An atypical finding in an idiopathic unilateral frosted branch angiitis case: premacular hemorrhage

BACKGROUND: The authors describe a case of unilateral idiopathic acute frosted branch angiitis with premacular hemorrhage. CASE: A 35-year-old woman was referred because of acute vision loss in her left eye during the puerperal period. Her initial visual acuity was 20/20 OD and 20/200 OS. The left eye presented severe sheathing of retinal vessels inferiorly, heavy perivascular intraretinal hemorrhages, and premacular hemorrhage. There was no evidence of vascular leakage in fluorescein angiography. All of the laboratory workup was negative for frosted branch angiitis (FBA). During the follow-up period, FBA resolved spontaneously within a few days, but the amount of premacular hemorrhage increased. Vitrectomy with internal limiting membrane peeling was performed at the third month, resulting in 20/25 vision and no recurrence of the disease during the 13-month follow-up. Conclusion: This is an idiopathic case of acute FBA that exhibited spontaneous rapid regression of angiitis but was complicated by an unusual premacular hemorrhage.     

Retinal venous macroaneurysm associated with premacular hemorrhage

To report an unusual association of a retinal venous macroaneurysm with premacular hemorrhage in a 50-year-old man, using a case report method. The patient exhibited a dense premacular hemorrhage in the left eye. Fluorescein angiography demonstrated that the source of bleeding was an isolated retinal venous macroaneurysm. The anterior surface of the hematoma was opened with an argon green laser, resulting in rapid clearing of the premacular hemorrhage and improvement in vision. Treatment of the retina surrounding the macroaneurysm to prevent recurrence of bleeding was ineffective to achieve occlusion of the lesion. No recurrent hemorrhage occurred during the observation period. Retinal venous macroaneurysm, a quite rare condition, may be complicated by premacular hemorrhage. Argon green laser may be useful in treating such hemorrhage. Hemorrhagic detachment of the internal limiting membrane or subhyaloid hemorrhage in the macula may occur after retinal vessel rupture with physical exertion (Valsalva retinopathy) or in retinal vascular diseases, such as proliferative diabetic retinopathy, and retinal arterial macroaneurysm. Arterial macroaneurysms are a common, well-described retinal vascular disorder. In contrast to retinal arterial macroaneurysms, retinal venous macroaneurysms are quite rare. In this article we describe a patient who presented with premacular hemorrhage that was caused by a retinal venous macroaneurysm. The hematoma and the macroaneurysm were treated with argon green laser.     

Nd:YAG laser photodisruption of hemorrhagic detachment of the internal limiting membrane

We used a Q-switched Nd:YAG laser to create an opening in the internal limiting membrane in three eyes with hemorrhagic detachment of the internal limiting membrane. In all instances, after membranotomy blood was rapidly cleared from the preretinal space resulting in prompt improvement in visual acuity. No retinal injury was observed. Nd:YAG laser photodisruption may be useful in the treatment of some cases of subinternal limiting hemorrhages.     

Retinopathy associated with acute pancreatitis

Two patients (a 28-year-old woman and a 23-year-old man) with acute pancreatitis developed severe visual loss. The acute stage of retinopathy consisted of retinal edema, cotton-wool patches, and retinal hemorrhages, predominantly in the posterior pole of both eyes. During the five-year follow-up period, visual acuity improved and sequential fluorescein angiography of both patients demonstrated reperfusion of previously occluded retinal vessels. After resolution of the cotton-wool patches, the previously edematous areas were replaced by foci of retinal thinning which created irregularities in the internal limiting membrane light reflex. Visual fields demonstrated scotomas corresponding to the areas of the previous cotton-wool patches.     

The natural history of nontraumatic subarachnoid hemorrhage-related intraocular hemorrhages

