Premacular Subhyaloid Haemorrhage Drainage by Frequency

Original Article
Delhi Journal of Ophthalmology
Premacular Subhyaloid Haemorrhage Drainage
by Frequency-Doubled (532 nm) Nd:YAG Laser
MK Rathore1 MS, Eva Tirkey1 MS, Shivcharan Lal Chandravanshi1 MS,
Jainendra Shivdas Rahud1 MS, Rachhana Gupta2 MS
Abstract
Aim:- To evaluate the safety and efficacy of frequency-doubled Nd:YAG Laser hyaloidotomy in drainage of
premacular subhyaloid haemorrhage of varied aetiology.
Methods:- This was a retrospective study in which frequency-doubled Nd:YAG laser was used for draining
entrapped premacular subhyaloid haemorrhage of varied aetiology into the vitreous cavity in 22 eyes of 18
patients by a single surgeon over a period of one year. In this series, visual acuity improvement was defined
as an improvement of three or more lines on Snellen’s visual acuity chart.
Results:- We found best visual acuity improvement in cases of anaemic and Valsalva retinopathy and limited
improvement in proliferative and non proliferative diabetic retinopathy despite successful drainage of
haemorrhage. Three eyes required two sitting and four eyes required higher energy for drainage.
Conclusion:- Frequency-doubled Nd:YAG laser (532 nm) hyaloidotomy is a safe, simple and noninvasive
procedure with a high success rate for the management of premacular subhyaloid haemorrhage. It is
an effective, conservative and safer treatment modality for management of premacular subhyaloid
haemorrhage.
Del J Ophthalmol 2012;23(1):29-33.
Key Words : frequency-doubled Nd:YAG laser, subhyaloid haemorrhage, premacular haemorrhage, Laser
hyaloidotomy, anaemic retinopathy.
DOI : http://dx.doi.org/10.7869/djo.2012.37
Premacular subhyaloid haemorrhage refers to blood
accumulation in the subhyaloid or the retrohyaloid space,
which lies between the posterior hyaloid face and the
internal limiting membrane of the retina. Premacular
subhyaloid haemorrhage has a circular shape in beginning
and latter assumes a hemispherical configuration with a
straight upper margin due to the effect of the gravity and
typically is boat shaped.1 The source of blood in subhyaloid
haemorrhage is the capillaries of the retinal blood vessels.
Premacular subhyaloid haemorrhage may occur from
various vascular or haematological disorders which include
anaemic retinopathy, proliferative diabetic retinopathy,
blunt trauma, branch retinal vein occlusion, Valsalva
retinopathy, retinal macroaneurysm rupture, Terson
syndrome, age related macular degeneration, etc. Sudden,
painless and profound loss of vision is the most common
presentation.2-7 Spontaneous resorption of blood entrapped
in the subhyaloid space tends to be very slow and may take
several months to years to resolve.8 In long standing cases,
complications like formation of an epiretinal membrane8,
macular traction, retinal detachment, cataract, amblyopia
1 Shyam Shah Medical College, Rewa, M.P., India
2 Gandhi Medical college, Bhopal, M.P., India
Correspondence to : Dr. Mahesh Kumar Rathore
E-Mail : [email protected]
Vol. 23, No.1, July - September, 2012
and toxic effect of long standing haemorrhage may cause
irreversible retinal damage and result in permanent visual
loss. Observation2,3 and vitrectomy8-12 are the two old modes
of treatment. Alternative newer methods are hyaloidotomy
or membranotomy using different lasers like Nd:YAG laser
(1064 nm)13-16 or Argon laser (514 nm)17 The present study
was undertaken to evaluate the efficacy of frequencydoubled Nd:YAG laser (532 nm) hyaloidotomy.
Materials & Methods
This is a retrospective study of 22 eyes of 18 patients
having premacular subhyaloid haemorrhage of varied
aetiology. The study period was from June 2007 to May 2008.
