Nd:YAG laser membranotomy for premacular haemorrhage.

Abstract

Sir, Premacular haemorrhages may occur in a variety of disorders, including diabetic retinopathy, retinal vein occlusion, valsalva retinopathy, retinal artery macroaneurysm and ocular trauma. In these conditions the blood is entrapped in the retrohyaloid space or beneath the internal limiting membrane, leading to acute and severe visual loss. Spontaneous resorbtion of the blood usually takes several months, and may occasionally induce epiretinal membrane formation or tractional macular detachment (Cleary et al. 1975; O'Hanley & Canny 1985). The present report describes the drainage of premacular haemorrhages into the inferior vitreous cavity through Nd:YAG laser membranotomies. Patient 1 (a 43-year-old man) and Patient 2 (a 26-year-old man) noticed a sudden loss of vision in one eye. Visual acuity (VA) was reduced to finger counting and hand movements, respectively, due to large premacular haemorrhages (1, 2). A Nidek ophthalmic Nd:YAG laser YC-1400 (Nidek Co. Ltd, Gamagori, Japan) was used to make membranotomies at the inferior margin of the anterior surface of the haematomas. In Patient 1 the photodisruption was performed 10 days after the initial symptoms, with a single Nd:YAG laser pulse of 5.0 mJ through a 25 mm Peyman wide-field YAG laser lens (Ocular Instruments Inc., Washington, District of Columbia, USA) (Fig. 1B). Patient 2 was treated 1 day after his visual loss, with a Nd:YAG laser pulse of 6.0 mJ through a Volk Area Centralis lens (Volk Optical Inc., Mentor, OH, USA) (Fig. 2B). In both patients the premacular area cleared completely within 3 days, and VA improved to 6/18 and 6/6, respectively. No retinal or systemic pathological condition could be identified during follow-up (1, 2). Patient 1. (A) Right fundus at presentation, showing a premacular haemorrhage with a glistening light reflex.(B) A photographic montage reveals a stream of blood flowing inferiorly into the vitreous cavity immediately after successful Nd:YAG laser membranotomy.(C) Two years after treatment, the fundus is normal and VA is 6/4. Patient 2. (A) Left fundus at presentation, showing a large premacular haemorrhage.(B) Shortly after Nd:YAG laser membranotomy, the premacular haemorrhage has drained into the vitreous.(C) Two months after treatment, the premacular area has cleared and VA is 6/4. A circinate line in the posterior pole demarcates the extent of an empty retrohyaloid space (arrows). Patient 3 (a 52-year-old man) presented with VA of finger counting in his right eye. Fundoscopic examination revealed a non-ischaemic central vein occlusion with multiple intraretinal haemorrhages, mild dilatation of the retinal veins and two preretinal haemorrhages, one located in the macular area and one located superiorly to the optic disc (Fig. 3A). Eleven days later, Nd:YAG laser membranotomy was performed through a 25 mm Peyman wide-field YAG laser lens (Ocular Instruments Inc.), with four pulses of 3.5 mJ at the inferior margin of the premacular haemorrhage, leading to a rapid dispersion of blood into the vitreous. Visual acuity improved to 6/9 after 3 days and to 6/4 after 3 months (Fig. 3B). Patient 3. (A) Right fundus at presentation, showing two preretinal haemorrhages, one in the macular area and one superior to the optic disc. Note the multiple intraretinal haemorrhages and the mild dilatation of the retinal veins. (B) Three months after Nd:YAG laser membranotomy, the premacular haemorrhage has completely cleared and VA is 6/4. (C) Six months after the initial symptoms, the preretinal haemorrhage superior to the optic disc has evolved into depositions of altered blood. Several authors have shown the beneficial effect of Nd:YAG laser disruption of the posterior hyaloid and the internal limiting membrane to allow drainage of the haemorrhages into the lower vitreous cavity (Faulborn 1988; Ulbig et al. 1998; Rennie et al. 2001). Although macular hole and retinal detachment have been described after treatment (Ulbig et al. 1998), complications seem to be very rare. The present case series confirms that Nd:YAG laser membranotomy is a safe and effective procedure leading to a rapid restoration of visual function. The positive effect of preretinal blood drainage is well illustrated in Patient 3, who had two uniform haemorrhages in his right eye. The premacular haemorrhage disappeared completely within a few days of the membranotomy. On the other hand, the untreated preretinal haemorrhage superior to the optic disc led to a long-lasting deposition of altered blood (Fig. 3C).