Subhyaloid Space Research Articles

Extension of Choroidal Neovascular Membrane into Subhyaloid Space after Trauma

Extension of Choroidal Neovascular Membrane into Subhyaloid Space after Trauma

Valsalva Retinopathy: Clinical Features and Treatment Outcomes.

To report the clinical presentation and outcomes in patients with Valsalva retinopathy. Retrospective case series of patients diagnosed with Valsalva retinopathy between June 1, 2010 and May 31, 2020. Clinical notes, operative reports, fundus photography, and optical coherence tomography images were reviewed. The study comprised 58 eyes of 58 patients. The most common causes were lifting (34.4%), vomiting (20.6%), straining (20.6%), and coughing (17.2%). Mean best-corrected visual acuity (BCVA) at diagnosis was 20/163. The most frequently involved vitreoretinal compartment was the subhyaloid space (42.3%) followed by the intraretinal (32.7%), intravitreal (23.1%), and subretinal (13.4%) spaces. Mean BCVA of all patients was 20/59 at 3 months, 20/48 at 6 months, and 20/22 at 1 year. Mean time to clearance of hemorrhage on clinical exam was 99.0 ± 18.7 days in patients who underwent observation and 4.5 ± 3.5 days after surgery in patients who received pars plana vitrectomy. Valsalva retinopathy is generally associated with a favorable visual prognosis. Most eyes perform well with observation although pars plana vitrectomy may be indicated in patients requiring rapid resolution of hemorrhage.

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.

ИАГ-лазерная гиалоидопунктура при субгиалоидных кровоизлияниях (клинические случаи)

Purpose. Тo present the results of YAG laser hyaliodopuncture in patients with subhyaloid hemorrhages. Material and methods. 4 patients underwent YAG laser hyaloid puncture. These patients were followed up for at least 12 months. In all cases, YAG laser hyaloid puncture was performed with the YAG III device (Carl Zeiss Meditec AG, Germany). Hyaloid puncture was performed at a wavelength of 1064 nm through the central part of the Goldmann lens with the application of 3 to 7 pulses with a power of 1.7–2.8 mJ in the lower segment of the BGM at the point corresponding to the greatest prominence of hemorrhage. Results. In all cases, laser treatment was carried out without complications. Intensive blood flow into the vitreal cavity and subjective improvement in visual acuity were obtained during the first 2 hours after laser treatment for 3 adult patients. BCVA in the 2nd case increased from pr. certae to 0.3, in the 3 rd case from 0.2 to 0.5, in the 4 th case from 0.1 to 0.4. A defect in the posterior hyaloid membrane was determined according to SOCT. All patients had complete elimination of blood from the subhyaloid space after 1 month at the control examination. Only the 4 th patient noted periodic «floating opacities», in other cases, the patients did not complain. BCVA in 1 st and 2 nd cases was 1.0, in 3 rd and 4 th cases it was 0.8. IOP was within normal limits in all cases. Conclusion. YAG laser hyaloid puncture can be used to treat subhyaloid hemorrhages. The technique shows high efficiency when performed as soon as possible after the development of hemorrhage under the control of laboratory methods of blood analysis. Keywords: subhyaloid hemorrhage, YAG-laser hyaloid puncture.

Posterior Subhyaloid Precipitates: ‘KPs’ of the Posterior Segment

ABSTRACT Purpose: To describe the course of posterior subhyaloid precipitates (PSPs) accompanying active retinitis. Methods: Retrospective study of three retinitis cases associated with PSPs and literature review. Results: Cases 1 and 2 were Toxoplasma retinochoroiditis. Case 3 had bilateral retinitis post-febrile illness. PSPs were yellowish-white spherical lesions seen in the presence of partial posterior hyaloid detachment (PVD) in the retro-hyaloid space lining the inferior PVD margin. In all 3 cases, PSPs resolved during treatment for primary disease. Resolution of PSPs preceded resolution of retinitis. Literature review revealed similar lesions in CMV retinitis and syphilis in addition to Toxoplasma retinochoroiditis. Conclusion: PSPs were seen in the presence of active retinitis and partial PVD when inflammatory aggregates gravitate inferiorly in the subhyaloid space. They were observed during active retinitis and their resolution preceded the resolution of retinitis, thus providing a potential marker for disease resolution.

Posterior subtenon injection of triamcinolone acetate in subhyaloid space: A rare complication.

Posterior subtenon injection of triamcinolone acetate in subhyaloid space: A rare complication.

CLINICAL FINDINGS IN TRIAMCINOLONE-ASSOCIATED MACULOPATHY.

