Sub-internal Limiting Membrane Hemorrhage Research Articles

Photoreceptor Damage in Terson Syndrome.

To describe photoreceptor damage in patients with Terson syndrome as a potential cause for inconsistent clinical outcomes. Clinical evaluation and retinal imaging in six patients. Four patients were female and two male, with an average age of 46.8 years (SD 8.9). Four patients suffered aneurysmal subarachnoid haemorrhage, one vertebral artery dissection, and one superior sagittal sinus thrombosis. In 11 eyes, we observed a consistent pattern of outer retinal damage within the central macula affecting the ellipsoid zone and the outer nuclear layer, indicating photoreceptor damage. Areas of photoreceptor damage showed poor spatial correlation with intraocular haemorrhage, particularly sub-internal limiting membrane haemorrhage. The observed retinal abnormalities demonstrated incomplete recovery over long-term follow-up 3.5 to 8 years post-haemorrhage, irrespective of surgical or conservative treatment strategy, and had variable impact on the patients' visual function. The observations suggest that photoreceptor damage in Terson syndrome likely represents a distinct manifestation of this condition, which could be caused by transient ischaemia resulting from disturbed choroidal perfusion secondary to acute rise in intracranial pressure.

Removal of Sub-Internal Limiting Membrane Hemorrhage Secondary to Retinal Arterial Macroaneurysm Rupture: Internal Limiting Membrane Non-Peeling Technique.

The appropriate surgical technique to improve the closure rate of perioperative full-thickness macular hole (FTMH) secondary to submacular hemorrhage (SMH) with sub-internal limiting membrane (ILM) hemorrhage caused by retinal arterial macroaneurysm (RAM) rupture remains an unsolved clinical problem. Several ILM transplantation techniques have been attempted, but these are challenging. Our new technique can remove sub-ILM hemorrhage with the central fovea ILM intact, without peeling the ILM. The medical records of three eyes from three patients with SMH and sub-ILM hemorrhage secondary to RAM rupture were retrospectively reviewed. During the surgery, a small ILM fissure was made outside the central fovea with ILM forceps, and sub-ILM hemorrhage was washed out through it by manually spraying balanced salt solution. Sub-ILM hemorrhage removal was achieved successfully in all eyes, with no occurrences of FTMH or other complications. Best-corrected decimal visual acuity improved from 0.05 (Snellen equivalent (SE), 20/400), 0.05 (SE, 20/400), and 0.05 (SE, 20/400) preoperatively to 0.3 (SE, 20/63), 0.4 (SE, 20/50), and 0.15 (SE, 20/125) at 3 months postoperatively, respectively. This new technique may help keep the foveal ILM intact and prevent perioperative FTMH formation.

Green Laser Pointer–Induced Subinternal Limiting Membrane Hemorrhage

Green Laser Pointer–Induced Subinternal Limiting Membrane Hemorrhage

Retinal arterial macroaneurysm rupture by Valsalva maneuver: a case report and literature review

BackgroundRetinal artery macroaneurysms (RAMs) are focal dilations of the large retinal arteries. Most RAMs are asymptomatic, however, when hemorrhage or exudation caused by a RAM involves the macula, patients can experience marked vision loss. This article reported a rare case of a ruptured RAM due to the Valsalva maneuver in an elderly female with constipation and offered a review of the relevant literature.Case presentationA 78-year-old woman with several risk factors presented with multi-level retinal hemorrhages following a Valsalva maneuver during constipation. Due to the poor coagulation and heavy bleeding in this case, the blood broke through the internal limiting membrane and drained "on its own" into the vitreous cavity. First, we observed the patient and controlled for her risk factors. After the blood was completely drained into the vitreous cavity, the root cause of the bleeding was found to be a RAM rupture. After laser photocoagulation, the patient's vision recovered significantly and remained stable for a long time despite the presence of an epiretinal membrane and a lamellar macular hole.ConclusionsThis is the first reported case of a RAM rupture by Valsalva maneuver during constipation. For multi-level hemorrhages caused by RAM, measures should be taken to drain out the sub-internal limiting membrane hemorrhage and simultaneously control for risk factors. After the RAM is exposed, laser photocoagulation can be performed.

