Retinal Hemorrhages Research Articles

Retinal haemorrhage and infiltration in a patient with hyperleukocytosis.

Retinal haemorrhage and infiltration in a patient with hyperleukocytosis.

Delayed high-altitude retinal hemorrhages in well-acclimatized lowlanders: A hidden risk unveiled.

High-altitude retinal hemorrhage (HARH), a frequent entity of high-altitude retinopathy (HAR), is associated with acute exposure to high altitudes (HAs) with rapid ascent. However, the delayed occurrence of HARH in well-acclimatized individuals has received less attention. This study explored the prevalence and characteristics of HARH in individuals who were acclimatized to HA for extended periods, aiming to elucidate the physiological responses of the retina to chronic hypoxic conditions. We conducted an observational cross-sectional study involving 1,457 male participants who had resided at altitudes above 3353 meters (11,000 ft) in the Himalayan region for more than three months. Patients who had ocular or systemic diseases affecting the retina, chronic retinotoxic medication use or smoking were excluded. Participants underwent comprehensive ophthalmic examination, including the best corrected visual acuity test, dilated fundus examination and photography. A total of 1,457 males were screened, and the mean age was 34 ± 2 years. Of all the participants screened, 12 (0.82%) had HAR, with all cases occurring at altitudes above 4267 meters (14,000 ft). Seventy-five percent (75%) of the HAR patients had retinal hemorrhage and venous dilatation. Macular involvement and cotton wool spots were observed in 34% and 25% of HAR patients, respectively. Only four participants had foveal involvement with significant visual impairment. Delayed HARH in acclimatized individuals underscores the importance of long-term ocular monitoring for those exposed to HA, despite acclimatization, to prevent and manage potential visual impairments.

A 52-year-old man from Somalia with an asymptomatic macular hemorrhage

A 52-year-old man from Somalia with an asymptomatic macular hemorrhage

Visual and anatomical outcomes following vitrectomy with subretinal tPA injection in patients with submacular haemorrhages secondary to wet AMD

Purpose: Submacular haemorrhages (SMHs) are most commonly associated with wet age-related macular degeneration (AMD) and their size and duration are strong prognostic factors for visual outcome. The aim of this audit was to evaluate outcomes of direct injection of submacular tissue plasminogen activator (t-PA) into these lesions during pars plana vitrectomy (PPV). Methods: All patients presenting to the Mater Misericordiae Hospital from January 2017 to December 2019 with large SMHs secondary to wet AMD who underwent this treatment were included for review. All ten patients underwent complete PPV, injection of 0.2ml (50µg) subretinal t-PA and air tamponade. Pre-operative and post-operative evaluations included visual acuity testing (VA), optical coherence tomography (OCT) and slit lamp examination. Results: Eight patients (80%) showed improvement of their VA, with 4 patients achieving a VA of ≤0.4 LogMAR (20/50). Six patients had a total clearing of the macular haemorrhage, with a further 2 having sub-total clearance. One patient subsequently developed a retinal detachment requiring oil tamponade. Conclusions: SMH secondary to wet AMD is a sight threatening event with a varied prognosis but in most cases, vitrectomy with subretinal t-PA injection results in improved anatomical and visual outcomes.

Retinal vasculopathy and choroiditis after pegcetacoplan injection: clinicopathologic support for a drug hypersensitivity reaction