All were treated with frequency-doubled Nd:YAG laser
(532 nm) hyaloidotomy to drain the premacular subhyaloid
haemorrhage. Pre and post treatment examination included
visual acuity on Snellen’s chart, fundus examination
by direct ophthalmoscopy and slit lamp biomicroscopy
with +90 D Volk lens for posterior pole examination. A
detailed peripheral retinal examination with indirect
ophthalmoscope was also done to rule out any other
peripheral retinal lesion or retinal vascular diseases. Colour
fundus photographs of all patients were taken before and
after treatment. The horizontal and vertical diameters of the
preretinal haemorrhage were measured in disc diameters
by layover with transparencies for either 30 degree or 50
degree fundus photographs in a standardized manner.
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Delhi Journal of Ophthalmology
TABLE 1. Patient Demographic Data And Clinical Characteristics
SL. No
Age/Sex
Diagnosis
Duration of
Size of
Visual Acuity
haemorrhage Haemorrhage
Before T/t
(days)
1.
23y/F
2.
28y/F
Anaemic
Retinopathy
Anaemic
Retinopathy
3.
16y/F
Anaemic
Retinopathy
7
4.
25y/F
5.
20y/F
6.
7.
60y/F
20y/M
8.
9.
10.
68y/F
46y/M
12y/F
11.
12.
52y/M
18y/F
13.
10y/F
14.
63y/M
15.
14y/F
16.
17.
57y/M
45y/M
18.
22y/F
Anaemic
Retinopathy
Anaemic
Retinopathy
PDR
Valsalva
Retinopathy
NPDR
BRVO
Anaemic
Retinopathy
NPDR
Anaemic
Retinopathy
Anaemic
Retinopathy
Retinal macro
aneurysm
Anaemic
Retinopathy
PDR
Valsalva
Retinopathy
Anaemic
Retinopathy
15
5 DD
CF ‘3 Feet
Visual acuity after Treatment
1 Year
1st week 3rd mth
6/6
6/6
6/6
40
OD -3 DD
OS – 2.5 DD
OD -1.0 DD
OS – 3.0 DD
OD -1/60
OS- 3/60
OD -2/60
OS – 1/60
OD-6/6 OD-6/6 OD-6/6
OS-6/9
OS-6/6 OS- 6/6
OD -6/6 OD- 6/6 OD – 6/6
OS – 6/6 OS – 6/6 OS – 6/6
17
4.0 DD
CF 2 Feet
6/6
6/6
6/6
12
2.0 DD
1/60
6/6
6/6
6/6
14
3
2.5 DD
3.5 DD
CF 3 Feet
6/60
6/24
6/6
6/24
6/6
6/18
6/6
5
4
10
6
16
2.5 DD
2.0 DD
OD – 1.0 DD
OS – 2.0 DD
4.0 DD
1.0 DD
4/60
6/60
OD-6/60
OS- 4/60
6/60
6/60
10
2.5 DD
CF 3 Feet
6/6
6/6
6/6
5
3.5 DD
6/60
6/18
6/6
6/6
15
2.0 DD
6/60
6/6
6/6
6/6
14
5
3.0 DD
4.5 DD
CF 2 Feet
CF 2 Feet
6/36
6/6
6/36
6/6
6/36
6/6
10 days
OD – 2.5 DD
OS – 3.0 DD
OD-3/60
OS-2/60
6/36
6/12
6/9
6/9
OD- 6/6 OD-6/6
OS- 6/6 OS -6/6
6/18
6/12
6/6
6/6
6/12
6/6
OD-6/6
OS-6/6
6/12
6/6
OD-6/9 OD- 6/6 OD -6/6
OS- 6/9 OS -6/6 OS- 6/6
PDR-Proliferative Diabetic Retinopathy; NPDR-Nonproliferative Diabetic Retinopathy; BRVO-Branch Retinal Vein Occlusion ; ODOculus Dexter; OS-Oculus Sinister; V/A-Visual Acuity; CF-Counting Finger; BCVA-Best Corrected Visual Acuity; PRP-Pan Retinal
Photocoagulation ; CSME-Clinically Significant Macular Ooedema.
