Laser Membranotomy Research Articles

Nd:YAG laser membranotomy in sub-ILM hemorrhage as a result of a Valsalva retinopathy

Nd:YAG laser membranotomy in sub-ILM hemorrhage as a result of a Valsalva retinopathy

Multilayered premacular haemorrhage associated with central retinal vein occlusion

AbstractPurpose: We aimed to report a rare case of multilayered premacular haemorrhage complicating central retinal.vein occlusion (CRVO) and to describe its management and follow‐up.Methods: An observational case report of a 38‐year‐old man with no medical history who presented with sudden loss of vision in his left eye (LE) 4 days ago. The patient underwent complete ophthalmologic examination, fluorescein angiography (FA) and swept‐source optical coherence tomography (SS‐OCT).Results: Ophthalmologic examination of the right eye (RE) was unremarkable with a best‐corrected visual acuity (BCVA) of 20/20. In the LE, BCVA was limited to light perception (LP), intraocular pressure was 12 mmHg and anterior segment showed no abnormalities. Ophthalmoscopy showed dilated veins, multiple flame haemorrhages and a large dome‐shaped premacular haemorrhage with a double‐ring sign. SS‐OCT revealed a dome shaped clotted haemorrhage surrounded by hyperreflective dots under the internal limiting membrane (ILM) corresponding to a multilayered sub‐ILM haemorrhage. On FA, we noticed a delay in venous filling time and no areas of capillary‐non perfusion. Systemic work‐up with glaucoma screening were unremarkable. Nd:YAG laser hyaloidotomy and membranotomy of the ILM were performed. At one‐week follow‐up, there was evidence of the sub‐ILM and subhyaloid blood draining into the vitreous cavity. At 3 weeks following the laser treatment, persistence of clotted blood was noted. Pars plana vitrectomy with ILM peeling were performed. Two months post‐operatively, BCVA improved from LP to 20/25 with complete resolution of the haemorrhages on fundoscopy and SS‐OCT.Conclusions: Premacular haemorrhage associated with CRVO is a rare condition. SS‐OCT allows accurate diagnosis and non‐invasive follow‐up. Nd: YAG laser hyaloidotomy should be considered as the first line treatment. But if failed, vitrectomy with ILM peeling should not be delayed in order to avoid toxic damages to the retina.

A brief review of Valsalva retinopathy

Background: Valsalva retinopathy is a specific type of retinopathy that appears following an acute rise in intrathoracic or intra-abdominal pressure. This review focuses on current literature and future directions for the diagnosis and management of Valsalva retinopathy.
 Methods: In this brief review, the literature was searched to provide an extensive general and updated description of Valsalva retinopathy, focusing on its management and prognosis. Selected articles are summarized to present the etiology, general pathology, pathophysiology, symptoms, signs, diagnosis, differential diagnosis, treatment, and prognosis of Valsalva retinopathy.
 Results: The main symptom of Valsalva retinopathy is loss of visual acuity following exertion. This is caused by the rupture of small superficial vessels in the macula and perimacular areas, leading to extravasation of blood. No link between age, sex, or race has been found, although fundus vessel abnormalities pose some predisposition to the disease. During fundoscopy, Valsalva retinopathy appears most frequently as well-defined preretinal hemorrhages confined to the sub-internal limiting membrane (ILM) or subhyaloid space. If ILM rupture occurs, hyaloid hemorrhage can appear. Diagnosis is based on the patient’s medical history and a standard examination. Usually, only observation of the patient is required, with the hemorrhage resolving within weeks to months. In cases of large premacular hemorrhage or large sub-ILM/subhyaloid hemorrhage, vitrectomy or Nd:YAG krypton laser membranotomy can be performed.
 Conclusions: Of all the aspects of Valsalva retinopathy that might trouble the physician, the most challenging features are differential diagnosis and the choice of optimal treatment. Therapeutic strategies for Valsalva retinopathy can be either conservative or based on Nd:YAG laser membranotomy and/or vitrectomy. All methods seem to have good outcomes. However, physicians should not be afraid of advancing beyond conservative therapy, especially in the event of persistent premacular hemorrhage, which could lead to permanent retinal damage if valuable time is lost, even after vitrectomy.

