groups, a complete ophthalmological examination was conducted prior to PRP and at 4, 9, and 16 weeks following treatment. The primary endpoint studied was the occurrence of VH.

RESULTS

The control group included 69 patients (mean age 63±12.3 years) with high-risk PDR who received PRP treatment only, and the anti-VEGF treatment group included 67 patients (mean age 63.13±10.3 years). None of the demographic variables or comorbidities showed any significant difference between the two groups. The number of PRP sessions was not significantly correlated to the occurrence of VH in either of the groups (P=0.167). Vitreous hemorrhage within 16 weeks following laser treatment occurred in 10 patients (14.5%) in the control group and in only 3 patients (4.5%) in the anti-VEGF group (P=0.047).

CONCLUSION

Our case-control pilot study demonstrates that a bevacizumab injection preceding the initial PRP session might be beneficial in reducing the occurrence of VH in the first 16 weeks following PRP.

Refining vitrectomy for proliferative diabetic retinopathy

Pars plana vitrectomy (PPV) is the main treatment modality for patients with severe diabetic retinopathy. With the development of systems for microincision, wide-angle viewing, digitally assisted visualization, and intraoperative optical coherence tomography, contemporary PPV for diabetic retinopathy has been performed on a wider range of indications than previously considered. In this article, we reviewed, in conjunction with our collective experiences with Asian patients, the applications of new technologies for PPV in eyes with diabetic retinopathy and highlighted several important procedures and entities not generally reiterated in the literature, in order for vitreoretinal surgeons to optimize their approaches when facing the challenges imposed by the complications in diabetic eyes.

Photocoagulation Up to Ora Serrata in Diabetic Vitrectomy to Prevent Recurrent Vitreous Hemorrhage

PURPOSE

To evaluate the role of performing photocoagulation up to ora serrata during vitrectomy in preventing recurrent vitreous hemorrhage (VH) in patients undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR).

METHODS

This retrospective, nonrandomized study included 60 eyes from 60 patients who had undergone PPV for VH due to PDR. These patients were divided into two groups: group 1, those who underwent photocoagulation up to ora serrata using the scleral indentation technique during surgery; and group 2, those who did not undergo scleral indentation when photocoagulation and underwent photocoagulation up to vortex veins. Their hospital records were analyzed to investigate the recurrence rate of VH, the time until recurrence of VH after surgery, logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) measured before surgery and at 1, 2, and 3 years after surgery, and the occurrence of complications such as neovascular glaucoma (NVG) during follow-up.

RESULTS

Group 1 exhibited lower recurrence rate of VH (2 of 30 [6.7%] vs. 10 of 30 [33.3%], p = 0.01) and lower occurrence of postoperative NVG (2 of 30 [6.7%] vs. 8 of 30 [26.7%], p = 0.038) compared with group 2. There were no statistically significant differences in logMAR BCVA measured at 1, 2, and 3 years between the two groups (at 1 year: 0.54 ± 0.43 vs. 0.54 ± 0.44, p = 0.954; at 2 years: 0.48 ± 0.47 vs. 0.55 ± 0.64, p = 0.235; at 3 years: 0.51 ± 0.50 vs. 0.61 ± 0.77, p = 0.200). Logistic regression analysis showed that among several factors that could affect recurrence rate of VH, only range of photocoagulation performed was a statistically significant factor (odds ratio, 0.119; 95% confidence interval, 0.022-0.659; p = 0.015).

CONCLUSIONS

Photocoagulation treatment over a wider range with scleral indentation could be a beneficial adjunct procedure for preventing postoperative recurrent VH following diabetic vitrectomy.

Anterior chamber fluorescein leakage in a child with intraocular pressure elevation and vitreous hemorrhage

Purpose

To report a case of a child with neovascular and ghost cell glaucoma in the setting of previously treated vitreous hemorrhage with unique fluorescein leakage from abnormal iris vessels ultimately preventing successful fluorescein angiography.

Observations

A 3-year-9-month-old female with a medical history of very high-risk B-cell acute lymphoblastic leukemia presented with eye pain and was noted to have a complete vitreous hemorrhage and intraocular pressure elevation in the right eye which was refractory to maximum medical therapy and vitrectomy. Following vitreous hemorrhage resolution, an examination under anesthesia with fluorescein angiography was found to have diffuse leakage of fluorescein into the anterior chamber, presumably due to the active iris neovascularization. This anterior chamber fluorescein signal prevented visualization of the retinal vasculature. The patient was diagnosed with mixed mechanism glaucoma (neovascular and ghost cell) due to a resolved vitreous hemorrhage in the setting of a presumed prior ischemic event.

Conclusions and Importance

We report a case of an unsuccessful fluorescein angiogram in the setting of anterior chamber fluorescein leakage due to active iris neovascularization, and review considerations for the differential diagnosis and useful diagnostic tests in this clinical scenario.

Systemic Risk Factors for Vitreous Hemorrhage Secondary to Polypoidal Choroidal Vasculopathy

INTRODUCTION

It remains unclear whether systemic factors are associated with an increased risk of vitreous hemorrhage (VH) secondary to polypoidal choroidal vasculopathy (PCV), and there is no method to predict the possibility of VH occurrence in patients with PCV. This study aimed to investigate and visualize systemic risk factors for VH in patients with PCV.

METHODS

Data on the sex, age, history of systematic diseases, best-corrected visual acuity, intraocular pressure, and laboratory data of patients with PCV were collected from the medical record system. Univariate and multivariate binary logistic regression analyses were applied to investigate independent risk factors for VH in patients with PCV. Receiver operating characteristic analysis and nomograms were used to visualize the independent risk factors.

RESULTS

The patient population comprised 115 patients with VH secondary to PCV and 181 patients with PCV without VH. Binary logistic regression analyses showed that higher white blood cell count [WBC; odds ratios (OR) 1.247], higher aspartate aminotransferase/alanine aminotransferase ratio (AST/ALT; OR 2.339), and longer activated partial thromboplastin time (APTT; OR 1.196) were independent risk factors of VH in patients with PCV. Integrated application of APTT, AST/ALT, and WBC as markers showed the best performance for distinguishing patients with VH, with an area under the curve of 0.723. The nomogram was created for doctors to calculate the possibility of VH in a patient with PCV.

CONCLUSIONS

Higher WBC, higher AST/ALT, and longer APTT are independent serum risk factors of VH secondary to PCV, which may shed light on VH prevention in patients with PCV.

[Medico-surgical management of intravitreal hemorrhage in diabetic patients]

Vitreous hemorrhage (VH) is the main complication of proliferative diabetic retinopathy and remains the primary indication for vitrectomy in diabetic patients. The objective of our study is to compare our medical and surgical management of VH with data from the literature and to report the functional results of our series. We studied a series of 284 cases collected over 2 years in two tertiary care centers. In our series, 90.1% of patients had type 2 diabetes, and 70% had glycosylated hemoglobin greater than 7.5%. On fundus examination, 35.2% presented with stage 1 VH, 42.6% with stage 2, 3.6% with stage 3 and 5.2% with stage 4. Ocular ultrasound performed when fundus exam was difficult diagnosed an associated tractional retinal detachment in 8.8% of patients. Medical treatment was sufficient in 77.8% of patients, while 22.2% of our patients underwent vitrectomy, argon laser endophotocoagulation and postoperative anti-VEGF injection. Peeling of tractional fibrovascular membranes and or associated epiretinal membranes was performed in 69.8% of cases. Iatrogenic tears were noted in 11.8% of patients. In this study, 31.5% of patients underwent intraocular gas tamponade, while 23.8% of cases underwent silicone oil tamponade. Postoperative visual acuity improved by at least 2 lines in 60% of our patients, and the VH recurred in 24.2% of cases after surgery.

