saving the sinking boat….!!! (nd:yag laser hyaloidotomy for the treatment of recent subhyaloid...

SAVING THE SINKING BOAT….!!!

(ND:YAG LASER HYALOIDOTOMY FOR THE TREATMENT OF RECENT SUBHYALOID HEMORRHAGE)

Token no: 0287

Presenting author: Dr. Anand A. Tibdewal

Co-authors: Dr. Mehul Shah Dr. Shreya Shah

Dr. Ankita Mulchandani

There is no financial interest of any of the authors behind conducting this study and no financial assistance was provided by any institute or organization & there are no competing interests.

INTRODUCTION • Subhyaloid hemorrhage is defined as a localized

detachment of vitreous from the retina caused by the accumulation of blood, which can lead to sudden and severe loss of vision when it takes place in the macular area.

• The treatment ranges from conservative to posterior vitrectomy, depending on the cause, age and the status of the other eye.1

• Although spontaneous resolution is expected in most cases, it occurs in a slow, frustrating and sometimes incapacitating manner to the patient, especially in bilateral cases or in one-eyed patients.2

• A case study was performed with the aim to assess the benefit of pulsed Nd:YAG laser posterior hyaloidotomy/ vitrectomy in patients with premacular subhyaloid hemorrhage.

CASE REPORT

• We present a case series of 4 patients of different age groups and associated medical conditions.

• Anterior segment examination was performed according to standard protocol and Posterior segment examination was done following cycloplegic dilatation with an indirect ophthalmoscope and +90 D biomicroscopic examination.

• The patients were treated by different modalities depending on the judgement of the treating surgeon. Three patients were treated with a double frequency Nd:YAG laser and one was treated with vitrectomy.

• Nd:YAG laser posterior hyaloidotomy was performed using three mirror Goldman contact lenses and fluid blood trickled with gravity.

• Treatment given - Nd:Yag hyaloidotomy.

• Patient was followed up weekly for one month.

• At the end of one month the patient regained visual acuity of 6/9.

Patient 2• 15 yrs / M with sudden loss of vision in OS since 10 days.

• OD 6/6• OS 2/60

• No systemic disease present

• Anterior Segment: OU – WNL

• Posterior Segment: OD – WNL

• OS - subhyaloid haemorrhage

• Treatment given – initially Nd:Yag hyaloidotomy, but without any symptomatic relief & no visual improvement.

• The patient was then taken up for vitrectomy.



Patient 1• 38 yrs / F with sudden loss of vision in OS since 1 day.

• OD 3/60• OS 6/6








Patient 4• 18 yrs / F with sudden loss of vision in OD since 4 days.

• OD FCNF• OS 6/6



• Posterior Segment: OD – subhyaloid haemorrhage

• OS - WNL



• At the end of one month, the patient regained visual acuity of 6/36

Patient 3• 55 yrs / M with sudden loss of vision in OS since 10 days.

• OD 6/18• OS 3/60

• HTN & DM since 10 yrs.

• Anterior Segment: OU – nuclear sclerosis



Patient 1 on initial presentation Patient 1 on final visit

Patient 3 on initial presentation Patient 3 on final visit

DISCUSSION

• Premacular subhyaloid hemorrhage may occur from various vascular or hematological disorders, which include anemic retinopathy, proliferative diabetic retinopathy, blunt trauma, branch retinal vein occlusion, Valsalva retinopathy, retinal macroaneurysm rupture, Terson syndrome, age-related macular degeneration, etc. Premacular subhyaloid hemorrhage has also been reported in shaken, battered baby syndrome3 and in acute childhood leukemia.4

• Sudden, painless and profound loss of vision is the most common presentation.5,6 Spontaneous resorption of blood entrapped in the subhyaloid space tends to be very slow and may take several months to years to resolve.

• In long-standing cases, complications like formation of an epiretinal membrane, macular traction, retinal detachment, cataract, amblyopia and toxic effect of long-standing hemorrhage may cause irreversible retinal damage and result in permanent visual loss.