A Multi-Lumen Glaucoma Stent With Titratable Pressure-Lowering Effect: A Proof of Concept Study

PurposeTo explore the feasibility of a glaucoma stent with a titratable pressure-lowering effect.MethodsThis was an in vitro study. We created a resin stent with a micro-precision three-dimensional printer. It represented a cylinder with one primary and two secondary lumina. The inner opening of each secondary lumen was sealed with a membrane. We used a surgical eye model to simulate implantation of the stent and a laser procedure analogous to argon laser trabeculoplasty (ALT) to ablate each membrane. To study the fluid dynamics, we used a high-precision syringe pump and measured the steady-state pressure for one, two, and three lumina in parallel at flow rates of 2.5, 5.0, and 10.0 µL/min.ResultsThe stent could be implanted into the eye model and visualized in the anterior chamber angle. Coloring the membrane facilitated laser membranotomy, and a 0.1-second laser pulse with 250-mW power was enough to ablate one membrane. The steady-state pressure for one lumen increased linearly with increasing flow rate, in accordance with the Hagen–Poiseuille equation. Two and three lumina in parallel decreased the pressure by factors of 2.1 and 3.2, respectively, in accordance with the electronic–hydraulic analogy and Ohm's law applied to parallel resistors.ConclusionsThe study presents proof of concept for a glaucoma stent with multiple lumina, which can be separately opened with an ALT-like procedure to induce a predictable, stepwise increase in pressure-lowering effect.Translational RelevanceThe glaucoma stent in this experimental study can be reproduced in a biocompatible material and further studied in vivo.

Efficiency and Complication of 577-nm Laser Membranotomy for the Treatment of Retinal Sub-Inner Limiting Membrane Hemorrhage.

We investigated the clinical efficiency and complications of treatment of retinal sub-inner limiting membrane (sub-ILM) hemorrhage by 577-nm semiconductive laser membranotomy. The clinical features, ocular fundus photography, and SD-OCT image of patients who received 577-nm laser membranotomy for sub-ILM hemorrhage were assessed from January 2017 to April 2022 in this retrospective case-series study. A total of 19 patients (19 eyes) were treated for sub-ILM hemorrhage of the macula, in which eight were women and 11 were men. The age was 15-83 years (with an average age of 49.05 ± 19.41 years old). The right eye was affected in 12 patients, the left eye in seven patients. The follow-up period after laser treatment was from 0.5 to 9 months (with an average follow-up time of 3.25 ± 2.45 months). Treatment was not successful in one patient, and 577-nm laser membranotomy was successful in 18 patients (equaling a success rate of 94.74%). The best corrected visual acuity (BCVA) before laser treatment was from figure count to 40/200, and the BCVA after laser treatment was from 20/2000 to 20/20. Complications after laser treatment comprised macular hole (one patient), macular epi-membrane (one patient), vitreous hemorrhage without absorption (two patients), and sub-ILM cavity (12 patients). The 577-nm laser is effective in treating sub-ILM hemorrhage and has a high success rate. Posttreatment complications should be monitored, and vitrectomy was needed with long-lasting vitreous hemorrhage and macular hole.

Inverse drainage Nd:YAG membranotomy for pre-macular hemorrhage.

To report the outcomes of the "inverse drainage Nd:YAG laser membranotomy" technique for the management of pre-macular hemorrhage (PMH), which has its inferior margin near the fovea. This retrospective study included eyes with PMH, with its inferior margin located within 0.5 disc-diameter (DD) of the fovea. Laser membranotomy was performed near the superior margin of PMH followed by intravitreal injection of 0.3 mL undiluted sulphur hexafluoride (SF6) gas. The patients were advised to maintain a prone position for three days. Twenty patients (20 eyes) with a mean age of 46.1 ± 18.6 years were included in the study. The mean duration of symptoms was 6.9 ± 7.0 days. The mean size of PMH was 4.1 ± 1.2DD. The causes of PMH were Valsalva retinopathy (n = 11) and retinal artery macroaneurysm (RAM, n = 9). The mean maximum height of the blood collection, measured by optical coherence tomography (OCT), within 1 disc-diameter from the inferior and superior borders of the PMH was 738.9 ± 232.9μm and 1240.6 ± 338.1μm respectively (p = 0.001). The mean best-corrected visual acuity (BCVA) improved from logMAR 1.32 ± 0.44 (Snellen equivalent, 20/418) to logMAR 0.11 ± 0.20 (Snellen equivalent, 20/26) (p = 0.001). Vitrectomy was not required in any case. Persistent pre-macular cavity, macular hole, epiretinal membrane (ERM), intra-ocular pressure spike, or rhegmatogenous retinal detachment (RRD) was not noted in any patient. This technique can be safely used to treat eyes with PMH having its inferior margin near the fovea.

