Subhyaloid Hemorrhage Research Articles

Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura

Dear Editor, We read with great interest the article titled “Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura” by Majji et al.[1] We would like to share our experience in a similar case. The patient, a 56-year-old male was a known case of diabetes, hypertension and presented to us with blurring of vision in both eyes since 10 days. On examination, his best corrected visual acuity (BCVA) was 20/30, N8 in the right eye and 20/50,N12 in the left eye. Anterior segment examination was normal except for nuclear sclerosis Grade 1. Fundus examination of both eyes revealed intraretinal dot and blot hemorrhages suggestive of non-proliferative diabetic retinopathy, but could not account for the presence of subhyaloid hemorrhage and subretinal hemorrhage without any clinical evidence of neovascularization [Figs 1 and 2]. Fundus fluorescein angiogram (FFA) confirmed absence of neovascularization. Patient was examined by a hematologist for systemic evaluation and underwent routine blood counts, peripheral blood smear examination and bone marrow aspiration biopsy. His platelet count was 42,000/cmm, hemoglobin (Hb) level was 10.8 g% and bone marrow aspiration study revealed normocytic, normochromic anemia with plenty of megakaryocytes suggestive of platelet deficiency. He was diagnosed to have normocytic, normochromic anemia with idiopathic thrombocytopenic purpura (ITP). He received platelet transfusion followed by oral steroids. After one month, his platelet count increased to 2.15 lakh/cmm and was accompanied by resolution of retinal hemorrhages to a great extent. At final follow-up (three months after first presentation), BCVA improved to 20/20, N6 and 20/40, N10 in the right and left eye respectively, with platelet count of 2.5 lakh/cmm and fundus examination revealed marked resolution of hemorrhages [Figs 3 and 4].Figure 1: Fundus photo of right eye showing pre retinal and subretinal hemorrhages before treatment of ITPFigure 2: Fundus photo of left eye showing pre retinal and subretinal hemorrhages before treatment of ITPFigure 3: Fundus photo of right eye showing marked resolution of hemorrhages after treatment of ITPFigure 4: Fundus photo of left eye showing marked resolution of hemorrhage after treatment of ITPITP is known to cause vitreo-retinal and subretinal hemorrhages.[2–4] Retinal hemorrhages could be the first clinical manifestation as noted in our patient.[1] Oral corticosteroids and platelet transfusion administered in the initial management of ITP help in the resolution of vitreo-retinal hemorrhages as noted in our patient.[4] Though it is not uncommon to find retinal and / or subretinal hemorrhages in patients with ITP, FFA would be an important diagnostic tool in a patient with ITP and coincidental diabetic retinopathy to ascertain the cause of retinal hemorrhages.

Spontaneous bilateral subhyaloid hemorrhage in congenital hypofibrinogenemia.

The purpose of this study was to report a case of spontaneous bilateral subhyaloid hemorrhage in congenital hypofibrinogenemia. This is a single case report. A 14-year-old girl presented with a spontaneous bilateral decrease in vision. Her history was unremarkable. On examination, visual acuity was 20/80 in the right eye and 20/1200 in the left eye. Fundus examination showed bilateral subhyaloid hemorrhage. Clotting profile showed normal activated partial thromboplastin time and normal prothrombin time with fibrinogen decreased to 50 mg/dL (normal, 200-400 mg/dL). Therapeutic cryoprecipitate infusion was administered. At 3 months, visual acuity improved to 20/20 with resolution of subhyaloid hemorrhage in both eyes. Estimation of fibrinogen in the absence of other evaluated causes of blood dyscrasias would help with prompt diagnosis and successful management.

Dengue Fever presenting with macular hemorrhages.

To report ocular manifestations in cases of previously undiagnosed dengue fever. A retrospective study was done to evaluate the cause of sudden painless loss of vision in three cases with history of fever. Detailed systemic evaluation and ophthalmologic examination consisting of fundus photographs, fundus fluorescein angiography, and optical coherence tomography were done, where needed. All three patients tested positive for dengue serology, which had been undiagnosed earlier. Retinal hemorrhages were found in all three patients, while one patient also showed evidence of retinitis-like lesions. He was treated with oral steroids and showed improvement in visual acuity over a period of 6 weeks. Two of the three patients had subhyaloid hemorrhages, which were seen to resolve spontaneously. A significant subset of patients with mild form of dengue fever may go undiagnosed.