PurposeTo report the detailed histopathology of two enucleated eyes from two patients who developed severe visual loss associated with retinal hemorrhages, vessel sheathing and vascular nonperfusion after administration of an initial dose of intravitreal pegcetacoplan, and to propose, with supportive histopathology, the pathogenesis of the clinical syndrome previously termed hemorrhagic occlusive retinal vasculitis (HORV). DesignCase series. SubjectsTwo enucleated eyes from two patients treated with intravitreal pegcetacoplan. MethodsRetrospective, multicenter consecutive clinical-pathologic analysis. Main Outcome MeasuresHistopathologic review and immunophenotypic characterization. ResultsBoth patients presented with inflammation and significant vision loss nine days following the initial injection of pegcetacoplan with no subsequent improvement and underwent enucleation for pain control. Histologic examination of the enucleated eyes (patient one at 4 months post-injection and patient two at 40 days) revealed extensive vascular thrombosis, retinal hemorrhages and necrosis, and a dense inflammatory infiltrate in the uvea and variably the optic nerve, episclera, and muscle tendons composed of predominantly of T-cells, macrophages, and eosinophils. Notably, the inflammatory infiltrate was absent from the retina. In addition, one eye demonstrated multiple foci of glomerular-like vascular proliferations in the uveal tract and thrombosis with focal recanalization of vessels in the optic nerve. ConclusionDrug-induced, immune-mediated, retinal vasculopathy and choroiditis (DIRVAC) is a rare complication following pegcetacoplan injection. Although some limitations arise in interpretation of histopathologic findings due to compensatory changes in the eyes over time (prior to enucleation), the authors propose that the combined clinical, histopathologic, and immunohistochemical findings suggest a mixed-type, delayed hypersensitivity reaction as mechanism of initial injury.

Retinal hemorrhages in anemia

Retinal hemorrhages in anemia

Ocular and adnexal manifestations post dengue hemorrhagic fever.

This study aims to present a case series detailing sight-threatening ocular and adnexal manifestations following dengue fever. A retrospective observational study was conducted, analyzing records of patients presenting with ocular manifestations post dengue fever at a tertiary eye care institute in Uttar Pradesh from October 2023 to November 2023. Demographic details, systemic comorbidities, and detailed ophthalmic examinations were recorded. Fifteen eyes of 13 patients with dengue fever were studied. The mean age of presentation was 39.07 years, with a male predominance (84.61%). Systemic comorbidities were noted in 30.76% (diabetes mellitus) and 23.07% (hypertension) of patients. Thrombocytopenia was observed in 53.84% of patients, while 23.07% required blood transfusions, and 15.38% experienced systemic bleeding episodes. The majority of cases were unilateral (84.61%), with the best-corrected visual acuity of perception of light in 84.61% of cases. Diminution of vision was the most common presenting symptom (84.61%), followed by pain (53.84%), redness (38.46%), and watering (23.07%). Major ocular manifestations included panophthalmitis (26.07%), total ophthalmoplegia (26.07%), endogenous endophthalmitis (20%), central retinal artery occlusion (20%), retinal hemorrhage (20%), ischemic optic neuropathy (20%), orbital cellulitis (13.3%), proptosis (13.3%), retrobulbar hemorrhage (13.3%), retinal detachment (13.3%), and foveolitis (6.7%). The diverse array of ocular and adnexal manifestations in dengue hemorrhagic fever may result in permanent visual loss, emphasizing the need for adequate treatment and timely intervention. The risk of sight-threatening complications underscores the importance of early screening by ophthalmologists and increased public awareness.

Addressing the oversight medical cases in low-middle-income countries: poor mention of shaken baby syndrome in Nigeria; reasons, challenges, and recommendations.

Shaken baby syndrome (SBS) is a severe form of child abuse that results in a triad of clinical findings: subdural hematoma, retinal hemorrhages, and encephalopathy. These injuries can lead to significant brain damage, developmental delays, disabilities, or even death. In addition to these, other indicative signs include bruises, vomiting, full fontanelles, sleepiness, seizures, and fractures. This paper reviews the existing literature on SBS in Nigeria, identifies the challenges contributing to its underrecognition, and provides evidence-based recommendations for improving diagnosis, management, and prevention strategies in the region. Despite the profound impact of SBS, its recognition and management are inadequate, particularly in low- and middle-income countries (LMICs) like Nigeria, due to limited diagnostic capabilities and documentation. Addressing these gaps is crucial for safeguarding the well-being of infants and young children in Nigeria.