Clinicopathologic analysis of a case of small cell lung carcinoma metastatic to the retina

Purpose

Tumor metastases to the retina are a relatively rare occurrence. We report a unique case of retinal metastasis of a systemic malignancy with clinical and histopathologic correlations.

Observations

A 62-year-old female with a history of stage IV small cell carcinoma of the lung (SCC, status post chemotherapy and maintenance immunotherapy) presented with hand motions vision and vitreous hemorrhage, status post prior vitrectomy and biopsy that was non-diagnostic. She was found to have unilateral retinal metastatic tumor and underwent a repeat vitrector-assisted biopsy which confirmed the diagnosis. The eye became blind and painful due to recurrent non-clearing vitreous hemorrhage and ghost cell glaucoma and was enucleated. Detailed histopathologic analysis of the globe confirmed small cell carcinoma metastatic to the retina and vitreous cavity and sparing the choroid.

Conclusions and importance

This case demonstrates the importance of maintaining a high index of suspicion for metastasis in patients with a known history of malignancy who present with new vitreoretinal lesions.

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience

BACKGROUND

Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept.

METHODS

All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05.

RESULTS

A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001).

CONCLUSIONS

TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Tractional Retinal Detachment in Eyes with Vitreous Hemorrhage and Proliferative Diabetic Retinopathy and Posterior Vitreous Detachment in Fellow Eye

Purpose

To predict the presence of tractional retinal detachment (TRD) in eyes with dense vitreous hemorrhage (VH) and proliferative diabetic retinopathy (PDR) by evaluating the status of posterior vitreous detachment (PVD) in fellow eyes using optical coherence tomography (OCT).

Methods

A total of 44 eyes from 22 patients who underwent vitrectomy due to dense VH with PDR were enrolled. Using OCT, the PVD status in the fellow eye was divided into two groups (incomplete and complete PVD). The incomplete PVD group included eyes without PVD and eyes with partial PVD. B-scan ultrasonography (USG) was performed on eyes with dense VH to evaluate the presence of TRD. Both OCT and B-scan images were reviewed by four ophthalmologists (two novices and two experienced), and the inter-observer agreement was evaluated.

Results

There was a difference in the inter-observer agreement regarding the presence of TRD in eyes with dense VH evaluated by B-scan between novice and experienced ophthalmologists (novice, kappa = 0.421 versus experienced, kappa = 0.814), although there was no difference between novice and experienced ophthalmologists in the inter-observer agreement regarding the status of PVD in the fellow eye evaluated by OCT (novice, kappa = 1.000 versus experienced, kappa = 1.000). All observed TRD during vitrectomy occurred in eyes with incomplete PVD in the fellow eye. Logistic regression analysis revealed a statistically significant relation between TRD and the age of the patient (odds ratio [OR] = 0.874, p = 0.047), and between TRD and incomplete PVD in the fellow eye evaluated by OCT (OR = 13.904, p = 0.042).

Conclusion

Evaluation of the PVD status in the fellow eye using OCT may be a useful predictor for detecting the presence of TRD in eyes with dense VH and PDR.

Combined hamartoma of the retina and retinal pigment epithelium: A case report

BACKGROUND

Combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) is a rare congenital benign tumor which is commonly monocular. Typical CHRRPE comprises slightly raised lesions at the posterior pole, with proliferation membrane often leading to vascular distortion. In severe cases, macular edema, macular hole, retinal detachment or vitreous hemorrhage may occur. Patients with atypical clinical manifestations are prone to misdiagnosis by inexperienced ophthalmologists.

CASE SUMMARY

A 33-year-old man reported onset of right eye blurred vision for one week prior. Anterior segment and intraocular pressure were normal in both eyes. Left eye fundus photography was normal. Right eye ophthalmoscopy showed vitreous hemorrhage and off-white raised retinal lesions below the optic disc. Proliferative membranes on the lesion surfaces resulted in superficial retinal detachment and tortuosity and occlusion of peripheral blood vessels. A horseshoe-like tear in the temporal periphery was surrounded by retinal detachment. Optical coherence tomography revealed retinal thickening at the focal site with structural disturbance indicated by high reflectance. Right eye ultrasound showed retinal thickening at the lesion, stretching and uplifting of the proliferative membrane, with moderately patchy echo at the optic disc edge. Cytokines and antibodies were detected in vitreous fluids during the operation to rule out other diseases. Fundus fluorescein angiography (FFA) at postoperative follow-up led to final diagnosis of CHRRPE.

CONCLUSION

FFA is helpful in diagnosing retinal and retinal pigment epithelial combined hamartoma. In addition, other cytokine and etiological tests facilitate further differential diagnosis to rule out other suspected diseases.

Analysis of Posterior Vitreous Detachment and Development of Complications Using a Large Database of Retina Specialists

PURPOSE

To examine the incidence of complications after posterior vitreous detachment (PVD) through an extended follow-up period and to identify patient-specific factors associated with a greater incidence of complication.

DESIGN

Multicenter, retrospective observational study.

PARTICIPANTS

Eyes with acute PVDs between 2015 and 2019 were identified through the Vestrum Health database.

METHODS

Complications (vitreous hemorrhage, retinal break, and retinal detachment) were evaluated after acute PVD at presentation and throughout the 6-month follow-up period.

MAIN OUTCOME MEASURES

Rate of complications throughout the 6 month follow-up period after PVD and odds of complications by patient-specific factors.

RESULTS

A total of 9635 eyes were included. The rate of any complication was 25.0%, isolated vitreous hemorrhage was 13.1%, retinal breaks without detachment was 16.0%, and retinal detachment was 4.2%. The majority of each complication was noted at presentation; however, 8.0% of isolated vitreous hemorrhages, 19.2% of retinal breaks without detachment, and 25.8% of retinal detachments were first noted within the 6-month follow-up period. Men experienced a significantly higher rate of any complication than women (30.0% versus 21.7%, P < 0.001), as well as retinal breaks and retinal detachments at both presentation and within 6-month follow-up. Patients with pseudophakia experienced significantly higher rates of delayed retinal detachment than phakic eyes (odds ratio, 1.85 [1.13, 3.04], P = 0.01). Among eyes with lattice/peripheral retinal degeneration, 44.2% experienced any complication throughout the clinical course. The presence of a retinal break in the fellow eye and retinal detachment in the fellow eye was associated with a significantly increased rate of any complication at any time point (retinal break: P < 0.0001; retinal detachment: P = 0.02), as well as each individual complication within the 6 month follow-up period. Among eyes with vitreous hemorrhage at presentation, 42.0% had a concurrent or delayed retinal break and 10.5% had concurrent or delayed retinal detachments.

CONCLUSIONS

A clinically significant proportion of PVD-related complications are detected late, warranting extended follow-up, especially in higher-risk groups such as men, pseudophakic eyes, eyes with lattice/peripheral retinal degeneration, and eyes with a history of retinal breaks or detachment in the fellow eye.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Typical and atypical clinical presentations of X-Linked retinoschisis: A case series and literature review

X-linked retinoschisis (XLRS) is an X-linked inherited retinal dystrophy characterized by mild-to-severe visual impairment, splitting of the retinal layers, and a reduction in the dark-adapted b-wave amplitude on the electroretinogram. Typical clinical features include macular and peripheral schisis. Relatively common features reported include rhegmatogenous or tractional retinal detachment, vitreous hemorrhage, retinal pigment epithelial changes, vitreous veils, and various retinal vascular abnormalities with or without exudation. Macular hole and macular folds are atypical presentations of XLRS, along with several other rare findings. Here, we report 4 cases of XLRS with atypical clinical presentations and review the literature on XLRS, with a focus on the variable clinical features of this condition.

Late Vitreoretinal Complications of Regressed Retinopathy of Prematurity: Retinal Break, Vitreous Hemorrhage, and Retinal Detachment

PURPOSE

To investigate late vitreoretinal complications and visual outcomes in patients with regressed retinopathy of prematurity (ROP) with or without prior treatment.