Chorioretinal Granuloma in Tuberculosis

A 17-year-old boy presented to the emergency room with a 48-hour history of deterioration in the vision of his right eye. Visual acuity was measured at 6/24 in the right eye and 6/6 in the left eye. In the right eye, a small subhyaloid hemorrhage and an associated vitreous hemorrhage were noted. During the next month, the preretinal hemorrhage cleared, revealing a vascularized chorioretinal granuloma in the superotemporal quadrant. A serous retinal detachment with marked retinal exudate was evident, indicating that the lesion was active (Panel A). A physical examination showed no other abnormalities, and the patient's history was unremarkable . . .

Terson's Syndrome

A 51-year-old male was admitted following subarachnoid hemorrhage (SAH) (Figure 1). His Glasgow coma score was 15. Other than headache and a defect in his right visual field, his neurological exam was normal. Cerebral angiography demonstrated a 3 mm anterior communicating artery aneurysm which was successfully excluded with endovascular coiling. Due to persistent visual complaints, an ophthalmology consult was obtained, which revealed a scotoma of the right eye. Fundoscopy demonstrated a large subhyaloid hemorrhage of the right eye (Figure 2), and a small retinal hemorrhage with papilledema of the left eye. Intraocular pressure was slightly higher than normal, 31 mmHg, in both eyes. The diagnosis of Terson’s syndrome (TS) was made, and the decision was made to follow him conservatively for at least six months.

Carbon Monoxide Poisoning: A Patient with Bilateral Internuclear Ophthalmoplegia and Exotropia

Carbon monoxide poisoning, which occurs in poorly ventilated areas, is associated with different symptoms and signs. This report describes an 8-year-old girl with severe carbon monoxide intoxication, scattered retinal nerve fiber layer and subhyaloid hemorrhages, and exotropia with bilateral internuclear ophthalmoplegia.

The Ocular Pathology of Terson's Syndrome

To improve understanding of vision loss and clinical findings, we studied gross and microscopic pathology of retinas and optic nerves of individuals with Terson's syndrome. Retrospective case series with clinicopathologic correlation. We included 109 deceased individuals with Terson's syndrome. Histologic sections and gross photographs from 109 cases of Terson's Syndrome, accessed from 1955 to 1992 at the Wm R. Green Laboratory of Ocular Pathology, were studied and photographed; a representative case is described in detail. Abnormalities in retina and optic nerve. Hemorrhages occur in vitreous, subhyaloid, sub-internal limiting membrane (ILM), intraretinal, and subretinal spaces, in association with macular holes, retinal detachments, and optic neuropathy. Subhyaloid hemorrhages have diffuse morphology, whereas sub-ILM are well-demarcated. Continuous and noncontinuous blood occurs along optic nerves, within nerve sheaths, and in the subdural and subarachnoid spaces. Blood occurring in various layers and locations of the retina, particularly the macula, causes various complications that influence clinical management and visual outcome. Morphology differentiates subhyaloid from sub-ILM hemorrhage. Patterns of hemorrhages of optic nerve contribute to understanding mechanisms of Terson's syndrome. The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Individualised treatment of proliferative diabetic retinopathy: optimal surgical timing improves long-term outcomes.

Ocular treatment of progressing proliferative diabetic retinopathy is based on retinal laser photocoagulation and pars plana vitrectomy. Improvements in instrumentation and advances in techniques and procedures have increased indications for vitrectomy. These include vitreous haemorrhage preventing laser photocoagulation, severe nonclearing vitreous haemorrhage, subhyaloid and premacular haemorrhage, tractional retinal detachment involving or threatening the macula, combined tractional and rhegmatogenous retinal detachment, progressive fibrovascular proliferation, clinically significant macular oedema and rubeosis iridis. Together with the increasing number of indications, timing for vitrectomy has also changed. The beneficial effect of early vitrectomy for these indications has been clinically shown and supported by several studies. The benefit is evident in case of type I diabetes and when the duration of the diabetes is less than 20 years. Long-term outcomes can therefore be improved when individualised treatment algorithms are applied.