Procedure
After taking written consent, the pupil was dilated with
0.8% Tropicamide and 5% Phenylephrine hydrochloride eye
drops. All laser procedures were done on out patient basis
under topical anesthesia with 4% xylocaine. The frequencydoubled Nd: YAG laser 532 nm (Zeiss -Visulas YAG laser
with lio 532 nm) was delivered via a slit lamp microscope and
Mainster wide field lens (Ocular Instruments Incorporation,
Bellevue, WA).
Ø
Laser setting - Duration 100 msec
Ø
Spot size for penetration burn – 75 micro metre
The sloping edge of the most dependent and prominent
portion of the anterior surface of the subhyaloid haemorrhage
30
was the site of choice for hyaloidotomy, which was farthest
from fovea to protect the foveola from laser impact and also
to support outflow by gravity. Frequency-doubled Nd:YAG
laser (532 nm) hyaloidotomy is like a two step procedure
to drain entrapped blood into the vitreous. Two stretch
burns are given to make the membrane stable and taut. The
penetration burns are placed between stretch burns. In our
series, hyaloidotomy was achieved with 1 to 4 burns on the
surface of posterior hyaloid face. Initially laser setting was
started with 140 mJ and then it was gradually increased
until perforation became visible at the surface of premacular
subhyaloid haemorrhage. In eyes with diabetic retinopathy
associated with clinically significant macular oedema, grid
or panretinal photocoagulation was performed before laser
hyaloidotomy. The laser parameter settings were recorded
Vol. 23, No.1, July - September, 2012
Delhi Journal of Ophthalmology
TABLE 2. Frequency Doubled ND:YAG (532 nm) Parameters
SL. No
No. of penetration burns
Energy per penetration burn
Remarks
1.
Ist sitting -4
2nd sitting -3
Ist sitting-300 / 340 /400 /440
2nd sitting-320 / 340 /380
2 sittings, 1 week apart
2.
OD - 5
OS - 4
OD – 280 /300 /320/340/ 400
OS- 320 /340 /380 / 400
2 sittings, 1 week apart
3.
OD - 1
OS - 2
OD-320
OS-320 / 340 /380
No complication
4.
1
340
No complication
5.
2
340 /360
No complication
6.
4
320 /340/360/380
PRP done
7.
3
280 / 300 /320
No complication
8.
4
260/ 280/300/320/
Diabetic macular oedema, Grid
laser photocoagulation
9.
2
320/ 340
No complication
10.
OD - 1
OS - 2
340
340 / 360
No complication
11.
5
280/320/360/380/400
2 sittings, PRP done for CSME
12.
1
360
No complication
13.
4
300/320/340/360
No complication
14.
4
320 /360 /380 /380
No complication
15.
4
280 /300 / 340 / 360
No complication
16.
4
300 /320 /360 / 380
PRP done
17.
4
260 /300 /320 /380
No complication
18.
OD – 3
OS - 4
OD-300 /320 / 360
OS-280 /320 / 360
No complication
in all patients and immediate post laser colour fundus
photographs were taken.
After laser treatment patient was advised head end
elevated position till the blood cleared from the visual axis.
All patients were followed up at 24 hours, 1 week and 1,3,
6 and 12 months after procedure. The study followed the
tenets of the declaration of Helsinki institutional review
board/ethics committee approval was obtained and the
study adhered to research governance requirements.
