Nd:YAG laser hyaloidotomy in the management of Premacular Subhyaloid Hemorrhage

Abstract

BackgroundPremacular subhyaloid hemorrhage results in a sudden profound loss of vision. Among the modalities for its treatment, Nd:YAG laser hyaloidotomy is a non invasive method enabling rapid drainage of the obstructed macular area and improved vision within days. This study was aimed to evaluate the efficacy, visual outcome and complications following Nd:YAG laser hyaloidotomy for premacular subhyaloid hemorrhage.MethodsPatients with premacular subhyaloid hemorrhage of more than 3 disc diameters (DD) of various etiologies, attending Tilganga Institute of Ophthalmology, Nepal from August, 2014 to February, 2015, were included. A comprehensive ocular evaluation was conducted and fundus photographs were taken to measure the size of the subhyaloid hemorrhage. Optical coherence tomography (OCT) were performed before and after treatment and on subsequent follow up visits. Fundus fluorescence angiography was done whenever necessary. Q switched Nd:YAG laser was applied to create an opening in the posterior hyaloids membrane for draining subhyaloid hemorrhage. The main outcome measures were success rate in performing hyaloidotomy, drainage of subhyaloid blood into vitreous cavity and its resorption, improvement in visual acuity, need for further intervention and postoperative complications.ResultsThere were 21 eyes of 19 patients, 17(89.48 %) male and 2(10.52 %) female. In 3, premacular subhyaloid hemorrhage was bilateral. Mean age was 41.68 ± 17.08 years and a mean duration of symptoms 15.04 days. Mean pretreatment hemorrhage was 6.27DD. Nd:YAG laser hyaloidotomy was successful in 19 eyes(86.4 %). In 2 patients, one each with Eales’ disease and retinal vein occlusion the procedure was unsuccessful, necessitating pars plana vitrectomy, while in a case with proliferative diabetic retinopathy (PDR), vitrectomy was resorted for non clearing vitreous hemorrhage. Vision improved from a median of 3/60 pre-operatively to 6/6, at 6 months follow up. At 3 months, 2 patients with Eales’ disease, one developed tractional detachment at macula while the other, an epiretinal membrane. No other complications were noted at 6 months.ConclusionNd:YAG laser hyaloidotomy is an inexpensive, effective and a safe outpatient procedure for premacular subhyaloid hemorrhage, producing rapid drainage with restoration of visual function avoiding more invasive procedures and enabling early assessment of the underlying retina. The final visual prognosis however, rests on the underlying cause of the subhyaloid hemorrhage and any accompanying retinal changes.

Spontaneous Macular Hole Closure after Valsalva Retinopathy and Nd:YAG Laser Treatment

“…In such a case, there is a likelihood that haemoglobin and iron have a toxic effect on retina [7]. Nd: YAG laser membranotomy is a widely used noninvasive method that usually improves vision acuity rapidly especially in cases of haemorrhage above 3 DD [8]. As regards complications, there is a small risk of epiretinal membrane, premacular cavity formation, and ILM thickening [9].…”

Spectral domain optical coherence tomography evaluation of macular changes in Eales disease

“…This feature has been reported very rarely in Eales disease. [ 14 15 ] Fig. 5 illustrates the fundus photograph of one of those two patients showing a premacular hemorrhage centered at the macula, around 2 disc diameters in size, surrounded by glistening striae, giving the clinical appearance of a “double ring.” A SD-OCT scan revealed that the outer ring (black arrows) was that of a subinternal limiting membrane (ILM) hemorrhage, while the inner ring (white arrows) was formed by hyperreflective deposits below the ILM that caused shadowing of the underlying retinal layers.…”

Iatrogenic parafoveal macular hole following Nd-YAG posterior hyaloidotomy for premacular haemorrhage

“…If possible, always drain from a region distant enough from the fovea along the inferior border where there is significant haemorrhagic elevation 7. Khadka et al 1 have recently reported an 86% success rate of Nd-YAG laser in management of premacular SHH in a study on 21 eyes with no complications at 6 months follow-up. They recommend that it is better to start with 5 MJ energy and then gradually increase by 1 MJ steps until 12 MJ.…”

“…Nd-YAG posterior hyaloidotomy is an established and promising treatment modality for rapid drainage of haemorrhage covering the macula 1. It is an inexpensive, effective and safe outpatient procedure.…”