• Observation and vitrectomy are the two old modes of treatment. Intravitreal tPA with an expansive gas is an alternative method to observation or vitrectomy for resolution of preretinal hemorrhages, which has been performed in battered babies, and may allow faster resolution of hemorrhages without the complications of vitrectomy.3

• Alternative newer methods are hyaloidotomy or membranectomy using different lasers like Nd:YAG laser (1064 nm) or Argon laser (514 nm).7-9 However, because the hemorrhage may cause permanent macular changes before it resolves, Nd:YAG laser posterior hyaloidotomy may be indicated in selected cases.7

• Nd:YAG laser can produce a defect in the posterior hyaloid/internal limiting membrane,8 allowing rapid diffusion of hemorrhage into the vitreous gel thus clearing the visual axis and allowing faster absorption of blood.10

• A study has been reported in which it is proved that Nd:YAG laser treatment for Valsalva retinopathy is an effective, noninvasive and safe procedure for patients with a premacular subhyaloid hemorrhage larger than 3 disc diameter and no longer than 3 weeks of duration.11

• It also allowed rapid restoration of visualization of the macular region with expedited access for fluorescein angiography and macular photocoagulation.

• It is important to identify the horizontal fluid level line so that performing laser hyaloidotomy allows blood to trickle into the vitreous cavity. Nevertheless, it should be used carefully with the lowest effective energy settings to avoid collateral damage to the retina.

CONCLUSION

• Nd:YAG laser hyaloidotomy is an effective procedure for the treatment of recent premacular subhyaloid hemorrhage, producing rapid dispersion of blood with restoration of visual function without a more invasive vitreoretinal procedure.

REFERENCES 1. Buliga S, Toma C, Taina A, Beraru V, Benone C. Diabetic retrohialoidianhemorrage--invasive minimal treatment. Oftalmologia

2011;55:82-5.

2. Gass JD. Stereoscopic Atlas of macular Diseases: Diagnosis and Treatment, 3rd ed. St. Louis. MO: C.V. Mosby; 1987. p. 560-4.

3. Conway MD, Peyman GA, Recasens MA. Intravitreal tPA and SF6 promote clearing of premacular subhyaloid hemorrhages in shaken and battered baby syndrome. Ophthalmic Surg Lasers 1999;30:435-41.

4. Khadka D, Sharma AK, Shrestha JK, Pant B, Pant S, Shrestha A. “Nd: Yag laser treatment for sub-hyaloid hemorrhage in childhood acute leukemia.” Nepal J Ophthalmol 2012;4:102-7.

5. Kuhn F, Morris R, Witherspoon CD, Mester V. Terson Syndrome: Results of vitrectomy and the significance of vitreous haemorrhage in patients with subarachnoid haemorrhage. Ophthalmology1998;105:472-7.

6. Postel EA, Mieler WF. Posterior segment manifestations of blunt trauma. In: Guyer DR, Yannuzzi LA, Chang S, editors. M, Jk. Retina-vitreous–macula. Vol. 1. Philadelphia: WB Saunders; 1999. p. 831-43.

7. Celebi S Kukner AS. Photodisruptive Nd: YAG laser in the management of premacular subhyaloid hemorrhage. Eur J Ophthalmol 2001;11:281-6.

8. Raymond LA. Neodymium: YAG Laser treatment for hemorrhages under the internal limiting membrane and posterior hyaloid face at the macula. Ophthalmology 1995;102:406-11.

9. Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long- term results after drainage of premacular subhyaloid haemorrhage into the vitreous with a pulsed Nd: YAG laser. Arch Ophthalmol 1998;116:1465-9.

10. Rennie CA, Newman DK, Snead MP, Flanagan DW.”Nd: YAG laser treatment for premacular subhyaloid haemorrhage.” Eye (Lond) 2001;15:519-24.

11. Durukan AH, Kerimoglu H, Erdurman C, Demirel A, Karagul S. Long-term results of Nd: YAG laser treatment for premacular subhyaloid haemorrhage owing to Valsalva retinopathy. Eye (Lond) 2008;22:214-8.

saving the sinking boat….!!! (nd:yag laser hyaloidotomy for the treatment of recent subhyaloid...

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