Nd: YAG laser of Weiss Ring for the Treatment of Symptomatic Vitreous Floaters in Patients with Posterior Vitreous Detachment

Purpose: To assess the effect of Nd: YAG laser vitreolysis of the Weiss ring in the management of symptomatic vitreous floaters in patients with posterior vitreous detachment in the outpatient department of a tertiary care hospital. Study Design: Quasi-experimental study. Place and Duration of Study: This quasi-experimental trial was conducted in the out-patient department (OPD) of The Layton Rahmatullah Benevolent Trust (LRBT) Tertiary Teaching Eye Hospital, Korangi, Karachi from February 2023 to July 2023. Methods: In this study, 75 eyes of 75 patients were selected using non-probability purposive sampling technique. Dilated fundus examination was performed and The National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) was used and compared pre and post Laser Floater Treatment (LFT). Results: Out of 75 eyes, 65 patients were included in final analysis. Mean age was 54.63±4.1 years. Out of these, 69.2% were 48–56 years old and 56.9% were females. Mean number of shots were 160±15.53. Mean Pre-LFT, VFQ was 56±5.89 and post-LFT was 74±13.2. The mean difference pre versus post treatment was -18 units with p<0.001. Twenty patients complained of blurring of vision and one patient suffered mild retinal hemorrhage which resolved spontaneously, two patients were lost to follow up. Conclusion: Nd: YAG laser vitreolysis of the Weiss ring can be a quick, and effective treatment option in patients suffering from symptoms of vitreous floaters after a posterior vitreous detachment. However, more trials with large number of patients and longer follow up durations are required for generalization of results.

BNT162b2 vaccine booster dose did not influence the activity of the exudative form of age-related macular degeneration during anti-vascular endothelial growth factor therapy.

Due to safety concerns, patients were hesitant to receive a booster dose of COVID-19 vaccine. In this study, we investigated whether neovascular age-related macular degeneration activity deteriorated after receiving the booster dose of the BNT162b2 vaccine. Optical coherence tomography (OCT) of the macula, best-corrected visual acuity (BCVA), and slit-lamp examination data were collected from 89 patients. All these individuals were diagnosed with neovascular age-related macular degeneration (AMD) and treated with intravitreal injections of aflibercept or ranibizumab. During the process of treatment, patients received a booster dose of the BNT162b2 vaccine. Time points included two visits before (marked as "-2", "-1") and two visits after (marked as "1", "2") the uptake of the booster dose. There were significant differences in the average thickness and total volume of the macula during follow-up. Moreover, a decreased average thickness, total volume, total thickness of the macula, subretinal fluid thickness, and subretinal complex thickness was observed between the time points "-2" and "2", but only in the aflibercept group. There were no significant differences in the frequency of occurring intraretinal cysts, subretinal fluid, serous retinal pigment epithelial detachments retinal hemorrhage, subretinal hyperreflective material, complete RPE and outer retinal atrophy, and BCVA before and after the booster dose. These results demonstrate that the BNT162b2 vaccine booster dose did not deteriorate the course of neovascular AMD.

Bilateral purtscher-like retinopathy associated with DRESS syndrome: a case report

BackgroundTo report a case of Bilateral Purtscher-like retinopathy associated with DRESS syndrome managed with ocular and systemic treatments.Case presentationA 29-year-old healthy female developed multi-organ (cutaneous, hematologic, renal and hepatic) disfunction and profound vision loss 1 month after Human papillomavirus vaccine injection. At the first presentation, her visual acuity was counting fingers in both eyes. Fundus exam showed remarkable cotton-wool spots, retinal hemorrhages and macular edema. She was diagnosed DRESS syndrome and Purtscher-like retinopathy and treated with intravitreal injection of ranibizumab, systemic steroids anticoagulants, and plasma exchange. The patient finally recovered from this life-threatening condition but left with permanent visual damage.ConclusionPurtscher-like retinopathy could be complicated by DRESS syndrome which is usually considered a type IV hypersensitivity reaction.

Occlusive retinal vasculitis associated with intravitreal Faricimab injections

PurposeWe describe a case of occlusive vasculitis associated with intravitreal Faricimab (Vabysmo) injections.MethodsA retrospective case report.ResultsA 52-year old man treated with monthly Faricimab injections for diabetic macula oedema presented with sudden reduced vision, new retinal hemorrhages, significant retinal vascular occlusions and ischemia. After screening for differential diagnoses was unremarkable, the patient was treated with oral and intravitreal steroid therapy under which the occlusive vasculitis was stabilized.ConclusionOcclusive vasculitis, though rare, is a potential complication of Faricimab therapy. Comprehensive reporting and large-scale analyses are essential to better understand and manage this adverse event.