Clinical research on the treatment of central exudative chorioretinopathy with blood-activating and stasis-removing Chinese medicines

Objective To observe the effects of central exudative chorioretinopathy(central exudative chorioretinopathy,CEC)treated with blood-activating and stasis-removing Chinese medicines.Methods All 339 cases of central exudative chorioretinopathy with 346 infected eyes were randomly recruited into a treatment group(176 cases with 181 infected eyes)and a control group(163 cases with 165 infected eyes).The treatment group was treated with traditional Chinese medicine by dialectical combination of syndrome and disease,while the control group was treated with conventional treatment.Results The corrected visual acuity was 0.01～1.2 in the treatment group.Of all 181 eyes in 176 patients,76 eyes were cured(41.98%),85 eyes were improved(46.96%),and 20 eyes were ineffective(11.6%),with a total effective rate being 88.94%.BY contrast,in the control group,of all 165 eyes in 163 patients,62 eyes were cured(37.57%),67 eyes were improved(40.60%),and 36 eyes were ineffective(21.83%),with a total effective rate being 78.17%.There was significant difference in the total effective difference between the two groups(U=2.05693,P＜0.05).FFA and OCT were reexamined for the patients in the treatment group three menths after the treatment.The results showed that fluorescein leakage and choroidal neovascularization(choroid al neovascularisation,CNV)lesions disappeared in 76 eyes;fluorescein leakage and CNV lesions relieved in 85 Eyes;fluorescein leakage still existed in 12 eyes;and sear formed in 8 eyes.Conclusion Blood-circulating and stasis-removing Chinese medicines have good effects in promoting subhyaloid hemorrhage and exudation,eliminating retinal oedema,and improving eyesight. Key words: Central exudative chorioretinopathy; Chinese medicine; Promoting blood circulation and removing blood stasis

Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura

A 42-year-old female presented to us with a complaint of sudden painless loss of vision in both eyes of three days duration. Visual acuity was 20/100 for distance in both eyes. Fundus examination showed bilateral peripapillary hemorrhages, with subhyaloid and vitreous hemorrhage in both eyes. Hematological investigations revealed hemoglobin (HB 7 gm %) and severe thrombocytopenia (12,000/ ul). She was referred to a hematologist where a diagnosis of idiopathic thrombocytopenic purpura (ITP) was made. She was treated for systemic condition with regular ophthalmic follow-up. Over the next nine months, retinal hemorrhages completely resolved and the patient regained her visual acuity. The purpose of this case report is to highlight the clinical presentation of severe anemia, which is different from previous reports and the role of an ophthalmologist in first detecting the Idiopathic thrombocytopenic purpura (ITP), which led to successful recovery.

Bilateral circumferential macular folds in inflicted childhood neurotrauma.

To report an infant with inflicted neurotrauma who exhibited bilateral circumferential macular folds. Bedside ophthalmic examination and fundus photography using RetCam-II (Clarity Medical Systems, Pleasanton, CA). Both pupils were miotic and nonreactive. External and anterior segments showed no abnormality. The fundus showed bilateral diffuse multilaminar retinal, subhyaloid, and vitreous hemorrhages. Distinctive macular folds were noted bilaterally. Circumferential macular folds are most commonly found in abused infants, although it has been suggested that they may be associated with Terson syndrome and severe crush injury.

Marathon Runner’s Retinopathy

Purpose: To report a case of an unusual retinopathy in an otherwise healthy 25-year-old marathon runner.Methods: Case report.Results: A 25-year-old female marathon runner developed sudden onset of monocular vision loss during a routine training run. The retinal features included a large, central, subhyaloid hemorrhage, multiple intraretinal hemorrhages, disc edema and venous dilation and tortuosity resembling characteristics of both valsalva retinopathy and nonischemic central retinal vein occlusion. Work up for underlying systemic cause was negative. However, the patient did participate in endurance exercise.Conclusion: Strenuous exercise increases activated platelets and other clotting factor elements. During exercise, this increase in clotting factors in the coagulation cascade is usually balanced by activation of key elements in the fibrinolysis cascade as well. However, certain individuals, especially those who already have a predisposition to clotting or other thrombogenic risk factors may disrupt the balance between coagulation and fibrinolysis during strenuous exercise favoring coagulation which places them at risk for thrombus formation.