DESIGN

International, multicenter, noncomparative retrospective case series.

PARTICIPANTS

We analyzed 264 eyes of 238 patients from 13 centers worldwide who developed vitreoretinal complications (retinal detachment [RD], vitreous hemorrhage [VH], or retinal break) ≥ 2 years after resolution of acute ROP.

METHODS

Each participant was assigned to 1 of 3 groups (the RD, VH, and retinal break groups) according to their primary diagnosis. The average age at presentation, visual acuities, refractive error, axial length, gestational age, birth weight, acute ROP classification, prior treatments for acute ROP, postoperative visual acuity (VA), and concomitant eye conditions in the 3 groups were documented and compared.

MAIN OUTCOME MEASURES

Clinical features and visual outcomes of late vitreoretinal complications in patients with regressed ROP.

RESULTS

A total of 264 eyes of 238 patients were included. The prior acute ROP status was comparable among the 3 groups, except that the VH group had a higher proportion of patients with type 1 ROP (P = 0.03) and prior treatment (P < 0.001) than the other groups. The average age at presentation was earlier in the RD (20.3 ± 15.5 years) and VH (21.4 ± 18.9 years) groups than in the retinal break group (31.9 ± 18.2 years; P < 0.001). The retinal break group had the best presenting best-corrected VA, followed by the RD and VH groups (P < 0.001). Surgical intervention improved VA in both the RD and VH groups (both P < 0.05). The overall trend of VA was the most favorable in the retinal break group, followed by that in the VH and RD groups. Cicatricial changes in the fellow retina were observed in > 90% of patients with unilateral involvement.

CONCLUSIONS

Infants with acute ROP remain at a high risk of vision-threatening complications throughout childhood and adulthood. Continual follow-up of patients with ROP is important. When severe complications, such as RD or VH, are detected, timely surgical intervention is necessary to ensure favorable visual outcomes in these patients.

A pilot study of viscoelastic agent to prevent recurrent vitreous hemorrhage after vitrectomy for proliferative diabetic retinopathy

BACKGROUND

To evaluate the possibilty of preventing recurrent vitreous hemorrhage (RVH) after vitrectomy in proliferative diabetic retinopathy (PDR) patients with unabsorbed vitreous hemorrhage (VH) by intravitreal injection of viscoelastic agent (VA) at the end of the surgery and compared its effect with triamcinolone acetonide (TA).

METHODS

This was a pilot prospective, observational study. PDR patients with VH who underwent vitrectomy were assigned to 3 groups according to the tamponade applicated at the end of the surgery, including VA group (intravitreally injected 1 ml VA if the retina was prone to bleed during the operation), TA group (intravitreally injected 2 mg TA when there was much exudates), or balanced salt solution (BSS) group (no tamponade). Then postoperative follow-up was performed routinely until 6 months after surgery. The primary outcome was the incidence of RVH, secondary outcome were the best-corrected visual acuity (BCVA) and introcular pressure (IOP). Cataract formation and other complication were also assessed.

RESULTS

A total of 68 eyes, from 68 patients, were included. 18,18,32 eyes were enrolled in the VA group, TA group and BSS group, respectively. The integral incidence of RVH after vitrectomy was 5.6%, 5.6% and 12.5% respectively (P = 0.602). There was no early RVH in VA or TA group, whereas 3 early RVHs were identified in BSS group, however there was no significant difference (P = 0.171). Every group had one late RVH case. In all groups, final BCVA showed significant improvement compared to baseline. BCVA at any postoperative visit showed no significant differences among 3 groups. Mean IOP was higher 1 week after surgery in VA group compared with the other groups; however, in other times the differences were not significant. No cataract formation and other complication was noted in 3 groups.

CONCLUSION

Intravitreal injection of VA or TA at the end of vitrectomy for PDR patients with unabsorbed VH tend to reduce the incidence of early RVH after vitrectomy similarly. As VA was preferred to applicate in the eyes that were prone to bleed, intravitreal injection of VA at the end of vitrectomy might be a promising method for preventing RVH in PDR patients.

Vitreous hemorrhage in a pregnant woman with a history of simultaneous pancreas and kidney transplantation: A case report

Pregnancy after simultaneous pancreas and kidney transplantation (SPKT) carries a high risk of maternal and fetal complications. We report the case of a 39-year-old woman with three consecutive pregnancies with favorable outcomes after SPKT. Within the first year of SPKT, the patient had a spontaneous pregnancy. At 32 weeks of gestation, she underwent an emergency cesarean section (CS) due to severe preeclampsia and HELLP syndrome. The infant was of average birth weight and was transferred to the neonatal intensive care unit for further management. A second unplanned pregnancy occurred almost nine months after the first. The antenatal assessments for fetal growth, blood glucose, and blood pressure were normal throughout follow-up. Early in her pregnancy, the patient developed an uneventful retinopathy of the left eye. At 37 weeks of gestation, she underwent an elective CS due to a short inter-pregnancy interval and delivered a healthy baby with an average birth weight. At the age of 39 years, the patient had a third unplanned pregnancy. She was diagnosed with seronegative antiphospholipid syndrome. She suffered from bilateral vitreous hemorrhage and was managed successfully with a minimally invasive laser treatment combined with an intravitreal injection of anti-vascular endothelial growth factor during her third trimester. At 35 weeks of gestation, the patient presented with labor pain and underwent an emergency CS and delivered a healthy baby with an average birth weight. Pregnancy after SPKT requires a multidisciplinary approach with a careful workup.

Predictors of Long-term Ophthalmic Complications after Closed Globe Injuries Using the Intelligent Research in Sight (IRIS®) Registry

Purpose

To identify clinical factors associated with the need for future surgical intervention following closed globe ocular trauma.

Design

Retrospective cohort study.

Subjects Participants and/or Controls

Patients in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry with a diagnosis of closed globe ocular trauma occurring between 2013 and 2019, identified using International Classification of Disease, 10th Revision and Systematized Nomenclature of Medicine codes.

Methods

Diagnosis codes were used to identify multiple concomitant diagnoses present on the date of closed globe ocular trauma. Survival analyses were performed for each outcome of interest, and linear regression was used to identify clinical factors associated with the risk of surgical intervention.

Main Outcome Measures

Outcomes included retinal break treatment, retinal detachment (RD) repair, retinal break treatment or RD repair, glaucoma surgery, and cataract surgery.

Results

Of the 206 807 patients with closed globe ocular trauma, 9648 underwent surgical intervention during the follow-up period (mean, 444 days): 1697 (0.8%) had RD repair, 1658 (0.8%) had retinal break treatment, 600 (0.3%) had glaucoma surgery, and 5693 (2.8%) had cataract surgery. Traumatic cataract was the strongest risk factor for cataract surgery (hazard ratio, 13.0; 95% confidence interval, 10.8-15.6), traumatic hyphema showed highest risk for glaucoma surgery (7.24; 4.60-11.4), and vitreous hemorrhage was the strongest risk factor for retinal break treatment and detachment repair (11.01; 9.18-13.2 and 14.2; 11.5-17.6, respectively) during the first 60 days after trauma date. Vitreous hemorrhage was a risk factor for cataract surgery at > 60 days after trauma date only. Iris-angle injury was the strongest risk factor for glaucoma surgery > 60 days after trauma, while vitreous hemorrhage remained the strongest factor for retinal break treatment and detachment repair at > 60 days. Traumatic hyphema was a risk factor for all surgical outcomes during all follow-up intervals.

Conclusions

Diagnosis of concomitant traumatic cataract, vitreous hemorrhage, traumatic hyphema, and other risk factors may increase the likelihood of requiring surgical intervention after closed globe ocular trauma.

Hypertension: A Cause of Bilateral Proliferative Retinopathy

Purpose

To describe the case of a 67-year-old female with proliferative retinopathy secondary to uncontrolled hypertension.