Report of a Cluster of Cases of Toxic Anterior-segment Syndrome After Implantation of a Specific Intraocular Lens Model

To report a cluster of cases of toxic anterior-segment syndrome (TASS) in eyes implanted with a specific foldable acrylic intraocular lens (IOL) model. Retrospective case series. The medical records were reviewed for 7 eyes of 4 patients diagnosed with TASS after cataract surgery at Shimane University and Matsue Red Cross Hospital between July and November 2020. Among the 162 eyes implanted with the Lentis Comfort/LS-313 MF15 IOL, acute anterior chamber (AC) inflammation with fibrin formation developed 1-15 days after uneventful surgeries in 7 (4.3%) eyes (cataract surgery alone, n=4 eyes; combined cataract and minimally invasive glaucoma surgery, n=3 eyes). Other than local steroid use, fibrin membrane removal, YAG laser membranotomy, pars plana vitrectomy, and AC washout were performed to treat inflammation and/or secondary angle closure due to pupillary obstruction. We experienced a cluster of TASS cases in eyes implanted with the Lentis Comfort/LS-313 MF15 IOL in a short period of time. To our knowledge, this is the first report of TASS associated with this IOL.

Laser membranotomy by Nd

Laser membranotomy by Nd

Bilateral and multiple sub-internal limiting membrane hemorrhages in a familial retinal arteriolar tortuosity patient by Valsalva-like mechanism: an observational case report

BackgroundBilateral and multiple Valsalva-related sub-internal limiting membrane (ILM) hemorrhages in a familial retinal arteriolar tortuosity (FRAT) patient is rare, and we treated this patient by both observation and Neodymium yttrium aluminum garnet (Nd: YAG) laser membranotomy methods.Case presentationA 13-year-old female student presented with sudden visual loss and central scotoma in both eyes after running 800 m at the school gym. The examination revealed six sub-ILM hemorrhages with the biggest hemorrhage measuring approximately 1.5-disc diameters (DD) in the right eye and two sub-ILM hemorrhages with the biggest one measuring 5.5 DD in the left eye. The patient was diagnosed as having Valsalva retinopathy associated with FRAT. Nd: YAG laser membranotomy was performed at the biggest hemorrhages and the rest hemorrhages were treated with observation in both eyes. The visual acuity recovered to 20/16 in the right eye and 20/20 in the left eye. Epiretinal membrane (ERM) formation was observed in the left eye.ConclusionsNd: YAG laser could be considered for treating premacular hemorrhage in FRAT patient especially when a quick vision recovery was needed. This is the first reported case of a FRAT patient suffering from bilateral and multiple Valsalva-related sub-ILM hemorrhages which were treated by both observation and Nd: YAG laser treatment.

Permanencia de la membrana de Descemet y del endotelio receptor tras queratoplastia penetrante. A propósito de un caso clínico

A case is presented of a retained Descemet's membrane after penetrating keratoplasty, highlighting the importance of the anterior segment optical coherence tomography (OCT) in the diagnosis and treatment planning of keratoplasty complications.A review of literature is also presented.An 88 year-old man underwent penetrating keratoplasty for bullous keratopathy.A retained host Descemet's membrane was detected. The retained membrane went unnoticed until the visual acuity decreased. The ophthalmological examination showed the presence of an opalescent membrane located below the endothelium, and was identified as the Descemet membrane of the receptor. Nd:YAG laser membranotomy was performed after the diagnosis.To conclude, it is noted that the inadvertent retention of the host Descemet membrane is a rare complication in penetrating keratoplasty. The anterior segment OCT was used to determine the diagnosis, and Nd:YAG laser membranotomy is an indicated treatment in these cases.