Results
Frequency doubled Nd:YAG laser (532 nm) was used
to drain subhyaloid haemorrhage of different aetiologies
into the vitreous in 22 eyes of 18 patients. The causes of
premacular haemorrage were anaemic retinopathy (14
eyes), diabetic retinopathy (4 eyes), Valsalva retinopathy
(2 eyes), branch retinal vein occlusion (1 eye), ruptured
retinal macro aneurysm (1 eye) . Table No. 1 shows patient
demographic data and clinical characteristics. There were 6
males and 12 females. All patients of anaemic retinopathy
were female. Age group of the patients ranged from 10
to 68 years with an average age of 33.27 years. The time
of presentation of patients ranged from 3 to 40 days with
an average time of 11.55 days. Visual acuity at the time of
Vol. 23, No.1, July - September, 2012
presentation ranged from counting finger at 2 feet to 6/60
on Snellen’s visual acuity chart. All patients of anaemic
retinopathy had haemoglobin less than 6 gm per deciliter.
Success of Nd:YAG laser (532nm) procedure was defined
as complete drainage of subhyaloid haemorrhage into the
vitreous cavity and its subsequent absorption within one
month and visual improvement of three or more lines on
Snellen’s chart. Immediate displacement of blood was
seen in fresh cases with visual acuity improvement within
a day after laser treatment. Dispersed haemorrhage in the
vitreous completely resolved within a month in all eyes.
At one week 17 out of 22 eyes had regained near normal
vision (6/9 to 6/6). One patient with ruptured retinal artery
macroaneurysm had 6/18 vision at one week but he regained
normal vision (6/6) within 3 months as the dispersed blood
took more time to absorb. The remaining 4 eyes had limited
visual acuity improvement from 6/36 to 6/12, which
was probably due to diabetic retinopathy associated with
macular oedema, for which subsequent additional grid &
panretinal photocoagulation were performed. Overall best
visual improvement was seen in anaemic and Valsalva
retinopathy, branch retinal vein occlusion, and retinal artery
macroaneurysms. During the one year follow up period
no laser related complications were found. In our series
we found that usually 140 to 200 mJ energy was sufficient
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Delhi Journal of Ophthalmology
1(a)
1(b)
2(a)
1(c)
2(b)
Figure 1(a): Pretreatment fundus photograph showing dense premacular subhyaloid haemorrhage in Anaemic retinopathy patient;
Figure 1(b): Immediate post treatment fundus photograph showing displacement of blood; Figure 1(c): Fundus photograph after
one month; Figure 2(a): Fundus photograph showing Premacular Subhyaloid haemorrhage after valsalva retinopathy;
Figure 2(b) : Fundus photograph after 1 week Nd: YAG Laser hyaloidotomy
for drainage of premacular subhyaloid haemorrhage into
the vitreous (Table 2). Shows frequency Doubled Nd:YAG
(532 nm) parameters used in laser hyloidotomy. In fresh
cases drainage was possible with 140 to 200 mJ energy but
in old cases higher energy (300 to 400 mJ) was required for
drainage.
Discussion
In 1988 Faulborn22 first described the application of
Q-switched Nd:YAG laser for the drainage of premacular
subhyaloid haemorrhage into the vitreous. Anterior segment
applications of pulsed Nd:YAG lasers are common, but
posterior segment procedures remain limited. The Nd:YAG
laser has been used for vitreolysis and photodisruption of the
internal limiting membrane but focusing and localization are
difficult, when deep vitreous membranes are being cut .This
treatment may be difficult to use in eyes with less extensive
haemorrhage. Moreover, most of the energy is absorbed by
the ocular media in the Nd:YAG laser wavelength spectrum,
thus requiring a high energy level and several bursts. The
frequency doubled Nd:YAG laser (532 nm) may be preferred
over the standard Nd:YAG laser (1064 nm) due to its
focusing capability and greater inherent energy per photon
unit, negligible absorption by ocular media, high absorption
by haemorrhage and excellent delivery system. There is also
less scattering in the ocular media and better transmission
through cataract.Ulbig et al13 had used Nd:YAG laser (1064
32
nm) in their series for drainage of premacular subhyaloid
haemorrhage due to different causes. They reported good
visual recovery in Valsalva retinopathy cases and poor
visual acuity in two eyes because of retinal detachment
and macular hole. Raymond et al14 reported six cases with
premacular subhyaloid haemorrhage originating from
proliferative diabetic retinopathy (4 eyes) and from a retinal
artery macro aneurysm (2 eyes) treated with Nd:YAG laser.