Methods

Retrospective case report including multimodal imaging.

Results

A 67-year-old female presented with mild vitreous hemorrhage, retinal hemorrhage, hard exudate of the left eye and hard exudate, copper wiring of vessels, and retinal hemorrhages in the right eye. Optical coherence tomography depicted macular edema of both eyes. Fluorescein angiography revealed large areas of peripheral retinal ischemia and neovascularization with multiple areas of vascular leakage in both eyes.

Conclusions

Proliferative hypertensive retinopathy has been rarely reported in the literature. Our patient exhibited findings consistent with proliferative retinopathy secondary to hypertensive retinopathy.

Acute Onset of Dense Vitreous Hemorrhage Associated with Retinal Arterial Macroaneurysm on the Optic Disc

We present a rare case of acute onset of dense vitreous hemorrhage (VH) associated with ruptured retinal arterial macroaneurysm (RAM) on the optic disc. A 63-year-old Japanese man had undergone phacoemulsification combined with pars plana vitrectomy (PPV) including internal limiting membrane peeling in the right eye for a macular hole approximately 1 year before presentation. His decimal best-corrected visual acuity (BCVA) in the right eye was stable at 0.8 with no recurrence of macular hole. He visited our hospital emergently prior to his regular postoperative visit for a sudden decrease in visual acuity in the right eye. Clinical examinations and imaging tests revealed dense VH in the right eye, and we could not observe the fundus. B-mode ultrasonography of the right eye showed dense VH without retinal detachment and a bulge on the optic disc. His BCVA decreased to hand movement in the right eye. He had no medical history of hypertension, diabetes, dyslipidemia, antithrombotics, or ocular inflammation in both eyes. Accordingly, we performed PPV on the right eye. During vitrectomy, we found a RAM on the optic disc with retinal hemorrhage on the nasal side. We carefully reviewed the preoperative color fundus photographs and noticed that RAM was not present on the optic disc at the time of his visit 4 months earlier. After surgery, his BCVA improved to 1.2, the color of the RAM on the optic disc changed to grayish yellow, and optical coherence tomography images showed a shrunken RAM. RAM on the optic disc could cause VH early after its onset.

Vitreous Hemorrhage, Aetiology and Visual Outcome of Vitrectomy in a Black African Population

BACKGROUND

Information on the causes and outcome of treatment of vitreous hemorrhage (VH) in sub-Saharan Africa is limited.

OBJECTIVES

To determine the causes and postoperative vision after vitrectomy for VH.

DESIGN

A retrospective review of records from consecutive eyes, with VH greater than one-month duration, who had vitrectomy and adjunctive treatment in a retina unit in Nigeria.

METHODS

We assessed the change between preoperative and postoperative visual acuity, bio data, cause of VH, duration of follow up, and additional treatment. Data was analyzed using SPSS statistical package 17.0 to determine the significance of the change in visual acuity for each cause of VH. A p value <0.05 was considered statistically significant.

RESULTS

Of the 221 eyes of 219 patients, the common causes of VH were trauma 43 eyes, (19.7%), proliferative diabetic retinopathy, 37 eyes (17.0%) and proliferative sickle cell retinopathy, 30 eyes (13.8%). There was no association between cause and the presenting preoperative visual acuity. There was a statistically significant association between cause of VH and postoperative visual outcome. Postoperative visual improvement was significant for branch retinal vein occlusion, central retinal vein occlusion, proliferative diabetic retinopathy with VH only, proliferative sickle cell retinopathy, and trauma with VH only, p value = 0.000, 0.002, 0.001, 0.039, and 0.000 respectively. Postoperative visual change was not significant in age-related macular degeneration and polypoidal choroidal vasculopathy (p value = 0.155, 0.428 respectively).

CONCLUSION

Significant improvements in visual acuity can be achieved with active treatment of VH in the majority of cases in Nigeria. This information is useful for discussions on prognosis and agrees with previous studies.

[PEHCR-Peripheral exudative hemorrhagic chorioretinopathy: Diagnosis and treatment]

Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare degenerative chorioretinal disease with subretinal or subepithelial hemorrhage and exudation in the fundus periphery in older patients. Even though it is the second most common entity among pseudomelanomas and its characteristic features simplify diagnosis, PEHCR is often not recognized and therefore misdiagnosed. In most cases stabilization or regression spontaneously occur. Therefore, treatment for PEHCR should be cautiously selected when function is good and surgical intervention should be preferably considered when visual loss is imminent.

Refractive Outcomes of Combined Cataract Surgery and Vitrectomy Compared to Cataract Surgery Alone

PURPOSE

The aim of the study was to evaluate the refractive outcomes of combined cataract surgery and vitrectomy compared to cataract surgery alone.

METHODS

This retrospective chart review study included two groups: (1) combined surgery in 103 eyes (101 patients) who underwent cataract surgery with posterior chamber intraocular lens (PCIOL) placement by a single cataract surgeon and vitrectomy by a single vitreoretinal surgeon at the same surgical setting; (2) cataract surgery alone by the same surgeon in 107 eyes (84 patients). Refractive outcomes and complications between the combined and cataract surgery alone group were compared. The predicted refractive error was compared to postoperative refractive outcomes in both groups, surgically induced astigmatism (SIA), intraoperative or postoperative complications of either cataract surgery or vitrectomy, and cystoid macular edema.

RESULTS

There was no statistically significant difference between predicted and actual postoperative refractive outcomes between the combined and cataract surgery alone groups (within ±0.5 diopters [D], p = 0.099; within ±1.0 D, p = 0.721). There was no difference in SIA refractive outcomes between the two groups (p = 0.509). The use of intraoperative gas for retina tamponade did not significantly affect postoperative refractive outcomes. Both cataract surgery and vitrectomy were successfully performed without unexpected complications from either procedure affecting the other.

DISCUSSION/CONCLUSION

Combined cataract surgery and vitrectomy allows excellent refractive outcomes equal to cataract surgery alone, allowing each procedure to be performed independently by separate anterior and posterior segment surgeons. Combined procedures can be performed in eyes with a variety of retinal indications and can include fluid-gas exchange with minimal risk of PCIOL malposition or change in targeted refraction.

Ocular Ischemic Syndrome due to Internal Carotid Artery Occlusion with Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is associated with multiple vascular abnormalities, including internal carotid artery (ICA) stenosis/occlusion. Depending on the site of stenosis/occlusion of the ICA, both cerebral circulation and ocular circulation can be impaired. We describe a rare pediatric case of ocular ischemic syndrome (OIS) due to ICA occlusion in NF-1. The patient diagnosed with NF-1 suffered right ICA occlusion at 12 years of age, and developed right dense vitreous hemorrhage due to OIS at 13 years of age. The patient underwent right cerebral revascularization surgery to improve cerebral and ocular ischemia, but the visual acuity of the right eye did not improve. This case suggests that attention should be paid not only to cerebral ischemia but also to ocular ischemia in patients with ICA stenosis/occlusion of NF-1. Surgical interventions such as cerebral revascularization surgery should be considered in the early stages of OIS to protect visual function, and careful follow-up is required.

Salmon patch-associated vitreous hemorrhage in non-proliferative sickle cell retinopathy masquerading as infectious uveitis

PURPOSE

To report three cases of non-proliferative sickle cell retinopathy (NPSR) with vitreous hemorrhage masquerading as infectious uveitis.

OBSERVATIONS

Three patients were referred from ophthalmologists to our practices with clinical findings suggestive of infectious uveitis. The first patient was referred for new-onset floaters in both eyes, bilateral vitritis and dome-shaped lesions on B-scan ultrasound. He was initially treated for tuberculosis uveitis due to a positive purified protein derivative test. The second patient was referred with floaters and hazy vision in the setting of recent fever and headache and was also reported to have vitritis and unilateral yellow vitreoretinal lesions on fundoscopy. She was initially treated for toxoplasmosis and endogenous endophthalmitis. The third patient presented with flashes, floaters, and decreased vision four months after a ring-enhancing lesion was found on brain imaging, and was found to have unilateral vitritis with yellow vitreoretinal lesions. He was initially started on topical steroids and cycloplegics empirically for uveitis. All patients were ultimately diagnosed as having manifestations of NPSR, including vitreous hemorrhage, and dehemoglobinized salmon patch hemorrhages.