Bilateral extensive multiple multi-layered retinal haemorrhage in a patient with alcoholic liver disease.

We report a rare case of bilateral multiple bilateral vitreous, pre-retinal and intra-retinal haemorrhages after bouts of coughing in a 47 year old female patient with high international normalized ratio (INR) due to alcoholic liver disease. Patient has been complaining of 2 weeks history of reduced vision to her liver physician who referred her to local eye unit. She reported that the vision deteriorated following intense coughing. She was found to have bilateral vitreous, pre-retinal and intra-retinal haemorrhages. liver disease. The patient was kept under ophthalmic observation. The vitreous, preretinal and intraretinal haemorrhages resolved spontaneously and his vision recovered fully Alcoholic liver disease is becoming more common. Clinicians should be aware that the combination of increased intravenous pressure due to persistent coughing and possible early portal hypertension and a pathological increase in INR can lead to severe multiple multi-layered retinal haemorrhage. The haemorrhages, however, will resolve spontaneously in most cases. In foveal involving pre-retinal haemorrhage, YAG- laser membranotomy was shown to speed up visual recovery in previous reports.

Laser and Anti-Vascular Endothelial Growth Factor Agent Treatments for Retinal Arterial Macroaneurysm.

To describe the efficacy of laser and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents for patients with symptomatic retinal arterial macroaneurysm (RAM). From 2009 to 2016, we collected patients with exudative or hemorrhagic RAM all treated by focal laser photocoagulation. Nd:YAG laser was performed in patients with subinternal limiting membrane (sub-ILM) hemorrhage. Intravitreal anti-VEGF agents were given in eyes with macular exudation as adjuncts. Changes of visual acuity and central foveal thickness before and after treatment were recorded and compared with Wilcoxon signed-rank test. Thirty-five eyes that underwent a single session of laser photocoagulation for RAM resulted in macroaneurysm regression. The hemorrhagic group included 24 eyes having ruptured macroaneurysms without macular exudation. Five eyes with simultaneous sub-ILM hemorrhage receiving Nd:YAG laser membranotomy had resolution of preretinal hemorrhage. Exudative RAM having cystoid macular edema or submacular fluid with or without ruptured macroaneurysms was treated by focal laser photocoagulation alone in 3, or combined with single intravitreal anti-VEGF agent in 8 eyes. All patients had significantly improved vision when comparing visual acuity at baseline and final follow-up (P = 0.00016). Significant reduction of macular thickness was also observed after laser monotherapy or combined treatment in exudative RAM (P = 0.018). Focal laser photocoagulation was helpful for the management of ruptured or leaky RAM. Combined focal laser and intravitreal anti-VEGF agents could better reduce macular exudation caused by RAM. Additionally, Nd:YAG laser was a safe and effective method to remove the sub-ILM hemorrhage caused by RAM.

Premaküler Subhiyaloid Hemoraji Gelişen Gebe Hastada Argon Laser Hiyaloidotomi Uygulaması

A 27-year-old female patient had applied to our clinic with a complaint of sudden onset, painless and persistent loss of vision in the left eye starting after an airplane flight 3 days ago. She was 26 weeks pregnant. Visual acuity in the left eye was counting fingers with a normal anterior segment examination. On fundus exam, subhyaloid hemorrhage covering the macular region between the vascular arcades was noticed. After giving information about the pregnancy, complication risks and other treatment alternatives, drainage of the subhyaloid hemorrhage with Argon laser membranotomy treatment was performed. After laser treatment, drainage of the hemorrhage into the vitreous cavity and instant improvement of vision was observed with no complications. The visual acuity was 0.3 (Snellen chart) the following day and 0.9 on the third postoperative day. Premacular hemorrhage was completely drained at one month. No complications were observed on 2 month follow-up. 532 nm lasers are present in most clinics and when proper parameters are selected, it proved to be an effective and safe alternative for treating premacular subhyaloid hemorrhage in our patient.