Forecasting the Pharmacological Mechanisms of Plumbago zeylanica and Solanum xanthocarpum in Diabetic Retinopathy Treatment: A Network Pharmacology, Molecular Docking, and Molecular Dynamics Simulation Study.

(1) Background: Diabetic retinopathy (DR) is a major complication of diabetes, marked by abnormal angiogenesis, microaneurysms, and retinal hemorrhages. Traditional Ayurvedic medicine advocates multi-target strategies for DR management. However, the mechanisms by which Solanum xanthocarpum (SX) and Plumbago zeylanica (PZ) exert therapeutic effects are not well understood; (2) Methods: To investigate these mechanisms, we employed network pharmacology and molecular docking techniques. Phytochemicals from SX and PZ were identified using the IMPPAT database and Swiss Target Prediction tool. DR-related protein targets were sourced from the GeneCards database, and common targets were identified through Venn diagram analysis. STRING and Cytoscape were used to construct and analyze protein-protein interaction networks. Pathway enrichment was performed with Gene Ontology and KEGG databases; (3) Results: We identified 28 active phytoconstituents, targeting proteins such as EGFR, SRC, STAT3, AKT1, and HSP90AA1. Molecular docking and dynamics simulations confirmed the strong binding affinities of these compounds to their targets; (4) Conclusions: The study highlights the multi-target activity of SX and PZ, particularly in pathways related to EGFR tyrosine kinase inhibitor resistance and PI3K-AKT signaling. These findings provide valuable insights into their therapeutic potential for DR, suggesting the effective modulation of key molecular pathways involved in the disease.

Radiation Optic Neuropathy

Radiation optic neuropathy (RON) is a rapid-onset, severe, challanging optic neuropathy that can cause unilateral or bilateral vision loss, which may occur years after radiotherapy. RON mostly occurs with radiation therapy exceeding 50 Gy to the visual axis. The risk of RON occurring at radiation doses between 50-60 Gy is 5% within 10 years. Since RON can cause acute, irreversible, unilateral or bilateral profound vision loss, patients at risk need to be carefully monitored. Early diagnosis and treatment is very important to prevent serious vision loss. The first test to be performed in patients with suspected RON is fat-suppressed, non-contrast brain MRI, which is recommended to be performed in 3 mm and thinner sections. In addition; lumbar puncture and Optical coherence tomography angiography (OCT-A) are helpful tests in the differential diagnosis. Anti-VEGF molecules have been shown to be effective in treatment, which aim to reduce edema and retinal hemorrhages. Hyperbaric oxygen therapy is not a proven treatment for RON – but there are some studies about it’s speculated effect. Studies presenting the success rates of this treatment are quite limited in number. Systemic corticosteroids, heparin, warfarin and other anticoagulation treatments have not been proven successful in the treatment of RON. RON is one of the optic neuropathies that chronically damages visual function. The prognosis is generally poor. It is important for the patient and the physician to be aware of RON after radiotherapy and to minimize the possibility of permanent damage through preventive measures that can be taken. Since there are no definitive treatments for RON, preventive medicine is of great importance.

Automatic Segmentation of Hemorrhages in the Ultra-wide Field Retina: Multi-scale Attention Subtraction Networks and An Ultra-wide Field Retinal Hemorrhage Dataset.