Fundus Findings in Spontaneous Subarachnoid Hemorrhage and their Correlation with Neurologic Characteristics

To determine the incidence of fundus findings in spontaneous subarachnoid hemorrhage (SAH) and their correlation with neurologic characteristics. In a prospective case series, 202 eyes of 101 patients with SAH were evaluated from September 2003 to September 2006. The incidence of fundus findings was detected and correlated with gender, age, consciousness state, Fisher score, site and number of aneurysms, laterality of aneurysms, aneurysmal rebleeding, and mortality rate. Fifty (49.5%) patients had normal and 51 (50.5%) patients had abnormal funduscopic examination. Of all eyes, disc swelling in 85 (42.1%), retinal hemorrhage in 51 (25.2%), subhyaloid hemorrhage in 6 (3%), and vitreous hemorrhage in 3 (1.5%) eyes were detected. No relation was found between gender, age, Fisher score, number of aneurysms, laterality of aneurysms, aneurysmal rebleeding, and mortality rate and fundus findings. However, a correlation was observed between consciousness state and retinal hemorrhage (p=0.002) and disc swelling (p=0.002), and also between the anterior communicating artery location of aneurysm and retinal hemorrhage (p=0.017) and any kind of fundus findings (p=0.007). Fundus findings including hemorrhage and disc swelling are common in patients with SAH and are related to the consciousness state and anterior communicating artery location of aneurysm.

Subhyaloid hemorrhage as the presenting sign of pregnancy-induced hypertension

Subhyaloid hemorrhage as the presenting sign of pregnancy-induced hypertension

Valsalva retinopathy presenting with subhyaloid haemorrhage

A 46-year-old builder awoke with sudden loss of the superior visual field in the right eye. Best-corrected visual acuity measured 2/60 on the right and 6/5 on the left. There...

Terson hemorrhage in patients suffering aneurysmal subarachnoid hemorrhage: predisposing factors and prognostic significance

The association of vitreous and/or subhyaloid hemorrhage with aneurysmal subarachnoid hemorrhage (SAH) has been frequently identified since the original description by Terson in 1900. In this prospective clinical study the authors examined the actual incidence of Terson hemorrhage in patients suffering aneurysmal SAH, they attempted to identify those parameters that could predispose its development, and they evaluated its prognostic significance in the overall patients' outcome. A total of 174 patients suffering aneurysmal SAH were included in this study. The admitting Glasgow Coma Scale scores (GCS), World Federation of Neurological Societies (WFNS) scale scores, Hunt and Hess grades, and Fisher grades were recorded. A careful ophthalmological evaluation was performed in all participants. The exact anatomical locations and the largest diameter of the dome of the ruptured aneurysms were also recorded. Surgical clipping or endovascular coiling was used in 165 patients. Clinical outcome was evaluated at discharge from the hospital by using the Glasgow Outcome Scale and the modified Rankin Scale. Periodic ophthalmological evaluations were performed for 2 years. In this series, the observed incidence of Terson hemorrhage was 12.1%. Statistical analysis of our data demonstrated that patients with low GCS scores and high WFNS scores, Hunt and Hess grades, and Fisher grades had an increased incidence of Terson hemorrhage. The mortality rate for patients with Terson hemorrhage was 28.6%, whereas that for patients without Terson hemorrhage was 2.0%. Moreover, patients with Terson hemorrhage who survived had significantly worse outcomes than those in patients without Terson hemorrhage. Terson hemorrhage constitutes a common SAH-associated complication. Its incidence is increased in patients with low GCS and high WFNS scores, and high Hunt and Hess and Fisher grades. Its presence is associated with increased mortality and morbidity rates.