Optical coherent tomography angiography observation of macular subinternal limiting membrane hemorrhage in CO poisoning: a case report.

Optical coherent tomography angiography observation of macular subinternal limiting membrane hemorrhage in CO poisoning: a case report.

Traumatic Maculopathies Associated with Closed-Globe Injury

Traumatic maculopathies due to closed-globe injury are commotio retinae (Berlin’s edema), choroidal rupture, traumatic macular hole, retinitis sclopetaria, shaken baby syndrome, Valsalva retinopathy, and Purtscher retinopathy. The main pathology in commotio retinae is in the outer retinal layers and usually resolves spontaneously. Blunt eye traumas coming from the anterior aspect can cause choroidal ruptures. These are mainly due to the rupture of inelastic Bruch membrane and adjacent structures. If they involve fovea, visual loss can occur. Late choroidal neovascularisation may develop in 1/10 of the cases. Traumatic macular holes develop in less than 2% of the blunt ocular traumas. Early macular holes result from tangential traction whereas late holes from anteroposterior vitreoretinal traction. They can be closed spontaneously within 4 months, especially in young patients. Retinitis sclopetaria is rare. It results from high-velocity pellets that hit but do not penetrate the globe. Shock waves can cause the rupture of the choroid and overlie the neurosensory retina. The shaken baby syndrome is a result of the violence in the family. It must be reported to the police. Retinal hemorrhages, cotton wool spots, and hemorrhagic retinoschisis areas are the prominent features. The sudden increase in intrathoracic or abdominal pressure may lead to the rupture of the retinal capillaries and usually a sub-internal limiting membrane hemorrhage in Valsalva retinopathy. If it is larger than 3-disc diameters and persists for more than 3 weeks; it may be drained into vitreous with an Nd-YAG laser. Purtscher retinopathy is an occlusive microvasculopathy resulting from severe head trauma or compression injuries of the thorax. Intraretinal hemorrhages, geometric white areas (Purtscher flecken), and cotton wool spots are typical features. Usually fades within 1-2 months. Medicolegal aspects as well as ocular and systemic associations are also important in closed globe injuries and should not be neglected.

Follow-up of a traumatic sub-internal limiting membrane hemorrhage after exposure to a recreational laser

Follow-up of a traumatic sub-internal limiting membrane hemorrhage after exposure to a recreational laser

TREATMENT OPTIONS FOR PREMACULAR AND SUB-INTERNAL LIMITING MEMBRANE HEMORRHAGE.

Premacular hemorrhage (PH) and sub-internal limiting membrane hemorrhage (sub-ILM-H) are among the causes of sudden deterioration of central visual acuity. Anatomical and functional outcomes of different therapeutic options were evaluated retrospectively. The study included three eyes of three patients (2 females and 1 male). Location of the hemorrhage was determined by spectral domain optical coherence tomography. Subhyaloid premacular location of the hemorrhage was proven in one eye of each woman and sub-ILM location of the hemorrhage in one eye of the male. The baseline best corrected visual acuity (BCVA) was 0.63 in the eyes of the females and 0.16 in the eye of the male. Conservative treatment option was chosen in case of juxtafoveolar PH in the eye of the female patient on anticoagulant warfarin therapy. The female patient with PH secondary to proliferative diabetic retinopathy (PDR) underwent Nd: YAG laser hyaloidotomy. The male patient with unexplained cause of the sub- ILM-H underwent 25-Gauge vitrectomy with ILM peeling and subsequent ultrastructural morphometric and histopathological examination of the ILM. Both BCVA and retinal finding improvement were achieved in all patients. Final BCVA was 0.8 in the eye of the female patient with PDR and 1.0 in rest of the eyes of the other patients. No complications were recorded at follow-up visits. Histopathological and morphometric examination demonstrated variable ILM thickness (2.70 ±1.58 μm) and proved presence of fibroblasts and macrophages with hemosiderin deposits on the retinal side of ILM. The choice of the treatment option of PH and sub-ILM-H depends on input parameters such as the initial BCVA, the extent and the location of the hemorrhage, as well as the overall health of the patient. Nd: YAG laser hyaloidotomy is an effective method for rapid recovery of visual functions. Surgical ILM peeling and aspiration of the underlying hemorrhage result in the removal of breakdown products of hemoglobin and minimization of the risk of secondary epiretinal membranes development.