CONCLUSIONS AND IMPORTANCE

NPSR can occasionally masquerade as infectious uveitis. Obtaining a detailed history with relevant ancillary testing, along with performing a careful physical exam to recognize important clues, can help the physician arrive at the correct diagnosis in these equivocal cases.

Vitreous hemorrhage in X-linked retinoschisis

Purpose

To report a case of preretinal hemorrhage from extraretinal neovascularization related to capillary non-perfused retina within a large schisis in a pediatric patient with X-linked retinoschisis (XLRS).

Observations

A 4-year old male with an RS1 mutation and XLRS presented with preretinal and vitreous hemorrhage in the right eye. Retinal imaging, including wide angle fluorescein angiography (FA) and optical coherence tomography (OCT), showed vitreoretinal traction on extraretinal neovascularization and capillary non-perfused retina in the schisis cavity. Laser treatment to the non-perfused retina within the schisis was successful in reducing extraretinal neovascularization.

Conclusions

Vitreous hemorrhage is a well-known occurrence in XLRS. Imaging using wide angle FA and OCT were helpful to determine the causes of hemorrhage in order to develop a management plan.

Eales' disease: epidemiology, diagnostic and therapeutic concepts

Background

To describe the epidemiological traits, clinical characteristics, diagnostic procedures, therapeutic interventions and evolution in a large series of patients with diagnosis of Eales’ disease.

Methods

A clinical retrospective review of patients with Eales’ disease, evaluated and treated between April 2009 and April 2018, with a 1-year minimum follow-up. Thirty patients (59 eyes), were included. Age, sex, laboratory results (CBC, glycemia, protein electrophoresis, ACE levels) immunological profile and a Quantiferon-TB Gold Plus test were recorded. The patients were divided into groups according to their evolution, medical or surgical treatment, and visual outcomes.

Results

Seventeen male patients and 13 female patients were included, and their ages ranged from 14 to 35 years. The Quantiferon-TB Gold Plus test was positive in 25 patients. Twenty-eight patients had unilateral vitreous hemorrhage, 10 of whom presented with vasculitis and non-perfusion areas in the contralateral eye, 9 presented contralateral peripheral neovascularization and 9 had contralateral fibrovascular proliferation. The remaining 2 patients presented with a rhegmatogenous retinal detachment. In 6 patients, conservative treatment with intravitreal anti-VEGF injections and photocoagulation was performed after the hemorrhage cleared. Twenty-two patients, required vitrectomy, with good visual outcomes. Macular edema was found in 16 eyes, which responded to periocular and/or systemic corticosteroid therapy, except for 9 eyes that required intravitreal bevacizumab, with complete resolution in 7 eyes and partial resolution in 2 eyes.

Conclusions

Eales’ disease is a pathology of significant prevalence in our country. The distribution according to sex, tends to be equivalent. The etiology, even when it is not specifically determined, according to laboratory tests, confirms the probable immunologic response in the presence of Mycobacterium tuberculosis antigens. This is still a diagnosis of exclusion, and therefore, it is advisable to perform a complete laboratory work-up in each case. Timely application of laser and other medical treatments, help to avoid progression to more advanced stages and their complications. The surgical treatment of vitrectomy for vitreous hemorrhage, and/or tractional vitreous detachment yields good primary anatomical and functional outcomes. Secondary macular edema responds to periocular and intravitreal corticosteroids, and in refractory cases, the use of anti-VEGF therapy leads to an effective resolution.

Management of Complications and Vision Loss from Proliferative Diabetic Retinopathy

PURPOSE OF REVIEW

Diabetes can be associated with profound visual loss due to several mechanisms. As the duration of diabetes and blood glucose levels increase, these changes become more severe. The proliferation of new blood vessels, vitreous hemorrhage, and tractional retinal detachments may ultimately result and can be devastating to visual function. New advances, including anti-vascular endothelial growth factor (VEGF) medications and innovative microsurgical instruments, have provided additional methods for the management of diabetic retinopathy in the clinic and in the operating room, leading to improved outcomes.

RECENT FINDINGS

Advances in earlier treatment of proliferative diabetic retinopathy, especially with anti-VEGF injections, allow for a reduction in severity, improved vision, and more controlled and successful surgery. Modern surgical techniques and instrumentation have also allowed for improved patient outcomes. Future research into sustained delivery and release of anti-VEGF, reducing the need for frequent in-office injections, may prove to be additionally beneficial. Over the last decade, anti-VEGF has become an increasingly common treatment modality for the management of proliferative diabetic retinopathy, vitreous hemorrhages, and tractional retinal detachments. Further research is needed to determine the ideal method of delivery and timing of the treatment.

A Case of Idiopathic Dense Vitreous Hemorrhage: Suspected Rupture of a Large Retinal Arterial Macroaneurysm on the Optic Disc

We report a novel case of vitreous hemorrhage associated with suspected rupture of 2-disc-diameter retinal arterial macroaneurysm on the optic disc. A 90-year-old woman presented with blurred vision (sudden onset) in her left eye. Examination of the fundus revealed acute onset vitreous hemorrhage of unknown origin without retinal detachment. She underwent vitrectomy, but after excision of the dense vitreous hemorrhage, a 2-disc-diameter hematoma appeared on the optic disc and was removed promptly. Because the bleeding at the base of the hematoma was of arterial origin and pulsating, the first vitrectomy could not achieve hemostasis. Five days after the first surgery, we performed a second vitrectomy. This revealed a subretinal hemorrhage along the superior and inferior arcade vessels and a macular hole, which was almost completely closed with an inverted internal limiting membrane flap. Unfortunately, the macular hole reopened 41 days after the second surgery. In patients presenting with only a large hematoma on the optic disc, it might be prudent to leave the hematoma. However, this large retinal arterial macroaneurysm was on a rare location on the optic disc, making it doubly difficult for the surgeons to diagnose and choose the best option intraoperatively. The differential diagnosis for dense vitreous hemorrhage of unknown origin should include a large retinal arterial macroaneurysm on the optic disc.

Case report: Vitreous hemorrhage as the presenting sign of retinal cavernous hemangioma in a newborn

Purpose

To report a case of vitreous hemorrhage as the presenting sign of retinal cavernous hemangioma (RCH) in a newborn.

Observations

A five-week-old full-term male with a history of seizures and birth trauma underwent ophthalmology screening. Initial eye examination revealed vitreous hemorrhage. Subsequent examination under anesthesia with multi-modal imaging revealed vitreous hemorrhage and an intra-retinal mass with numerous sac-like aneurysmal dilatations, consistent with RCH.

Conclusions and importance

Vitreous hemorrhage in a neonate is an atypical presentation of RCH. Clinicians should be aware that birth trauma may lead to vitreous hemorrhage from RCH. This is the first description of RCH, a rare retinal vascular tumor, in a newborn.

Hypertension as an Unusual Cause of Proliferative Retinopathy: Case Report and Literature Review

Malignant hypertensive retinopathy is associated with characteristic fundus findings that typically do not include proliferative retinal vascular changes. We present the case of a 34-year-old patient who had bilateral decreased vision and was found to have malignant hypertension with hypertensive retinopathy changes along with unforeseen bilateral neovascularization and vitreous hemorrhage. Detailed history and extensive systemic and ophthalmic workup failed to reveal an alternative explanation for her proliferative retinopathy. Blood pressure control and panretinal photocoagulation halted further deterioration. Malignant hypertensive retinopathy can rarely cause profound retinal ischemia leading to retinal neovascularization. This case further supports the presence of "proliferative hypertensive retinopathy" that needs to be identified and addressed urgently through collaboration between internists and ophthalmologists.