Ultra-wide field (UWF) retinal imaging can improve the detection rate of retinal hemorrhage as compared with conventional fundus images. However, hemorrhages in UWF retinal images can also become smaller and more widely distributed, which can be time consuming and labor intensive. With the development of computer technology, automatic segmentation techniques can assist physicians in diagnosis. However, the lack of publicly available UWF retinal hemorrhage segmentation datasets has limited the development of automatic hemorrhage segmentation techniques in UWF retinal images. We present a large-scale high-quality UWF retinal hemorrhage segmentation dataset, named UWF-RHS Dataset, for public use. To the best of our knowledge, we are the first team to make the UWF retinal hemorrhage segmentation dataset publicly available. In addition, we propose a multi-scale attention subtraction network (MASNet) for UWF retinal hemorrhage segmentation. Specifically, highly focused lesion features are extracted by using the proposed multi-scale attention subtraction (MAS) module at the progress of the skip-connection. Several comparative experiments and ablation experiments were performed at the UWF-RHS Dataset, and all experiments state that our proposed method is effective in diagnosing retinal hemorrhages with state-of-the-art results. The proposed UWF-RHS dataset and MASNet will greatly facilitate the development of automated segmentation techniques for UWF retinal hemorrhages. Links to the UWF-RHS dataset and the MASNet model code are available fromhttps://github.com/wurenkai/UWF-RHS-Dataset-and-MASNet.

Abstract P387: Survival trajectories of the patients with malignant hypertension in the Rice Diet Program

Malignant hypertension (MH), severe arterial hypertension accompanied by retinal hemorrhage (Class III), papilledema (Class IV), or both was untreatable in 1942. Walter Kempner treated MH patients with a very low sodium (~200 mg/day), protein (~5% of calories), and fat (~5% of calories) diet with success in some patients. The scope and efficacy of this “Rice” Diet (RD) was not clear. We analyzed data from 563 non-diabetic MH patients treated from 1942-1988. The cohort, mostly male (69.4%) with a median age 51 years and median BMI 24.01 provided several interesting findings. First, the number of MH patients increased until the early 1950s, but then declined sharply by 1955, before effective pharmacotherapy was available. This sudden MH “disappearance” seems real, but is unexplained by therapy or other known events. Second, 341 MH patients showed that median survival more that doubled with RD treatment compared to untreated MH patients described by Keith-Wagner-Barker (KWB) in 1939. Third, the RD-diet survival benefit began after ~90-100 days into treatment. During the first ~90-100 RD days, survival closely tracks that of untreated MH patients described by KWB; thereafter, survival curves diverged substantially (e.g., calculated half-time survival for Class IV increased from 163.5 to 815.5 days, Figure ). Fourth, serial retinal photographs of 359 MH patients, showed that of 343 with initial hemorrhage, 36 of 177 patients surviving at 1 year (20%) still had hemorrhage; of 146 with initial papilledema, only 1 of 76 patients surviving at 1 year (1%) still had papilledema. Fifth, survival curves of MH patients with only hemorrhage or only papilledema were similar; however, survival was markedly shorter in those with both hemorrhage and papilledema, implying that the deleterious effects of vascular and neuropathic changes are independent of one another and additive. Remaining questions concern: why did MH “suddenly” disappear; how does RD impact vaculopathy; what factors impact survival trajectories.

SURGICAL OUTCOMES AND INTRAOPERATIVE PARAMETERS OF THREE-DIMENSIONAL VISUALIZATION SYSTEM VERSUS CONVENTIONAL MICROSCOPES FOR MACULAR SURGERY IN HIGHLY MYOPIC EYES: A Prospective Randomized Clinical Trial.

To investigate the surgical outcomes and intraoperative parameters of 3D visualization system for macular diseases in highly myopic eyes. In this single-center, prospective, randomized, comparative interventional study, 40 highly myopic eyes (axial length > 26 mm) were randomly assigned to either a 3D visualization system or a conventional microscope group. Surgical outcomes and intraoperative parameters, including the number of indocyanine green injections, surgical time, and epiretinal membrane/internal limiting membrane peeling time, were compared. The 3D group required significantly fewer indocyanine green injections (1.3 ± 0.5 vs. 2.3 ± 0.7, P < 0.001), had shorter epiretinal membrane/internal limiting membrane peeling times (522.8 ± 258.0 vs. 751.8 ± 320.2 seconds, P < 0.05), and experienced fewer intraoperative retinal hemorrhages (0 vs. 7 cases, P < 0.05) compared with the conventional microscope group. Anatomical and functional outcomes were comparable between the two groups. The 3D system exhibited a lower number of indocyanine green injections, shorter epiretinal membrane/internal limiting membrane peeling times, and a reduced incidence of intraoperative retinal hemorrhages, suggesting the 3D visualization system may offer advantages for macular surgery in highly myopic eyes.