Fundus and Optical Coherence Tomography Findings of Sub-internal Limiting Membrane Hemorrhage Following Retinal Arterial Macroaneurysm

Fundus and Optical Coherence Tomography Findings of Sub-internal Limiting Membrane Hemorrhage Following Retinal Arterial Macroaneurysm

Intraoperative optical coherence tomography (I-OCT)-guided identification of resolved sub-internal limiting membrane hemorrhage in leukemic retinopathy

Intraoperative optical coherence tomography (I-OCT)-guided identification of resolved sub-internal limiting membrane hemorrhage in leukemic retinopathy

Visual and Anatomic Outcomes of Premacular Hemorrhage in Non-Accidental Trauma Infants Managed With Observation or Vitrectomy.

The management of premacular hemorrhage secondary to non-accidental trauma (NAT) is unclear. The authors describe the outcomes of NAT infants referred for surgical evaluation of premacular hemorrhage. Retrospective institutional review board-approved case series between 2000 and 2019 of vision-threatening premacular hemorrhage (sub-hyaloid or sub-internal limiting membrane hemorrhage without vitreous hemorrhage) in NAT infants. Time to hemorrhage resolution, vision, and comorbidities were collected. Thirty-six patients (62 eyes) with mean age of 5.4 months (range: 2-10 months) were included. Nine eyes (14.5%) underwent vitrectomy. Median time to hemorrhage resolution by observation was 75 days (interquartile range [IQR]: 60-120 days), and time to vitrectomy was 54.5 days (IQR: 47.8-58.5 days). Eight eyes (12.9%) had amblyopia, which was not significantly different between groups. Despite hemorrhage clearance, a higher proportion of eyes in the vitrectomy group had pigmentary changes (P = .04) and strabismus (P = .002) at follow-up. Most cases of NAT-related premacular hemorrhage resolve within 3 months without surgical intervention. Comorbidities may limit visual prognosis. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:715-722.].

Valsalva retinopathy induced by handstand: a case report

BackgroundValsalva retinopathy is known to occur as a sudden preretinal or sub-internal limiting membrane hemorrhage induced by a rapid rise in venous pressure following increased intrathoracic or intraabdominal pressure. Here we report a case of Valsalva retinopathy that was probably induced by straining that occurred due to following a handstand.Case presentationA 15-year-old boy became aware of decreased visual acuity in his left eye immediately after doing a handstand for approximately 10 s during physical education class, and subsequently visited a local clinic on the same day. Upon examination, a vitreous hemorrhage (VH) in the posterior pole of the fundus was found in his left eye, and he was subsequently referred to our department 7 days later. Upon examination, the VH around the optic nerve head of the left eye appeared to be resolved, and an oval-shaped sub-internal limiting membrane (sub-ILM) hemorrhage was found in the superonasal side of the optic nerve head. No abnormalities were observed in the macular area. Four months later, the sub-ILM hemorrhage was found to have spontaneously resolved. Subsequent fluorescein angiography examinations revealed no abnormal findings at the lesion site.ConclusionsIn this patient, we hypothesize that the Valsalva retinopathy was induced by straining that occurred due to a handstand, and that the resultant sub-ILM hemorrhage progressed to VH.

"Arcus retinalis": A novel clinical marker of sub-internal limiting membrane hemorrhage.