Valsalva retinopathy with double ring sign: Laser membranotomy for twin bleeds

This report describes the case of a 27-year-old lady who presented with sudden decrease in vision in the right eye for one week. She was suffering from constipation and had a history of straining while passing stools. She was found to have two large sub-internal limiting membrane haemorrhages with the classical double ring sign, which were drained using laser membranotomy, following which her vision rapidly improved. This case of two sub-internal limiting membrane haemorrhages is reported for its rarity and also highlights the usefulness of laser hyaloidotomy or membranotomy in large haemorrhages of recent onset. The literature was also reviewed to discuss the other treatment options in brief.

Clinical Outcomes of Nd-YAG Laser Membranotomy in Retained Host Corneal Membrane after Keratoplasty

Purpose: To evaluate the clinical efficacy and shortcomings of neodymium-doped yttrium aluminum garnet (Nd-YAG) laser membranotomy in inadvertently retained host membrane. Methods: Among 742 patients who underwent penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) surgery at Seoul St. Mary’s Hospital between January 2007 and May 2013 by a single surgeon, 10 patients had a thin, opaque membrane in the anterior chamber observed under slit lamp examination and both a subjective decrease in visual acuity and decrease i best corrected visual acuity. A single surgeon performed membranotomy using the Nd-YAG laser at 4.9 months after graft surgery. In this study we compared the differences in visual acuity, endothelial cell count and correlations between distance from donor endothelium and retained host membrane and endothelial loss before and after the graft surgery. Results: Patients who had Nd-YAG laser membranotomy performed on the retained host membrane showed significant improvements in visual acuity (p = 0.039). Donor endothelial cell count was significantly reduced 1 month after Nd-YAG laser. The average distance between donor endothelium and retained host membrane was 712.0 ± 217.5 μm. The distance and the decreased donor endothelial cell count were not statistically correlated (R = 0.39, p = 0.072). There were no significant complications after the laser membranotomy. Conclusions: Inadvertently retained host membrane forms close to the donor endothelium as identified on optical coherence tomography (OCT) images. Nd-YAG laser membranotomy significantly affected clear vision but endothelial cell count loss was also observed. J Korean Ophthalmol Soc 2015;56(5):664-671

Nd:YAG membranotomy for preretinal hemorrhage secondary to valsalva retinopathy

PurposeTo report four cases of premacular hemorrhage secondary to valsalva retinopathy treated with Nd:YAG membranotomy and discuss techniques as well as the literature. DesignRetrospective case series. MethodsA retrospective review was conducted for four patients with vision obstructing hemorrhage secondary to valsalva retinopathy. These patients were all treated with Nd:YAG membranotomy. ResultsFour patients with premacular hemorrhage secondary to valsalva retinopathy were treated with Nd:YAG laser creating a membranotomy to drain the hemorrhage. Power settings ranged from 1.7 to 3.8mJ. Visual acuity at presentation ranged from 20/400 (1 patient) to count fingers (3 patients). Visual acuity improved in three out of four patients after laser treatment. Final visual acuity ranged from 20/20 to 20/30 in these three patients. One patient was lost to follow up after performing laser membranotomy and therefore visual acuity after treatment was not obtained. No complications were noted. ConclusionNd:YAG membranotomy is a non-invasive, office-based treatment option that may be successfully used to treat premacular hemorrhage secondary to valsalva retinopathy.

Spectral-domain optical coherence tomography findings of subinternal limiting membrane hemorrhage in the macula before and after Nd:YAG laser treatment

We reported the spectral-domain optical coherence tomography (SD-OCT) findings of a subinternal limiting membrane hemorrhage in the macula in one patient with Valsalva retinopathy and in one patient with macroaneurysm before and after neodymium-doped yttrium aluminum garnet (Nd:YAG) laser membranotomy. Within 1 week, the Nd:YAG laser treatment facilitated rapid absorption of the hemorrhage in both patients. Spectral-domain optical coherence tomography was helpful before laser treatment to evaluate the exact location of the blood and after laser treatment to confirm the amount and location of residual hemorrhage, which was hard to confirm by only indirect ophthalmoscopy.