The visual acuity was not satisfactory in his series due to
coexisting retinal changes.
Puthalath. S et al19 used frequency doubled Nd:YAG laser
(532 nm) to treat subhyaloid haemorrhage of different causes.
They noticed poor visual improvement in proliferative
diabetic retinopathy associated with clinically significant
macular oedema. Eyes with premacular subhyaloid
haemorrhage resulting from Valsalva retinopathy had
a good visual recovery. Ezra E et al17 identified macular
oedema after Nd:YAG laser membranotomy that required
focal or panretinal photocoagulation. Raymond et al16
and Ezra et al20 reported macular hole formation with
Nd:YAG laser (1064 nm) hyaloidotomy along with retinal
detachment following laser drainage in a case of bilateral
myopia and retinal breaks. Sahu et al19 used argon laser
treatment in 8 eyes for premacular haemorrhage. They used
one stretch burn with low energy to make the posterior
hyaloid membrane or the internal limiting membrane more
stable and taut. Penetration burns were then placed using
Vol. 23, No.1, July - September, 2012
Delhi Journal of Ophthalmology
high energy. Following argon laser treatment, visual acuity
improved to near normal within a week. No visible damage
was seen at the membranotomy site during follow up. In
our series, frequency-doubled Nd:YAG Laser (532 nm) has
been successfully used to drain the subhyaloid haemorrhage
into the vitreous. Complete intravitreal drainage of the
blood occurred within a week following Nd:YAG laser
hyaloidotomy and visual improvement occurred within
one week. Pretreatment duration of premacular subhyaloid
haemorrhage seems to be of prognostic importance. Our
findings are in support of good prognosis in Valsalva
retinopathy cases. Visual improvement was near normal
(6/6 to 6/9) in 17 eyes. One eye with retinal artery
macroaneurysm regained normal vision (6/6) within 3
months because dispersed blood took more time to absorb.
However, in 4 eyes with haemorrhage due to diabetic
retinopathy, we found limited improvement of vision
(6/36 to 6/12) due to clinically significant macular oedema.
Dispersion of entrapped blood into the vitreous hampers
panretinal photocoagulation. Thus we performed grid
or panretinal laser photocoagulation first in 4 cases of
diabetic retinopathy associated with macular oedema
before hyaloidotomy. In patients with diabetic retinopathy
and retinal artery macroaneurysm, improvement in visual
acuity was not as quick as with Valsalva retinopathy. The
good visual prognosis expected in all cases of Valsalva
and anaemic retinopathy is related to the fact that macula
was healthy unlike in diabetic retinopathy. The degree
of visual improvement of treated eyes depended on the
underlying cause and preexisting macular pathology. In
18 cases, we produced laser burns with 140 -200 mJ energy
and successful drainage of subhyaloid haemorrhage was
noticed with 1 to 4 burns of 100 microns size. Fresh cases ( <
3 weeks duration) of subhyaloid haemorrhage required less
energy (up to 200 mJ) and fewer burns, while long standing
cases required higher energy level (300-400 mJ) and more
burns. We believe that all complications are avoidable, if
case selection is proper and results in these selected cases
would be very good as seen in our series. We have done
doubled Nd: YAG laser (532 nm) hyaloidotomy successfully
in all cases and did not find any complications from the laser
treatment during one year follow up. Frequency-doubled
Nd:YAG laser (532 nm) is a simple, safe, quick effective non
invasive, and alternative procedure to drain premacular
subhyaloid haemorrhage of various etiologies. It also allows
rapid visual rehabilitation. However it goes without saying
that visual prognosis is dependent on macular health.
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