Leber’s Hereditary Optic Neuropathy with Retinal Hemorrhage

ABSTRACT Leber’s hereditary optic neuropathy (LHON) causes subacute visual loss, and, in the acute phase, the optic disc shows hyperemia, peripapillary telangiectasia, and swelling of the retinal nerve fiber layer (RNFL). Rarely, retinal hemorrhage may be present. In this study, we investigated LHON cases with retinal hemorrhage in the acute phase. Among 82 cases (164 eyes) of LHON who visited the Inoue Eye Hospital, retinal hemorrhage was observed in 5 cases (5 eyes). The age at onset was 36 (27–46) years, with 4 male cases. Mitochondrial DNA analysis revealed the presence of the m.11778G > A variant in four patients and the m.14484T > C variant in one patient. There was no medical history and no excessive smoking or alcohol consumption in any of the cases. In all cases, retinal hemorrhages were observed in the RNFL, accompanying the characteristic optic disc findings of LHON. Fluorescein angiography performed in three cases showed no leakage from the optic disc or blood vessels. While rare, the presence of retinal hemorrhage along the RNFL during the acute phase of LHON should be recognized, as it may warrant consideration of alternative diagnoses.

Heme: A link between hemorrhage and retinopathy of prematurity progression

Neovascularization is implicated in the pathology of retinopathy of prematurity (ROP), diabetic retinopathy (DR), and age-related macular degeneration (AMD), which are the leading causes of blindness worldwide. In our work, we analyzed how heme released during hemorrhage affects hypoxic response and neovascularization. Our retrospective clinical analysis demonstrated, that hemorrhage was associated with more severe retinal neovascularization in ROP patients. Our heme-stimulated human retinal pigment epithelial (ARPE-19) cell studies demonstrated increased expression of positive regulators of angiogenesis, including vascular endothelial growth factor-A (VEGFA), a key player of ROP, DR and AMD, and highlighted the activation of the PI3K/AKT/mTOR/VEGFA pathway involved in angiogenesis in response to heme. Furthermore, heme decreased oxidative phosphorylation in the mitochondria, augmented glycolysis, facilitated HIF-1α nuclear translocation, and increased VEGFA/GLUT1/PDK1 expression suggesting HIF-1α-driven hypoxic response in ARPE-19 cells without effecting the metabolism of reactive oxygen species. Inhibitors of HIF-1α, PI3K and suppression of mTOR pathway by clinically promising drug, rapamycin, mitigated heme-provoked cellular response. Our data proved that oxidatively modified forms of hemoglobin can be sources of heme to induce VEGFA during retinal hemorrhage. We propose that hemorrhage is involved in the pathology of ROP, DR, and AMD.

A child with recurrent headache, fever and diffuse meningeal enhancement on MRI.

Juvenile neurolupus presents primarily with neuropsychiatric manifestations which may also be the initial presentation. Such primary neuropsychiatric SLE (NPSLE) events are a consequence either of microvasculopathy and thrombosis, or of autoantibodies and inflammatory mediators. Diagnosis of NPSLE requires the exclusion of other causes, and clinical assessment directs the selection of appropriate investigations. These investigations include measurement of autoantibodies, analysis of cerebrospinal fluid, electrophysiological studies, neuropsychological assessment and neuroimaging to evaluate brain structure and function. In our patient, the disease presented with chronic headache initially diagnosed as migraine, followed by fever and paraparesis. Fundoscopy showed retinal haemorrhages. Investigations revealed anaemia, neutrophilic leucocytosis, thrombocytopenia and raised inflammatory markers (ESR 119mm/h CRP 58mg/L) and high globulin. MRI brain showed diffuse meningeal enhancement resembling meningitis but CSF analysis was normal. ANA and dsDNA were positive with low C3, C4. All diffuse meningeal enhancements may not be meningitis and one needs to corroborate all the clinical, biochemical and imaging analyses to come to a diagnosis.