Visual outcomes and complications following one-way air-fluid exchange technique for vitreous hemorrhage post vitrectomy in proliferative diabetic retinopathy patients

BACKGROUND

To evaluate the efficacy and outcomes of one-way surgical technique for the treatment of vitreous hemorrhage post vitrectomy on proliferative diabetic retinopathy (PDR) patients.

METHODS

This retrospective case series include 47 PDR patients who had vitrectomy with balanced saline solution tamponade and have developed vitreous hemorrhage without significant absorption. The one-way air-fluid exchange procedure which involves the application of a 0.22-μm pore size filter to exchange about 4.5-5.5 ml of fluid with a 10 ml syringe was performed on 47 patients (47 eyes). Post procedure, additional treatments were administered when needed. Best corrected visual acuity (BCVA), occurrence of intra-procedural and post-procedural complications were recorded and analyzed.

RESULTS

A total of 47 eyes of 47 PDR patients with a mean age of 50.8 ± 12.0 years were reviewed. Because of vitreous hemorrhage or tractional retinal detachment of PDR, all 47 eyes underwent vitrectomy with balanced saline solution tamponade prior to the exchange procedure. Four patients (8.51%) and 43 patients (91.5%) were diagnosed with type 1 diabetes mellitus (T1DM), or type 2 diabetes mellitus (T2DM), respectively. All 47 eyes were given the one-way air-fluid exchange procedure in the treatment room. Forty-two cases (89.4%) needed the air-fluid exchange procedure only once, 4 cases (8.51%) underwent the procedure twice, and 1 case (2.13%) was given the procedure three times, followed by additional retinal photocoagulation and one intravitreal injection of Conbercept. In addition to the procedure, no further treatment was needed for 5 eyes (10.6%) while additional retinal laser treatment was provided for 41 eyes (87.2%). The BCVA at the final follow-up was significantly improved from the initial acuity baseline in all cases. No complications were observed during the follow-ups.

CONCLUSION

This one-way air-fluid exchange procedure can effectively exchange the vitreous hemorrhage and improve visual acuity of PDR patients who develop vitreous rehemorrhage post vitrectomy without obvious complications.

Racemose hemangioma complicated with macular macroaneurysm rupture

Purpose

To describe a rare case of racemose hemangioma which developed spontaneous macular macroaneurysm (MA) rupture and vitreaous hemorrhage.

Observations

A 29-year-old healthy asian female visited our hospital and a racemose hemangioma was found in the left eye. At presentation, the best corrected visual acuity (BCVA) was 30/20 in her left eye. At 9 years after the first visit, MA-like lesion was noted in the macular area. After that, vitreous and subretinal hemorrhage appeared in the left eye. The patient underwent simultaneous vitrectomy and cataract surgery, but vitreous re-hemorrhage occurred two days after the operation. To avoid re-hemorrhage, silicone oil (SO) tamponade was added in the second vitrectomy. Two years after the second operation, SO was removed and postoperative BCVA in the left eye was 20/200 without re-bleeding in the vitreous.

Conclusions and Importance

Although retinal hemorrhages have been reported in the patients with a racemose hemangioma, in our case the macular MA rupture occurred at 9 years after the first visit. Congenital retinal arteriovenous anastomosis can show a change in vascular shape in some cases, thus it is important to observe carefully.

Surgical outcomes of vitrectomy for breakthrough vitreous hemorrhage in eyes with exudative age-related macular degeneration

PURPOSE

To report the outcomes of pars plana vitrectomy in cases with breakthrough vitreous hemorrhage (VH) secondary to exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy. We also investigated the relationship between the preoperative b-mode ultrasonographic findings and the postoperative visual acuity to determine if the ultrasonographic findings can predict the surgical outcome after pars plana vitrectomy.

METHODS

This was a retrospective, interventional, case series. Twenty eyes of 20 patients were studied. The associations between the pre- and intraoperative factors and the final best-corrected visual acuity (BCVA) were determined. Recombinant tissue-plasminogen activator (tPA) was used in cases with massive hemorrhagic retinal detachment.

RESULTS

Ten eyes with polypoidal choroidal vasculopathy (PCV), two eyes with choroidal neovascularization (CNV), and eight eyes with an unknown type of AMD were studied. The mean BCVA was 0.73 ± 0.57 logarithm of the minimum angle of resolution (logMAR) units before developing the VH, 2.25 ± 0.45 logMAR units before the surgery, and 1.52 ± 0.87 logMAR units after the surgery. The BCVA improved significantly after the surgery (P = 0.004) but was significantly worse than that before developing the VH (P = 0.012). The cases of PCV had better final BCVA than cases of CNV (P = 0.043, Mann-Whitney test). The preoperative presence of a subretinal elevation at the macula detected by ultrasonography was significantly associated with a poorer final BCVA (P = 0.031).

CONCLUSIONS

Vitrectomy significantly improved visual function in the eyes with VH associated with exudative AMD. The eyes with PCV and no macular subretinal elevation on ultrasonography had a better visual prognosis.

Iatrogenic Retinal Penetration from Intravitreal Injections

We present 2 cases of iatrogenic retinal penetration from intravitreal (IVT) injections in a retrospective noncomparative case series of 2 patients. The first patient, an 81-year-old Caucasian male, developed dense vitreous hemorrhage soon after receiving an IVT bevacizumab injection for macular edema from central retinal vein occlusion. A 25-g vitrectomy 1 week later showed a retinal hole surrounded by fresh hemorrhages in the same quadrant as the IVT injection. The second patient, an 87-years-old male, developed a retinal detachment after 28 injections of anti-VEGF medications for neovascular AMD. A peripheral round hole was observed during vitrectomy without any lattice degeneration in the same quadrant as prior IVT injections. Both eyes were pseudophakic, had normal axial lengths, and received injections without measuring the injection site. Retinal penetration from IVT injections can result in serious sight-threatening complications. Measuring the injection site from the limbus should be part of safe IVT injection technique.

Efficacy of YAG Laser Embolysis in Retinal Artery Occlusion

Objective:

To compare the anatomical and functional success between conventional medical method and Neodymium-Doped Yttrium Aluminum Garnet (Nd:YAG) laser embolysis in retinal artery occlusion.

Methods:

This randomized control trial was conducted at Armed Forces Institute of Ophthalmology (AFIO) Rawalpindi from July 2018 to May 2020. A total of 14 eyes of 14 patients were received with fovea involving branch or hemiretinal artery occlusion within 24 hours of onset of symptoms. They were divided randomly in two groups. Initial treatment was given to all cases, and seven eyes received Nd:YAG laser treatment for embolysis. Both groups were analysed for anatomical success (reperfusion) and functional success (defined as improvement in visual acuity to better than 6/60 on Snellen’s visual acuity chart from baseline visual acuity).

Results:

In conventional group, anatomical success was achieved in 2 (28.6%) eyes, while significant visual improvement was seen in 3 (42.8%) eyes. In Nd:YAG laser embolysis group, anatomical success was achieved in 5 (71.4%) eyes, while significant visual improvement was seen in 6 (85.7%) eyes. All eyes which showed functional improvement underwent Nd:YAG laser embolysis within 6 hours of onset of symptoms.

Conclusions:

Nd: YAG laser embolysis is more effective in management of fovea threatening retinal artery occlusion, as compared to conventional medical treatment, if performed within six hours of onset of symptoms.

A 5-YEAR REVIEW OF ULTRASONOGRAPHIC EVALUATION OF OCULAR DISEASES AT THE UNIVERSITY COLLEGE HOSPITAL IBADAN, SOUTH-WEST, NIGERIA

BACKGROUND

Orbito-ocular diseases are a major public health issue, often causing visual impairment with serious socioeconomic implications on individual lives. Ocular ultrasonography is an invaluable diagnostic tool when clinical examination of the ocular fundus is difficult.