Preretinal hemorrhages can be located in subhyaloid or sub-internal limiting membrane (ILM) space. Though optical coherence tomography (OCT) may help to distinguish the exact location of hemorrhage in selected cases, it is often difficult to discern clinically. The purpose is to describe a novel clinical sign named "arcus retinalis" as a clinical marker of sub-ILM hemorrhage. Retrospective observational case series. Ophthalmic records of 31 eyes with sub-ILM hemorrhage were analyzed. The sub-ILM nature of the hemorrhage was confirmed either by the presence of two distinct layers (ILM and posterior hyaloid) on OCT or on intraoperative sub-ILM localization of the hemorrhage during vitrectomy. 15 out of 31 eyes with sub-ILM hemorrhage demonstrated a retinal yellowish-white arc corresponding to the outer margin of the sub-ILM hemorrhage. A complete circle was not seen in most of the cases. This arc corresponded to a vertical peg-like structure in the outer retina on OCT and had a tendency to fade away over months. In 10 eyes, it was visible at presentation and in five eyes it could only be seen after clearing of the hemorrhage. Retinal yellowish-white arc ("arcus retinalis") is a useful clinical marker of sub-ILM hemorrhage with distinct OCT features that tends to disappear with time.

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.

Histopathological Changes and Clinical Outcomes following Intervention for Sub-Internal Limiting Membrane Haemorrhage

Introduction: Haemorrhage confined to the sub-internal limiting membrane (ILM) space can be associated with good visual recovery. There is controversy as to the best management of purely sub-ILM haemorrhage, which ranges from observation to immediate surgical intervention. Methods: We studied a retrospective case series of patients with sub-ILM haemorrhage who underwent vitrectomy with subsequent histological analysis of the removed ILM. Results: Sixteen patients underwent vitrectomy for sub-ILM haemorrhage. Five patients had underlying Terson syndrome, 6 had ruptured macro-aneurysms, and 5 had Valsalva retinopathy. Seven patients demonstrated cellular proliferation on the retinal surface of the ILM with staining for glial fibrillary acidic protein and cytokeratin 7, as well as CD68pg and Prussian blue. All but 1 of these cases were isolated from patients undergoing surgery >4 weeks following initial symptoms, the other presented at >2 weeks. Serial optical coherence tomography (OCT) was available in 8 patients; serial OCT in patients with delayed intervention demonstrated persistent inner retinal layer hyper-reflectance. Fourteen of 15 patients demonstrated symptomatic recovery and showed visual improvement with acuity ranging from –0.1 to 1.8 (mean 0.43) within 3 months of intervention (1 was lost to follow-up). The post-operative vision was 0.11 logMAR (mean; range –0.1 to 0.4) at 3 months in the group with intervention within 2 weeks of symptoms, and 0.9 logMAR (mean; range 0.0 to HM) in the group with delayed surgery. Conclusions: Early surgical intervention for sub-ILM haemorrhage resulted in good visual outcomes; delayed surgery may lead to proliferative vitreoretinopathy-like changes on the inner retinal surface of the ILM, and untreated cases may demonstrate persistent inner retinal changes potentially limiting visual prognosis despite subsequent surgical intervention.

Can Baseline Computed Tomography Scans Be Used to Identify Patients at High Risk of Vision Loss due to Terson Syndrome?

To determine if routinely performed computed tomographic (CT) scanning in patients with aneurysmal subarachnoid hemorrhages (aSAHs) is sufficient to identify patients at high risk of vision loss due to Terson syndrome (TS). Consecutive patients with a diagnosis of aSAH admitted to the neurologic intensive care unit of a regional referral hospital over a 3-year period were prospectively evaluated. Head CT scans performed in the emergency department were assessed for the presence of a "crescent sign" (evidence of significant subinternal limiting membrane hemorrhage). Dilated funduscopic examinations were performed by an ophthalmologist, masked to the results of the CT scan, to identify retinal and vitreous hemorrhages consistent with TS. Retinal hemorrhages were categorized according to size-those smaller than 2mm in diameter were deemed low risk (lrTS) for vision loss and those larger than 2mm in diameter were deemed high risk (hrTS) for vision loss. One hundred seventeen patients with aSAH were enrolled in the study. The overall incidence of TS was 24.9% (29 of 117 patients; 12 were bilateral). Compared to patients without TS, those with TS had a higher Fisher Hemorrhage Grade and a lower mean (±standard deviation) GCS score (8.66 ± 4.97 vs 12.09 ± 1.10; P < 0.001). The CT crescent sign was positive in 7 patients (6.0%), 6 (5.1%; 2 were bilateral) of whom were found to have hrTS. Of the 110 patients without a CT crescent sign, 88 (75.1%) patients did not have TS, 21 had lrTS, and 1 patient had hrTS in one eye. The CT crescent sign was highly sensitive (85.7%) and specific (99.1%) for diagnosing hrTS. The CT crescent sign is a highly sensitive and specific marker for hrTS. CT scanning may replace routine ophthalmologic examinations to identify patients at risk of vision loss due to aSAH.