PURPOSE: To describe the natural history of intraocular hemorrhages related to subarachnoid hemorrhage (SAH) as a result of ruptured intracranial aneurysms. METHODS: Retrospective review of patients with cerebral aneurysms examined by a referral neuro-ophthalmology service between 1980 and 1998. Patients with intraocular hemorrhages associated with SAH as a result of ruptured aneurysms were followed up without vitrectomy, unless bilateral vitreous hemorrhage occurred. RESULTS: Seventy of 450 patients with cerebral aneurysms had an SAH. Of these, 30 eyes of 19 patients had intraocular hemorrhages. Fourteen eyes had a vitreous hemorrhage; 12 had subhyaloid blood without a vitreous hemorrhage; and four had retinal hemorrhages alone. Two patients died shortly after presentation. Twenty-eight eyes were followed up for a mean of 4.8 years. Initial visual acuity was 20/100 to light perception in eyes with a vitreous hemorrhage, 20/20 to 20/400 in eyes with subhyaloid blood, and 20/20 to 20/40 in eyes with retinal hemorrhages. Three of the 12 eyes with a vitreous hemorrhage underwent vitrectomy. Of the nonoperated eyes, final visual acuity was at least 20/30 in 19 (76%) eyes, 20/40 to 20/60 in four (16%) eyes, and 20/100 in both eyes of one patient with premacular subhyaloid blood. None of the nonoperated eyes developed cataract formation or progression, retinal tears, or retinal detachment. Epiretinal membrane developed in one eye and pigmentary maculopathy developed in five. CONCLUSIONS: Except for patients with bilateral vitreous hemorrhages, early vitrectomy may not be necessary in most cases of intraocular hemorrhages associated with nontraumatic SAH.     

Epiretinal membrane formation with internal limiting membrane wrinkling after Nd:YAG laser membranotomy in valsalva retinopathy

PURPOSE: To report the location of premacular hemorrhage in Valsalva retinopathy and epiretinal membrane formation with internal limiting membrane (ILM) wrinkling after neodymium;yttrium-aluminum-garnet (Nd:YAG) laser membranotomy. DESIGN: Interventional case report. METHODS: A 35-year-old man with a massive premacular hemorrhage due to Valsalva retinopathy underwent Nd:YAG laser membranotomy. After membranotomy, his visual acuity improved from 20/200 to 20/25. Ten months later, he developed metamorphopsia with visual acuity of 20/30. A semiopacified membrane with radiating striae was found, and pars plana vitrectomy was performed for membrane removal. RESULTS: Histologic examination of the membrane showed hemosiderin deposits within macrophages on the retinal side of the ILM. One year later, the patient was asymptomatic with visual acuity of 20/20. CONCLUSIONS: To our knowledge, histopathologic confirmation of the sub-ILM hemorrhage in Valsalva retinopathy and epiretinal membrane formation with ILM wrinkling as a complication after Nd:YAG laser membranotomy have not been previously reported.     

Optical coherence tomography features of sub-internal limiting membrane hemorrhage and preretinal membrane in Valsalva retinopathy

CASE REPORT: Optical coherence tomography features of a sub-internal limiting membrane (ILM) premacular hemorrhage and dome-shaped preretinal membrane secondary to Valsalva retinopathy are described. COMMENTS: The origin of the membrane (internal limiting membrane or posterior hyaloid) and the location of the blood (sub-ILM or subhyaloid) are difficult to define by ophthalmoscopy.     

Nd:YAG laser treatment for Valsalva premacular hemorrhage

OBJECTIVE:To report a case of Valsalva premacular hemorrhage treated by Nd:YAG laser.;METHODS:A patient who presented with Valsalva premacular hemorrhage was treated with photodisruptive Nd:YAG laser to drain the entrapped premacular blood into the vitreous.;RESULTS:After photodisruption, vision in the affected eye improved rapidly due to exposure of the macula.;CONCLUSIONS:Nd:YAG laser treatment may be a good alternative for recent preretinal hemorrhages. Clinical benefits include rapid visual rehabilitation and the avoidance of vitrectomy.     

Opthalmoscopic Findings in Adult Patients with Severe Falciparum Malaria

Aim: To report the systemic and ocular findings of four Indian adult patients with severe Plasmodium falciparum infection. Materials and Methods: Case reports. Results: The commonest findings seen were posterior pole hemorrhages that were seen in all patients. These included superficial and subretinal hemorrhages. Some of the eyes with subretinal hemorrhages were associated with a premacular hemorrhage. The findings of retinal whitening and vascular changes were seen in one patient. Conclusions: A spectrum of ocular lesions was noted, including pre-retinal, subretinal hemorrhages, retinal whitening, and retinal vascular anomalies.     