OBJECTIVES

To describe the indications, sonographic findings, and contribution of orbito-ocular ultrasonography to the management of orbito-ocular diseases in the University College Hospital, Ibadan.

MATERIALS AND METHODS

A retrospective review of B-mode ocular ultrasound findings and hospital data of all patients referred to the Radiology department of the University College Hospital, Ibadan for ocular Ultrasound between January 2014 - December 2018.

RESULTS

There were 142 patients, aged 1-85 years, (median age =28 years). 72 (50.7%) patients were under 30 years of age, and 50 (35.2%) were pediatric cases. Male to female ratio was 1.84:1. The commonest presenting complaint was blurred vision in 97 (68.3%) cases, followed by eye trauma in 54 (38.0%). B-mode Ultrasound, demonstrated cataract in 63 (44.4%,) cases, vitreous hemorrhage in 42 (29.6%), retinal detachment in 27 (19.0%), vitreous detachment in 19 (13.4%), normal findings in 17 (12%) and orbital tumors in 13 (9.2%) patients. B-mode ultrasound scan and clinical diagnosis demonstrated good agreement in 91 /142 cases (64.1%), partial agreement in 23/142 (16.2%) cases, and no agreement in 28 (19.7%). Kappa agreement scores, K were 74.3% and 70.9%, for ruptured globe and cataract respectively.

CONCLUSION

Orbito-ocular ultrasonography contributes significantly to the diagnosis of orbito-ocular disease and shows good correlation with clinical diagnoses. However, a future study with larger numbers is required.

Subarachnoid hemorrhage-negative Terson syndrome after intracranial artery treatment with a flow diverter device

PURPOSE

To report a case of subarachnoid hemorrhage-negative Terson syndrome following intracranial artery treatment with flow diverter stents.

OBSERVATIONS

A 40-year-old Asian woman presented with floaters in her right eye after treatment of an intracranial aneurysm with flow diverter stents. Vitreous hemorrhage and sub-inner limiting membrane (sub-ILM) hemorrhage were present in her right eye. On fluorescein angiography, contrast perfusion and vascular occlusion were not noted. Magnetic resonance imaging (MRI) did not show any evidence of subarachnoid hemorrhage (SAH). We hypothesize that the bleeding was due to Terson syndrome associated with intracranial treatment with the flow diverter stents. During follow-up, the vitreous hemorrhage and sub-ILM hemorrhage disappeared, and the floaters in her vision improved.

CONCLUSIONS AND IMPORTANCE

This is the first reported case of vitreous hemorrhage and sub-ILM hemorrhage that should be considered to be Terson syndrome, after flow diverter stents treatment in the absence of SAH.

Pseudotumor cerebri syndrome causing a terson like syndrome

Purpose

Terson syndrome presents with retinal and vitreous hemorrhages in patients with a subarachnoid hemorrhage or after acutely elevated intracranial pressure. The source of this hemorrhage has been debated and may originate either from direct extension of intracranial hemorrhage or more likely from the peripapillary retinal vessels.

Observations

A 39-year-old woman presenting with nausea, vomiting, floaters and papilledema with normal neuroimaging was diagnosed ultimately with pseudotumor cerebri syndrome. She had a right vitreous hemorrhage and bilateral subretinal and intraretinal hemorrhages which were consistent with Terson like syndrome. Her symptoms resolved with acetazolamide over one month and the retinal and vitreous hemorrhages significantly improved over two months.

Conclusions and importance

This case with initial presentation of pseudotumor cerebri syndrome causing a Terson like syndrome may help elucidate the mechanism behind the etiology of these hemorrhages from leaking peripapillary vessels.

Post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis treated with clear lens extraction in an African

Purpose

To report the successful treatment of post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis managed with a clear lens extraction and posterior capsulectomy.

Observation

A 34-year-old female African, known SC hemoglobinopathy patient, presented with bilateral blur in vision and floaters of a week duration; worse in her right eye. Her visual acuity was right eye 6/9 (20/30) and left eye 6/6 (20/20). Her anterior segment examination was normal in both eyes. On fundus examination, she had a right eye vitreous hemorrhage and bilateral active Sea-fan neovascular proliferation in the retina periphery. Following the administration of bilateral simultaneous intravitreal bevacizumab, she presented 4 days later with a right eye infective endophthalmitis. She suffered multiple recurrences despite adequate treatment, including a vitrectomy with silicone oil injection. Multiple microbiological assessment of intraocular extracts confirmed persistent Burkholderia cepacia infection. A wide ring-shaped opaque plaque was noticed on the posterior capsule of her clear lens. A decision was taken to perform a lensectomy and posterior capsulectomy. This resulted in immediate resolution of hypopyon and all intraocular inflammation. Vision improved from Hand Motion to 6/18 (20/60).

Conclusion and importance

This report suggests than in some cases of recurrent, difficult to treat, Burkholderia cepacia endophthalmitis, since the organism may have colonized the posterior lens capsule, the eye and vision can be salvaged by timely removal of a clear lens and capsulectomy. Clear lens removal has not been previously reported for treating recurrent Burkholderia cepacia endophthalmitis.

Prognostic Factors and Long-term Surgical Outcomes for Exudative Age-related Macular Degeneration with Breakthrough Vitreous Hemorrhage

Purpose

We sought to evaluate the long-term outcomes for patients with exudative age-related macular degeneration (AMD) undergoing vitrectomy for breakthrough vitreous hemorrhage and to investigate possible prognostic factors.

Methods

Consecutive patients treated at two high-volume referral-based tertiary hospitals between July 2006 and December 2019 were retrospectively reviewed. Surgery was performed using the standard three-port vitrectomy. The primary outcome was the change in best-corrected visual acuity (BCVA) over long-term follow-up, while secondary outcomes included the assessment of possible prognostic factors.

Results

Among 50 eyes from 50 patients included in this study, 23 (46%) were diagnosed with polypoidal choroidal vasculopathy (PCV) and 27 (54%) were diagnosed with neovascular AMD. Preoperative vision at the time of vitreous hemorrhage onset was 20 / 3,027 (logarithm of the minimum angle of resolution [logMAR], 2.18 ± 0.34). At 12 months after surgery, the mean BCVA improved to 20 / 873 (logMAR, 1.64 ± 0.76; p < 0.001). At 24 months, the BCVA was 20 / 853 (logMAR, 1.63 ± 0.75; p < 0.001). Univariate analysis revealed that older age (odds ratio [OR], 0.879; p = 0.007] and the presence of submacular hemorrhage (OR, 0.081; p = 0.022) were factors associated with a poor 2-year visual outcome. Multivariable regression showed that older age (OR, 0.876; p = 0.026) and neovascular AMD (as compared with PCV) (OR, 0.137; p = 0.014) were significant negative factors influencing the 2-year visual outcome. The mean injection interval prior to vitrectomy was 4.53 months, which extended to 27.64 months after vitrectomy (p = 0.028).

Conclusions

Younger age, the absence of submacular hemorrhage, and PCV type were associated with a favorable 2-year visual outcome after vitrectomy for vitreous hemorrhage in patients with exudative AMD. Overall, vitrectomy resulted in improved visual acuity and patients showed a decreased need for anti-vascular endothelial growth factor therapy thereafter.

Vitreous hemorrhage in diabetes patients with proliferative diabetic retinopathy undergoing hemodialysis

AIMS/INTRODUCTION

For diabetes patients undergoing hemodialysis, vitreous hemorrhage seems to be a hemodialysis-induced hemorrhagic complication because of the effect of systemic anticoagulation. However, it is unclear whether hemodialysis is associated with vitreous hemorrhage in diabetes patients. We therefore carried out this cohort study to clarify the relationship between hemodialysis and vitreous hemorrhage in diabetes patients with proliferative diabetic retinopathy.