To describe a crystalline retinopathy observed in patients greater than 1 year after intravitreal injection of triamcinolone acetonide (IVTA). A retrospective, interventional, noncomparative, single-center case series of patients who received IVTA and developed subsequent crystalline retinopathy lasting greater than 1 year after injection. Eighteen eyes of 16 patients in which preretinal crystals were observed >1 year after IVTA were included in the study, with a mean follow-up (range) of 5.8 years (1.1-9.2) after IVTA. The crystals were refractile, not visible on fluorescein nor indocyanine green angiography, exhibited slow dissolution and movement, and were occasionally distributed in a circular fashion. Optical coherence tomography confirmed the preretinal and/or subhyaloid location of crystals. Macular crystals can persist for years after IVTA. The crystals localize to the preretinal or subhyaloid space, are angiographically silent, can exhibit slow dissolution and movement, may be distributed in a circular fashion reflecting the bursa premacularis, and appear nonpathologic.

Terson's Syndrome Due to Aneurismal Subarachnoid Hemorrhage

Vitreous or retinal hemorrhage occurring in association with subarachnoid hemorrhage is known as Terson's syndrome. In Terson's syndrome, intracranial hemorrhages are followed by intraocular hemorrhage, classically in the subhyaloid space, but may also include subretinal, retinal, preretinal, and vitreal collections. Usually occurs in adult, but can be at any age. It may be unilateral or bilateral. Vitreous hemorrhage recovery is usually spontaneous within 6 to 12 months, otherwise vitrectomy is considered. We report a case of Terson's syndrome which was admitted in Anwer Khan Modern Medical College & Hospital as unilateral Terson's syndrome with multiple intra retinal hemorrhage of left eye associated with Hypertension & Diabetes Mellitus.Anwer Khan Modern Medical College Journal Vol. 8, No. 2: Jul 2017, P 153-156

Terson Syndrome from Subarachnoid Hemorrhage in Aplastic Anemia

A 22-year-old woman presented with vision loss after weeks of menorrhagia and a recent fall. Fundoscopic examination showed a multilayered hemorrhage (intraretinal, subinternal limiting membrane, subhyaloid, intravitreal), with a “double-ring” from hemodissection of the internal limiting membrane and subhyaloid space (Fig 1A). Workup revealed pancytopenia and subarachnoid hemorrhage. Bone marrow biopsy showed hypocellular marrow (Fig 1B) with lymphoid cells and rare erythroid elements (Fig 1C), consistent with aplastic anemia. Terson syndrome is an intraocular hemorrhage, often multilayered, associated with intracranial hemorrhage. The pathogenesis is debated but likely related to sudden rises in intracranial pressure, resulting in venous hypertension and rupture of retinal vessels.

Posterior subhyaloid precipitates in cytomegalovirus retinitis

PurposeThis study aims to report a novel finding of posterior subhyaloid precipitates (PSPs) in two patients with cytomegalovirus (CMV) retinitis.MethodsA small case series was conducted.ResultsClinical findings, treatment, and follow-up of two patients with CMV and PSPs are presented.ConclusionsInflammatory precipitates may collect in the posterior subhyaloid space in acute CMV retinitis and resolve with treatment.

Valsalva Retinopathy in Pregnancy: SD-OCT Features During and After Nd:YAG Laser Hyaloidotomy

Valsalva retinopathy can present as a sudden, dramatic loss of central vision due to the premacular location of the resultant subhyaloid hemorrhage. Certain vascular conditions predispose to the condition and occasional reports exist of Valsalva retinopathy in pregnancy. The authors describe a case of Valsalva retinopathy in a pregnant patient in terms of the physical features present that led to making the decision to treat by Nd:YAG laser hyaloidotomy as opposed to conservative management. Spectral-domain optical coherence tomography (SD-OCT) was able to demonstrate the physical features of the lesion prior to, immediately after, and weeks after treatment, and showed not only the dispersion of hemorrhage into the vitreous cavity from the subhyaloid space, but also that the subhyaloid cavity dimensions were unchanged despite release of the hemorrhage. SD-OCT visualized the actual hyaloidotomy site and its subsequent closure, which has not previously been reported in the literature.