Optical coherence tomography findings in valsalva retinopathy

PURPOSE: To demonstrate the plane of premacular hemorrhage in Valsalva retinopathy with optical coherence tomography DESIGN: Observational case report METHODS: Two young men with Valsalva stress-related premacular hemorrhage were evaluated by OCT scans, taken just above the level of sedimented blood. RESULTS: In both cases, OCT demonstrated two distinct membranes: a highly reflective band immediately above the premacular hemorrhage, corresponding to the internal limiting membrane, and an overlying patchy membrane with low optical reflectivity consistent with posterior hyaloid. CONCLUSION: OCT supported the clinical impression that the plane of premacular hemorrhage in Valsalva retinopathy is probably under ILM. Larger case studies are required to confirm this finding.     

The effect of Nd:YAG laser membranotomy and intravitreal tissue plasminogen activator with gas on massive diabetic premacular hemorrhage.

BACKGROUND AND OBJECTIVE: To investigate the combined therapeutic effects of Nd:YAG laser membranotomy and intravitreal tissue plasminogen activator (tPA) (Actilyse; Boehringer Ingelheim, Ingelheim, Germany) injection with perfluoropropane (C3F8, 100%) injection on massive diabetic premacular hemorrhage. PATIENTS AND METHODS: Nd:YAG laser membranotomy was performed on the hemorrhagic membrane of premacular hemorrhage, and tPA (25 microg/0.1 mL) was injected into the vitreous cavity of seven eyes with massive diabetic premacular hemorrhage. For each procedure 0.2 mL of C3F8 was also injected. RESULTS: After the combined therapy, the patients recovered vision within 4 weeks and the hemorrhages were completely absorbed within 8 weeks. Visual acuity at the last follow-up visit improved to a mean of 10 logarithm of the minimum angle of resolution lines in all cases. There were no associated ophthalmic complications. CONCLUSION: The combined therapy resulted in resolution of premacular hemorrhages with proliferative diabetic retinopathy and may allow for faster resolution of premacular hemorrhages and lessen the need for vitrectomy.     

A case report of unusual retinal findings in a patient with Zieve syndrome

BACKGROUND: The Zieve syndrome is characterized by hemolytic anemia in conjunction with secondary hyperlipidemia in patients suffering from alcohol-related toxic liver damage. So far no retinal changes have been reported due to the Zieve syndrome. CASE REPORT: A 44-year-old diabetic attended a routine control by an ophthalmologist. It was known that he had steatohepatitis due to an abuse of ethanol for years and 1 month previously he had suffered from nausea and vomiting. The visual acuity was found to be good on both sides (1.0/0.8). In the fundus white-colored retinal vessels and peripapillary cotton wool exsudates with isolated hemorrhages were found. An extremely lipemic serum and a severe anemia were present. The patient was referred to the internal department for further investigation and because of the anemia the patient received two blood transfusions. The elevated cholesterol and triglyceride levels in the serum could be substantially reduced by treatment with a cholesterin synthetase inhibitor and a fibrate. The follow-up examination 3 weeks later revealed a regular blood flow and a regression of cotton wool exsudates and 1 month later no pathological retinal findings were detected. CONCLUSIONS: The retinal changes were caused by the combination of severe anemia and hyperlipidemia and these findings played a leading role for deciding further diagnostic procedures. After treatment of the metabolic disorder the retinal changes were completely reversible without functional restrictions.     

Double vital staining using trypan blue and infracyanine green in macular pucker surgery

AIMS: To study the clinical properties of double vital staining in premacular fibrosis, facilitating complete removal of all epiretinal tissue. METHODS: In a two step surgery, the epiretinal pucker was removed after staining with trypan blue, whereafter the inner limiting membrane was peeled after staining with infracyanine green. RESULTS: In all 30 patients, a separate epiretinal layer and inner limiting membrane were removed from the macular area. Pathological examination showed different histological properties of the removed layers. An increased visual acuity was measured in 26 patients, and a slightly decreased visual acuity in one patient. CONCLUSION: The described double staining technique could be a novel valuable tool that may help to achieve optimal anatomical and functional recovery after surgery for premacular fibrosis     

Ultrastructural study of epiretinal membrane stained by trypan blue: 15 case reports