MATERIALS AND METHODS

This was a single-center, retrospective, cohort study. We compared the incidence of vitreous hemorrhage in non-vitrectomized proliferative diabetic retinopathy eyes between the hemodialysis group (145 eyes) and peritoneal dialysis group (36 eyes), which does not require the use of systemic anticoagulation (parallel-group study), and in hemodialysis patients in the 12-month period before and after the start of hemodialysis (before-after study). We also determined the risk factors for vitreous hemorrhage after the start of hemodialysis based on the patients' systemic and ophthalmic characteristics.

RESULTS

There was no significant difference in the first-year incidence of vitreous hemorrhage between the hemodialysis (23.4%) and peritoneal dialysis groups (22.2%, P = 1.000). The incidence of vitreous hemorrhage in the dialysis period (23.4%) was significantly lower than that in the predialysis period (35.2%, P = 0.008). Only application of panretinal photocoagulation within the 6 months immediately before hemodialysis was significantly associated with the incidence of vitreous hemorrhage after the start of hemodialysis (P < 0.001).

CONCLUSIONS

Hemodialysis therapy does not seem to be associated with a higher risk of vitreous hemorrhage in diabetes patients with proliferative diabetic retinopathy.

Self-sealing posterior scleral perforation in airgun ocular trauma, surgical tip: a case report

Background

Intraorbital metallic foreign bodies have varied clinical presentations. Here, we report the unusual case of intraoperative evidence of spontaneously healed posterior scleral perforation in a severe ballistic trauma without previous instrumental signs of penetrating wound and complete visual restoration after surgery.

Case presentation

The patient was hit by several lead hunting pellets in the chest, abdomen, limbs, face and orbit. Computed Tomography (CT) images revealed the presence of a pellet within the orbitary cavity, close to the optic nerve, with no signs of penetrating ocular wound. While performing vitrectomy for severe vitreous hemorrhage, a point of strong adherence between a old hemorrhage and retinal surface was identified and managed conservatively, as it was attributed to trauma related-impact area. So, lead foreign body took an unusual trajectory impacting the globe and finally lodging back in the deep orbitary cavity, in absence of significant ocular injury and with visual prognosis preservation.

Conclusions

Our findings provide further information on orbital injuries from airguns, a theme of growing popularity and concern. Intraoperative recognition of hardly removable old hemorrhagic clot as self-blockage site of posterior scleral penetrating trauma, allowed for surgical stabilization and minimal solicitation of the area to avoid inadvertent perforation.

Intravitreal Aflibercept injection with Panretinal photocoagulation versus early Vitrectomy for diabetic vitreous hemorrhage: randomized clinical trial

Background

To compare efficacy and safety of intravitreal aflibercept (IVA) injection with panretinal photocoagulation (PRP) versus early vitrectomy for diabetic vitreous hemorrhage (VH).

Methods

Prospective, randomized study that included 34 eyes with diabetic VH. They were divided into two groups, Group Ι (17 eyes) received three successive IVA injections followed by PRP and group ΙΙ (17 eyes) for whom early vitrectomy was done. Follow up was carried out after one, two, three, six and nine months. The primary outcome measure was change in the mean best corrected visual acuity (BCVA) after nine months, secondary outcome measures were mean duration of clearance of VH and rate of recurrent hemorrhage with any additional treatment in both groups. Complications were reported.

Results

There was no statistically significant difference regarding initial demographic criteria between both groups. The mean final log MAR BCVA was statistically better than the initial BCVA in both groups (0.51 ± 0.20, 1.17 ± 0.48 for group I and 0.48 ± 0.18, 1.44 ± 0.44 for group II, P < 0.001). There was no statistically significant difference between both groups regarding the mean final Log Mar BCVA (0.51 ± 0.20 for group I, 0.48 ± 0.18 for group II, p ≥ 0.05), the mean duration of clearance of VH was 7.8 ± 1.8 weeks, 5 days for group I and II respectively. PRP was completely done for all eyes in group I after three months. The difference in the recurrence rate between group I (29.4%) and group II (11.8%) was statistically significant (p < 0.05). Vitrectomy was done for three eyes (17.6%) due to recurrent non-resolving VH in group I. late recurrent VH occurred in two eyes (11.8%) in group II, IVA was given with complete clearance of the hemorrhage. No vision threatening complications were reported in both groups.

Conclusion

Both intravitreal injection of aflibercept followed by PRP and early vitrectomy are effective and safe modalities for treatment of diabetic vitreous hemorrhage. Early vitrectomy leads to faster vision gain with less incidence of recurrence than intravitreal injection.

Trial registration

Randomized clinical trial under the number of NCT04153253 on November 6, 2019 “Retrospectively registered”.

Microsurgical observation of the posterior vitreous in patients with vitreous hemorrhage caused by Terson syndrome

Purpose

To describe features characteristic of vitreous hemorrhage in patients with Terson syndrome observed through a microsurgical scope.

Methods

Between May 2015 and February 2019, 12 eyes of 10 patients with vitreous hemorrhage occurring after subarachnoid hemorrhage (SAH) underwent pars plana vitrectomy.

Results

During vitreous surgery, we found 10 of 12 eyes did not have posterior vitreous detachment (PVD). Furthermore, we observed in 9 of the 10 eyes without PVD (90.0%) that there was no hemorrhage in the posterior vitreous cavity at the posterior pole while we removed vitreous hemorrhage. We confirmed that this clean space could be the posterior precortical vitreous pocket (PPVP).

Conclusion and importance

Terson syndrome may have no hemorrhage in the PPVP regardless of the presence of severe vitreous hemorrhage. The cases presented in our study may suggest one of the mechanisms of Terson syndrome.

The effect of adjunctive intravitreal conbercept at the end of diabetic vitrectomy for the prevention of post-vitrectomy hemorrhage in patients with severe proliferative diabetic retinopathy: a prospective, randomized pilot study

BACKGROUND

To investigate the effect of intravitreal conbercept (IVC) injections on the incidence of postoperative vitreous hemorrhage (VH) in eyes undergoing surgery for severe proliferative diabetic retinopathy.

METHODS

This was a pilot prospective, comparative, and randomized study. Thirty patients, who underwent vitrectomy for severe proliferative diabetic retinopathy, were assigned randomly to either group 1 (intravitreal conbercept [IVC] injection at the end of pars plana vitrectomy) or group 2 (no IVC injection). Postoperative follow-up was performed on the first day, first week, first month, third month, sixth month and first year after surgery. The primary outcome was the incidence of postoperative VH. Secondary outcomes were the initial time of vitreous clearing (ITVC), best-corrected visual acuity (BCVA) and central retinal thickness (CRT) after surgery.

RESULTS

A total of 30 eyes, from 30 patients, were included. Fifteen eyes were enrolled in the IVC group and fifteen in the control group. The incidence of early and late postoperative VH was not significantly different between the control and IVC groups. ITVC was shorter in the IVC group than that in the control group, but this was not significant (7.38 ± 10.66 vs 13.23 ± 17.35, P = 0.31). Final BCVA, 1 year after surgery, showed significant improvement compared to baseline in both groups. However, analysis of the BCVA at any postoperative visit after surgery showed no significant differences between the two groups. There were two cases of recurrent VH identified at 3 and 6 months after surgery in each group, requiring a second round of surgery. Foveal thickness was significantly different between the two groups at the 3-month, 6-month and 1-year follow-up visits.

CONCLUSIONS

In this pilot study, the effect of IVC injection in reducing the incidence of postoperative VH after diabetic vitrectomy at the end of vitrectomy was not shown.

TRIAL REGISTRATION

The study was registered with the Chinese Clinical Trial Registry. (Reference Number: ChiCTR1800015751).