Premacular subhyaloid haemorrhage in Eales' disease managed with Nd:YAG laser

Premacular subhyaloid haemorrhage in Eales' disease managed with Nd:YAG laser

Optical coherence tomography findings and management of sub‐internal limiting membrane haemorrhage

lymphoma and a history of severe trombopenia, with a platelet count of 50 · 10 ⁄ l after autologous bone marrow transplantation, presented with a loss of vision and central scotoma in his left eye of 3 months’ duration. Best corrected visual acuity (BCVA) in the left eye was counting fingers at 1 m. The fellow eye was normal. Fundus examination revealed an old, premacular haemorrhage containing mostly dehemoglobinized blood (Fig. 1A). A premacular vitreous detachment was seen on biomicroscopy examination. Stratus optical coherence tomography (OCT) V4.0 (Carl Zeiss Meditec Inc., Dublin, CA, USA) was performed. A line OCT scan, just above the level of sedimented blood, revealed a hyperreflective area under the internal limiting membrane (ILM) (Fig. 1B). Vitreous surgery was indicated by the appearance of the premacular haemorrhage, the time of evolution and the visual loss. Pars plana vitrectomy and ILM dissection with a soft-tipped extrusion cannula were performed. The blood under the ILM was removed. After 1 month, the macula was clear of blood, the subject’s vision had recovered to 20 ⁄ 20 and an OCT scan showed complete resolution of the sub-ILM haemorrhage (Fig. 1C, D). Premacular haemorrhage is described as a sub-ILM haemorrhage, a subhyaloid haemorrhage, or a combination of both, according to its anatomic location (Gass 1997). SubILM or subhyaloid haemorrhage in A

SUDDEN VISUAL LOSS IN ACUTE LEUKAEMIA

The presenting signs of acute leukaemia occur as a result of bone marrow failure and organ in' ltration. Increased bleeding tendencies are seen on the skin, gums and mucosal lining. Bleeding in the posterior segment of the eye, namely the retina and vitreous, may occur, but do not usually cause any visual disturbances. This case demonstrates visual loss as a result of premacular subhyaloid haemorrhage in acute leukaemia.

RESTORATION OF RETINAL BLOOD FLOW VIA TRANSLUMENAL Nd:YAG EMBOLYSIS/EMBOLECTOMY (TYL/E) FOR CENTRAL AND BRANCH RETINAL ARTERY OCCLUSION

Central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO) may be a result of platelet-fibrin emboli, cholesterol plaques, or calcific emboli that typically lodge at the bifurcation of retinal arterioles or at a location as the vessel narrows. Hollenhorst plaques (cholesterol emboli) can often be seen at the site of vessel obstruction. Obstruction of blood flow results in partial or complete retinal ischemia and sudden loss of vision. There is no effective therapy for CRAO and BRAO. The authors employed the Nd:YAG laser to photodisrupt emboli within the central retinal artery (CRA) and branch retinal arteries (BRA) to achieve rapid reperfusion of the retina. Translumenal Nd:YAG embolysis (TYL) or embolectomy (TYE) was performed on 19 patients with sight-threatening CRAO or BRAO. All patients had a visible embolus within the CRA or BRA. A fundus contact lens was used to focus the Nd:YAG laser on the embolus within the retinal arteriole. Laser applications were delivered directly to the embolus with increasing energy until the embolus was either fragmented within the lumen (embolysis) or was observed to pass into the vitreous through a small opening in the arteriole (embolectomy). TYL/E was achieved in all 19 patients. In 8 patients the emboli was fragmented (embolysis) and in 11 the embolus was transplaced into the vitreous (embolectomy). Reperfusion of the retina was observed in all patients as determined by fundus examination, fundus photography, and fluorescein angiography. Snellen visual acuity improved by an average of 4.7 lines (range, 1-11 lines) in 17/19 (89%) patients. Eleven of the patients (58%) gained greater than 4 lines. One patient had no improvement and another lost one line due to a persistent vitreous hemorrhage. Vitreous hemorrhage (VH) occurred in seven patients, and subhyaloid hemorrhage (SH) occurred in one patient. In five of the patients an early vitrectomy was performed to allow clinical assessment and documentation of the successful TYL/E. Photodisruption of an embolus within an occluded CRA or BRA can be achieved via TYL/E. Rapid reperfusion of the retina is associated with anatomic and visual acuity improvement. Translumenal Nd:YAG embolysis or embolectomy of a visible embolus in patients with CRAO or BRAO can be achieved resulting in restoration of retinal blood flow and improved visual function.