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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 587-588

Full thickness macular hole with subretinal bleed formation following Nd: Yag laser posterior hyaloidotomy for macular subhyaloid hemorrhage


Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission23-Aug-2021
Date of Acceptance19-Nov-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Basavaraj Tigari
Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2150_21

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  Abstract 


Keywords: Macular hole, Nd:YAG hyaloidotomy, subhyaloid hemorrhage, subretinal bleed


How to cite this article:
Markan A, Gautam N, Dogra M, Singh R, Tigari B. Full thickness macular hole with subretinal bleed formation following Nd: Yag laser posterior hyaloidotomy for macular subhyaloid hemorrhage. Indian J Ophthalmol Case Rep 2022;2:587-8

How to cite this URL:
Markan A, Gautam N, Dogra M, Singh R, Tigari B. Full thickness macular hole with subretinal bleed formation following Nd: Yag laser posterior hyaloidotomy for macular subhyaloid hemorrhage. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:587-8. Available from: https://www.ijoreports.in/text.asp?2022/2/2/587/342930



Various treatment modalities such as observation, pars plana vitrectomy (PPV), neodymium-doped yttrium aluminum garnet (Nd: YAG) laser posterior hyaloidotomy (LPH), and pneumatic displacement have been described for subhyaloid hemorrhage.[1] LPH, though a noninvasive procedure, is associated with various complications.[2],[3] We report the development of FTMH along with the occurrence of subretinal bleed due to the photodisruptive effect of LPH.

A 23-year-old female with aplastic anemia developed sudden painless diminution of vision in her right eye (OD) since the last 10 days. Blood investigations showed pancytopenia (hemoglobin: 7.7 gm/dl, total white blood cell count: 1.2 × 109/L, and total platelet count: 2 × 109/L), and bone marrow aspiration showed hypocellularity without evidence of any malignant cells. The patient was admitted under the hematology department of our institution and had received multiple blood transfusions. The best-corrected visual acuity (BCVA) in OD and left eye (OS) was hand motion close to face (HMCF) and 6/12, respectively, with normal intraocular pressures. Fundus evaluation of OD revealed the presence of a 2DD boat-shaped area of subhyaloid hemorrhage (SHH) obscuring the fovea with multiple dot-blot and white-centered retinal hemorrhages, suggestive of anemic retinopathy [Figure 1]a.
Figure 1: (a) Fundus color photo showing the presence of multiple intraretinal hemorrhages with premacular subhyaloid hemorrhage, suggestive of anemic retinopathy. The LPH was performed inferiorly at the most dependent position (white dot). (b) OCT through the premacular bleed shows localized hyaloid detachment with underlying hyperreflectivity suggestive of subhyaloid bleed. White arrow represents the site of LPH

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Swept-source optical coherence tomography (SS-OCT) showed localized posterior hyaloid detachment with underlying hyper-reflective blood obscuring the fovea [Figure 1]b. Nd: YAG LPH was performed (6 mJ, two spots) using bloodcGoldman three mirror contact lens (Volk) at the inferior margin of premacular SHH, which resulted in the creation of an opening in the posterior hyaloid with immediate trickling of blood into the vitreous cavity.

At 3 weeks follow-up, BCVA improved to 6/60 and vitreous hemorrhage had resolved, but there was a FTMH associated with subretinal bleed [Figure 2].
Figure 2: (a) Fundus color photo showing the presence of full-thickness macular hole with associated organized subretinal bleed (yellow). (b)OCT showing presence of full-thickness macular hole with surrounding hyperreflectivity in subretinal space (yellow arrow), suggestive of subretinal blood

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  Discussion Top


Both clinical examination and OCT can provide clues to differentiate SHH from sub-ILM bleed. Clinical clues such as the presence of surface striae and double ring favor sub-ILM bleed.[1],[4] Similarly, the presence of dual membranes or a persistent premacular cavity after membranotomy on OCT points toward sub-ILM bleed.[5],[6] Lack of any such clinical and OCT signs favored the diagnosis of SHH in our case.

FTMH occurred due to the direct impact of the photodisruptive laser at the fovea.[7] This was followed by subretinal migration of the premacular hemorrhage through the FTMH. The presence of subretinal blood could potentially hamper the anatomic and functional success after FTMH surgery. Thus, it is important to highlight the occurrence of this rare complication following LPH.

This report highlights the fact that Nd: YAG LPH should be performed with utmost caution by using minimal possible energy and should be reserved for SHH of at least 3DD to avoid iatrogenic damage to the fovea.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mennel S. Subhyaloidal and macular haemorrhage: Localisation and treatment strategies. Br J Ophthalmol 2007;91:850-2.  Back to cited text no. 1
    
2.
Khadka D, Bhandari S, Bajimaya S, Thapa R, Paudyal G, Pradhan E. Nd: YAG laser hyaloidotomy in the management of premacular subhyaloid hemorrhage. BMC Ophthalmol 2016;16:41.  Back to cited text no. 2
    
3.
Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd: YAG laser. Arch Ophthalmol 1998;116:1465-9.  Back to cited text no. 3
    
4.
Mathew DJ, Sarma SK. Valsalva retinopathy with double ring sign: Laser membranotomy for twin bleeds. Saudi J Ophthalmol 2016;30:68-70.  Back to cited text no. 4
    
5.
Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in valsalva retinopathy. Am J Ophthalmol 2005;140:134-6.  Back to cited text no. 5
    
6.
Meyer C, Mennel S, Rodrigues E, Schmidt J. Persistent premacular cavity after membranotomy in Valsalva retinopathy evident by optical coherence tomography. Retina (Philadelphia, Pa) 2006;26:116-8.  Back to cited text no. 6
    
7.
Bypareddy R, Chawla R, Azad SV, Takkar B. Iatrogenic parafoveal macular hole following Nd-YAG posterior hyaloidotomy for premacular haemorrhage. BMJ Case Rep 2016;2016:bcr2016217234.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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