INTRODUCTION: Idiopathic epiretinal membrane results from detachment of the posterior hyaloid and is believed to be related to naturally occurring defects in the internal limiting membrane (ILM) of the retina. Vitrectomy and peeling are the treatment of choice. Trypan blue 0.15% (TB) stains epiretinal membrane and internal limiting membrane. It allows selective and complete removal, facilitating surgery, with less retinal damage. An ultrastructural study was conducted showing ultrastructural features of idiopathic epiretinal membranes (ERM) and those of the internal limiting membrane and its connections with the retinal side. MATERIAL AND METHODS: After pars plana vitrectomy and induction of posterior vitreous detachment, 0.2 ml TB 0.15% was injected over the ERM in an air-filled eye. The stained tissue was peeled with intraocular forceps. Specimens were at once collected in 4% glutaraldehyde for a transmission electron microscopy study. RESULTS: TB may allow complete and easier ERM and ILM peeling. The staining does not present toxic effects. The major cellular contingent is represented by glial cells, participating actively in neocollagen synthesis. Their presence supports the hypothesis of a migratory movement of retinal cells toward the vitreoretinal side. CONCLUSION: The presence of an intact internal limiting membrane, the absence of optical fibers belonging to the under retina, and the absence of any sign of apoptosis make TB a useful staining agent for ERM and ILM peeling.     

Optical coherence tomography findings in Shaken Baby syndrome

PURPOSE: To evaluate features of optical coherence tomography (OCT) associated with Shaken Baby syndrome (SBS) in an attempt to gain new insight into the pathophysiology of this phenomenon. DESIGN: Institutional prospective observational case series. METHODS: We report three infants with SBS. Each patient underwent an ophthalmic examination including slit-lamp biomicroscopy, dilated indirect ophthalmoscopy, color fundus photography, and OCT. RESULTS: In all infants, numerous bilateral multilayered retinal hemorrhages were present. In one case, bilateral perimacular folds had occurred. OCT confirmed retinal hemorrhages and perimacular folds. Moreover, OCT revealed vitreoretinal traction in all infants and suspected hemorrhagic macular retinoschisis in one case. Based on OCT findings, a hypothesis of vitreoretinal traction development and retinal fold formation is proposed. CONCLUSIONS: OCT provided valuable additional information about the ocular pathology in patients with SBS. Vitreoretinal membrane formation seen in OCT could support the pathophysiological theory of a direct mechanical effect. OCT revealed preretinal blood accumulation as a cause for localized vitreous detachment and vitreoretinal traction. Furthermore, OCT showed persistent attachment of the vitreous to the internal limiting membrane at the apices of perimacular folds and suggested small hemorrhagic macular retinoschisis in one patient. Perimacular folds and hemorrhagic macular retinoschisis are regarded as highly specific for SBS and indicate poor visual outcome. Thus OCT might be of both diagnostic and prognostic value in SBS.     

Scanning laser ophthalmoscopic microperimetry on idiopathic epiretinal membrane and vitreomacular traction syndrome

PURPOSE: To evaluate visual function before and after vitrectomy for idiopathic epiretinal membrane and vitreomacular traction syndrome. METHODS: Microperimetry with scanning laser ophthalmoscope (SLO) was performed in 4 eyes with idiopathic epiretinal membrane (IERM) and 2 eyes with vitreomacular traction syndrome (VMTS), before and at least 3 months after vitrectomy. RESULTS: Five eyes had preoperative scotoma, which disappeared postoperatively. In 1 eye, absolute and relative scotomas developed postoperatively over the areas where the retinal surface was vigorously scratched to peel off an overlying membrane, and in another eye new scotomas appeared over a newly formed epiretinal membrane 8 months after vitrectomy. CONCLUSIONS: To our knowledge, the present report is the first to describe preoperative absolute scotoma in IERM, VMTS and also iatrogenic absolute scotoma due to retinal scratching. SLO microperimetry is useful for evaluation of visual function before and after vitrectomy for epiretinal membrane and vitreomacular traction syndrome.     

Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma

OBJECTIVE: To report 3 patients with type I osteogenesis imperfecta (OI) who developed retinal hemorrhages and subdural hematomas after minor trauma. DESIGN: Observational case series. METHOD: Children with OI who developed retinal hemorrhages after minor trauma were identified through an international e-mail-based mailing list for professionals with an interest in child abuse. RESULTS: Three patients with type I OI who presented to the emergency department after a short fall were identified. Clinical evaluation included pediatric and ophthalmic examination. Investigations included complete blood count, coagulation profile, computed tomography of the brain, and a skeletal survey. Ophthalmologic examination revealed retinal hemorrhages in all the children. In the first patient, these were flame shaped and located in the posterior pole of the left eye. The second patient had vitreous and retinal hemorrhages in both eyes. The third patient had scattered intraretinal hemorrhages in both eyes. Computed tomography demonstrated a subdural hematoma in all of the patients and, in patient 2, a simple parietal skull fracture. The child protection teams that investigated the cases believed the explanations offered for the injuries to be plausible, and a diagnosis of accidental injury was made in all 3 patients. CONCLUSION: This is the first report of retinal hemorrhages and subdural hematoma after trivial trauma in patients with type I OI. The collagen defects underlying this disorder of bone and connective tissue may predispose patients with type I OI to retinal hemorrhages and subdural hematomas after minor trauma.     

Acute bilateral vitreo-retinal hemorrhages following oxygen-ozone therapy for lumbar disk herniation

PURPOSE: To describe a case of acute bilateral intraocular hemorrhages occurring after injection of oxygen-ozone (O(2)O(3)) mixture. DESIGN: Observational case report. METHODS: A 45-year-old woman complained about acute bilateral visual loss after intradiscal and periganglionic injection of gas mixture (O(2)O(3)) for lumbar disk herniation. Detailed ophthalmologic examination; magnetic resonance imaging (MRI) of brain and spinal cord; and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser membranotomy in the left eye was performed. RESULTS: Ophthalmoscopy revealed a premacular hemorrhage involving the left macula. In the right eye multiple, flat, retinal hemorrhages around the optic disk and the posterior pole were observed. The MRI scan for intracranial hemorrhage was unremarkable. Drainage of the left premacular hemorrhage by pulsed Nd:YAG laser was obtained a few weeks later. CONCLUSIONS: Retinal hemorrhages seem to be an uncommon but significant complication of intradiscal O(2)O(3) infiltration, and we suggest that it should be carefully considered when recommending this procedure.     

Combined radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion.

To evaluate the efficacy of radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion. Eight consecutive eyes with central retinal vein occlusion with a duration of less than 6 months, cystoid macular edema, and best-corrected visual acuity (BCVA) of less than 20/200 were enrolled. BCVA, intraocular pressure, fluorescein angiography, and optical coherence tomography were evaluated. After 4.75 +/- 0.7 months, BCVA significantly improved, intraocular pressure was well controlled, and fluorescein angiography showed perfused state and reduction of the number of retinal hemorrhages in all eyes. Optical coherence tomography revealed significant reduction of macular thickness. Bleeding in the neurotomy site occurred in 3 cases. Radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide may be useful in the management of central retinal vein occlusion with macular edema.     

Krypton laser membranotomy in the treatment of dense premacular hemorrhage

BACKGROUND: Neodymium:YAG (Nd:YAG) laser and argon laser membranotomy have been used in patients with premacular hemorrhage to drain premacular blood into the vitreous cavity and rapidly clear the hemorrhage. However, the Nd:YAG laser appears to be difficult to use, and argon laser energy may be more likely to be absorbed by the ocular media. We performed a study to evaluate the safety and effectiveness of krypton laser membranotomy in selected cases of premacular hemorrhage. METHODS: Sixteen patients (17 eyes) with dense premacular hemorrhage for 2 weeks or less were enrolled from April 1998 to February 2004. The causes of premacular hemorrhage were proliferative diabetic retinopathy (PDR) in 12 eyes, Valsalva retinopathy in 3 eyes, leukemia in I eye and retinal arterial macroaneurysm in I eye. Krypton laser was used to create a membranotomy on the sloping edge of the premacular hemorrhage. Five eyes with PDR were treated with inferior panretinal photocoagulation and laser membranotomy simultaneously. After intravitreal dispersion of premacular blood, fundus examination was performed in all eyes and fluorescein angiography in five eyes to evaluate retinal damage. RESULTS: All eyes had visual improvement within 2 weeks postoperatively. No retinal damage was seen at the site of membranotomy in any eye. No eye needed vitrectomy postoperatively during a mean follow-up duration of 18.6 months. INTERPRETATION: Krypton laser membranotomy appears to be a safe and simple alternative procedure for treating selected cases of premacular hemorrhage. Further trials are necessary to evaluate its benefit.