Outcomes of Double Frequency Nd:YAG Laser Membranotomy for Premacular Haemorrhage Secondary to Valsalva Retinopathy

Purpose: To determine the outcomes of double frequency Nd:YAG laser membranotomy for premacular hemorrhage secondary to Valsalva retinopathy. Methods: Retrospective case series of 24 consecutive patients with premacular hemorrhage of duration less than two months between Jan 2008 and Dec 2012 were included. Patients with any other vascular diseases such as diabetic retinopathy were excluded. The main outcome measure was the best-corrected visual acuity (BCVA) at final follow up. Results: Among 24 patients, majority 16 (67%) were men and all had unilateral Valsalva retinopathy. All patients underwent laser membranotomy using the double frequency Nd:YAG laser on the same day of presentation. The mean age of subjects was 44.03 ± 17.33 years (14-78 years) and the mean duration of symptoms was 10.29 ± 11.7days. The mean follow-up duration was 4.72 ± 2.54 months. All patients presented with blindness or severe vision loss with a mean baseline visual acuity of 1.72 ± 0.58 logMAR (Snellen’s equivalent 20/1050; range 0.17-2.3). Significant improvement of visual recovery was noted in 91.66% of patients at 1 month (mean final BCVA 0.20 ± 0.56 logMAR (Snellen’s equivalent 20/30; range 0-2.3 logMAR). Twenty-two (91.66%) patients were successfully treated with laser alone. No complications were noted. Two patients underwent vitrectomy and achieved 20/20 visual acuity. Conclusion: Prompt treatment using the frequency doubled Nd YAG laser appears to be safe and effective in achieving significant visual recovery in patients with premacular hemorrhage due to Valsalva retinopathy.

Traitement précoce par laser Nd:YAG de la rétinopathie de Valsalva : résultats à propos de cinq cas et revue de la littérature

According to the literature, the treatment of retinopathy of Valsalva (VR) by laser is recommended when the macular hemorrhage has not regressed after 3 weeks. We report five cases of VR treated early (≤ 24 hours) by Nd:YAG laser membranotomy (LM). Clinical examination was performed before and after LM (D1, D7, M1, M3 and M6). Optical coherence tomography (OCT) analysis was performed to determine the precise location of the macular hemorrhage. Good visual recovery was obtained early by LM with a stable outcome at 6 months. The hemorrhage was located under the internal limiting membrane (ILM) and posterior hyaloid in two patients and only under the ILM in three patients. The literature review and our study confirm the good functional results for patients treated by LM for VR. Furthermore, very few side effects are reported with this type of treatment compared with the natural course of the disease, which may certainly regress spontaneously, but carries a risk of secondary preretinal fibrosis. However, to obtain optimal efficacy, the treatment should be carried out as soon as possible, in order to avoid clotting of the hematoma, preventing any subsequent evacuation by laser. LM for VR is an effective, safe and inexpensive technique compared to the surgical management of these patients presenting with a persistant premacular hematoma after a period of observation.

Persistent unsealed internal limiting membrane after Nd:YAG laser treatment for valsalva retinopathy

BackgroundTo report a long-term complication of unsealed and un-reattached internal limiting membrane in Valsalva retinopathy after neodymium-doped yttrium–aluminium–garnet (Nd:YAG) laser membranotomy.Case presentationA 41-year-old man presenting with a massive premacular hemorrhage due to Valsalva retinopathy underwent Nd:YAG laser membranotomy. During follow-up, best-corrected visual acuity, retinal alteration and optical coherence tomography (OCT) outcomes were documented. One month after membranotomy, his visual acuity improved to 20/20 and the hemorrhage resolved completely. At an 8-month follow-up visit, the fundus showed progressive wrinkling of the internal limiting membrane with the laser perforation located in the center. OCT showed a persistent unsealed and un-reattached internal limiting membrane.ConclusionsNot all patients with Valslava retinopathy with premacular hemorrhage are appropriate candidates for laser membranotomy, especially patients with sub- internal limiting membrane hemorrhage. The key point for observation is the interface between internal limiting membrane and retinal surface. The long-term consequences of unsealed internal limiting membrane after Nd:YAG laser membranotomy require further understanding.