Treatment of macular hemorrhage in retinal arterial microaneurysm: anatomic site-oriented therapy.

To investigate the usefulness of anatomic site-oriented therapy for macular hemorrhage secondary to retinal arterial macroaneurysm (RAM). Retrospective observational study, clinical case series METHODS: Twenty-seven consecutive patients (27 eyes) with macular hemorrhage secondary to RAM were classified according to the retinal layer(s) with hemorrhage identified by optical coherence tomography into 4 types and treated differentially. Vitrectomy was conducted for subinternal limiting membrane hemorrhage (SILMH), intravitreal gas injection for subretinal hemorrhage (SRH) or intraretinal hemorrhage (IRH), and vitrectomy and intravitreal air/gas exchange for multilevel hemorrhage (at least 2 among SILMH/SRH/IRH). Complete displacement or resolution of the macular hemorrhage was achieved in all 27 eyes: 7 with SILMH, 7 with SRH, 3 with IRH, and 10 with multilevel hemorrhage. Compared with the baseline score, the 3-month postoperative Early Treatment Diabetic Retinopathy Study score (mean ± SD) improved significantly in SILMH (+42.9 ± 6.9 letters; P < .0001, paired t test), multilevel hemorrhage (+23.9 ± 14.4 letters; P = .0005), and SRH (+17.7 ± 18.4 letters; P = .0440), but not in IRH (+6.7 ± 9.0 letters; P = .3228). Compared with the baseline thickness, the 3-month postoperative central retinal thickness decreased significantly in multilevel hemorrhage (-930.3 ± 290.8µm; P < .0001), SILMH (-628.4 ± 177.0µm; P < .0001), IRH (-508.3 ± 72.1µm; P = .0066), and SRH (-476.9 ± 300.0µm; P = .0056). The central ellipsoid zone was detectable in 7/7 eyes with SILMH but in none of the eyes in the other 3 groups (P < .0001). No retinal detachment or macular hole occurred in any eyes. For macular hemorrhage secondary to RAM, anatomic site-oriented therapy using different treatments targeting the hemorrhagic retinal layers is useful. The optimal treatments for individual hemorrhagic retinal layers require further studies.

Subinternal Limiting Membrane Hemorrhage Related to Laser Exposure in 2 Young Patients

Purpose: Lasers can be sight damaging, because they can produce severe and permanent retinal damage. Methods: This paper reports two cases of subinternal limiting membrane (sub-ILM) hemorrhage related to laser exposure. Results: The first patient was only observed for the reason that the retinal localization was extramacular; for the second patient, we decided to perform ultraspeed (7500 cuts per minute) 27-gauge pars plana vitrectomy (PPV) because of the foveal position of the hemorrhage and because of the nonimprovement of his clinical condition. The first patient recovered 20/20 Snellen after 10 days without intervention, whereas the second patient recovered 15/20 Snellen the day after surgery; 15 days later, his visual acuity was 20/20 Snellen. Conclusions: Sub-ILM hemorrhage after exposure to lasers can be treated using an ultraspeed 27-gauge PPV. This tool can be considered safe and effective on non–self-resolving sub-ILM hemorrhage.

Retinal haemorrhages: a clue to the underlying leukaemia

A 40-year-old man presented with a sudden onset of diminution of vision in his left eye for 2 days. Anterior segment of both eyes was within normal limits. Right eye...

Dissociated Optic Nerve Fiber Layer in Subinternal Limiting Membrane Hemorrhage

Dissociated Optic Nerve Fiber Layer in Subinternal Limiting Membrane Hemorrhage