OCT-guided Hyaloid Release for Vitreomacular Traction Syndrome

PurposeTo evaluate the usefulness of OCT retinal mapping in determining the configuration of a vitreomacular adhesion and selecting a meridian for entry into the subhyaloid space in patients with vitreomacular traction syndrome.MethodsSix consecutive patients (6 eyes) with vitreomacular traction syndrome underwent vitrectomy with peeling of posterior hyaloid. Ocular coherence tomography (OCT) retinal mapping was performed preoperatively. Access to the subhyaloid space was made by creating an opening with a 25 gauge needle at a location where the detached posterior hyaloid membrane was farthest from the retinal surface. The location was selected based on six preoperative meridional OCT scans. The posterior hyaloid was then gently peeled off in a circular fashion around the fovea with a micropick. Visual acuity and foveal thicknesses were measured before the operation and 3 months afterwards.ResultsAfter the operation, visual acuity improved and central macular thicknesses were reduced significantly in all six patients. The best corrected visual acuity improved from 0.4 to 0.75 with a mean increase by 3.5 lines on a Snellen chart 3 months after the operation. The mean foveal thickness was reduced from 406 µm to 241 µm. The restoration of foveal pit was observed in five patients. Neither intraoperative nor postoperative complications were observed during the follow up period.ConclusionsAn OCT retinal mapping program is a valuable diagnostic tool in understanding the configuration of vitreomacular adhesion and planning the surgical approach for operating on vitreomacular traction syndrome.

Valsalva Retinopathy as a Complication of Colonoscopy

To the Editor: We read with interest the case report by Oboh et al describing the occurrence of Valsalva retinopathy following a routine colonoscopy. The retinal hemorrhage resolved within a month without any sequelae. The authors concluded that the visual prognosis in this type of retinopathy was favorable and no treatment was deemed necessary. We would like to make further supplements from the ophthalmologist’s perspective. The severity, visual prognosis, and treatment modalities of intraocular hemorrhage induced by the Valsalva maneuver depend very much on the thickness, size, and anatomic level of hemorrhage, which can be intravitreal, preretinal, intraretinal, or even in the sheath of the optic nerve leading to blindness. Although the vast majorities of cases are self-limiting, the hemorrhage may cause profound visual loss of up to 6 months if left untreated. In long-standing cases, epiretinal membrane, macular traction, and toxic effect of dissolving hemoglobin may happen and lead to disturbing visual morbidity. To achieve rapid improvement in vision and to avoid complications, dense premacular hemorrhage may be managed with laser therapy, intraocular gas injection, or surgical vitrectomy. Laser photodisruption with Neodymium:YAG laser and argon laser has been reported. Laser puncture at the posterior hyaloid membrane allows rapid diffusion of hemorrhage from the subhyaloid space into the vitreous gel to facilitate the blood absorption. This office procedure is safe and effective and can be completed in minutes. Valsalva retinopathy may also be provoked by other interventions such as dental surgery or even fundus fluorescein angiography that can induce pain, nausea, and vomiting. Adequate explanation of the procedure and sufficient sedation, antiemetic, and analgesic may minimize this potential ocular complication, especially in vulnerable patients with the TTTrisk factors of diabetes mellitus, hypertension, and bleeding tendency. Vincent Y. W. Lee, FRCS David T. L. Liu, MRCS Wai-Man Chan, MRCP, FRCS Dennis S. C. Lam, FRCS, FRCOphth Department of Ophthalmology & Visual Sciences Chinese University of Hong Kong Prince of Wales Hospital New Territories, Hong Kong People’s Republic of China

A New Technique for Separation of Posterior Vitreous in Vitreous Surgery

To describe a new and effective technique, hydroseparation, for use in detaching the posterior cortical vitreous from the retina by the simple injection of fluid into the subhyaloid space. This technique was used in 7 eyes of 6 patients with diabetic retinopathy who had limited posterior vitreous detachment. Following core vitrectomy, a 32 gauge cannula was inserted into the subhyaloid space and a balanced salt solution (BSS) was injected. The injected fluid spread easily to the periphery, causing the vitreous cortex to be smoothly separated, except for areas with firm vitreoretinal adhesion. In those areas, we also used microscissors to separate the tissue. No iatrogenic retinal break occurred in any case. This simple technique, which exerts minimal traction force on the retina, was safe and useful for inducing posterior vitreous detachment in patients with diabetes.

Effect of vitreous detachment on vitreous fluorophotometry.

Twenty eyes of 17 normal subjects with or without posterior vitreous detachment (PVD) were examined to investigate the influence of various types of PVD on vitreous fluorophotometric readings. Biomicroscopic examinations of the vitreous body were performed with an El Bayadi - Kajiura preset lens, and the findings were classified according to the extent of vitreous detachment and the position of the posterior hyaloid membrane when the eye was stationary. Equivalent fluorescein concentration profiles along various directions in the vitreous cavity were obtained with vitreous fluorophotometry. The degree of PVD significantly affected the measurements. Close to the retina, fluorescein concentrations were significantly higher when the subhyaloid space was sampled than when the vitreous gel was sampled. Our findings have implications for vitreous fluorophotometric assessment of the permeability of the blood-retinal barrier.