Retinal Tears with Total Vitreous Hemorrhage

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  • RETINAL TEARS W I T H TOTAL VITREOUS HEMORRHAGE

    M O R T O N H. S E E L E N F R E U N D , M.D. , I D O STERNBERG, M.D. , ISRAELA H I R S C H , M.D. , AND B E N - Z I O N SILVERSTONE, M.D.

    Jerusalem, Israel

    In ten -cases of nontraumatic retinal tears with initial vitreous hemorrhages so dense that all retinal detail was obscured, medical management included hospitalization, sedation, and binocular patching. It took an average of 4.3 days for the vitreous to clear so that the tears could be examined. All the tears were on or anterior to the equator, and all were in the superior quadrants. Surgery was performed promptly once the tears were visible even though much of the retina was still covered with hemorrhage. After total clearing of the vitreous, no additional retinal tears were found in any of the ten cases. Postoperative complications included hemorrhages in three cases, macular pucker in one case, and a paramacular star in one case.

    Retinal tears with or without retinal detachment are rarely accompanied by total vitreous hemorrhage. More commonly, there is a small amount of blood in the vitreous which is responsible for the symptoms of sudden onset of hazy or blurry vision or of the appearance of "flies" or "cobwebs" in the field of vision of the affected eye.

    We examined ten patients with retinal tears who had total vitreous hemorrhage at the initial examinations.

    SUBJECTS AND METHODS

    For the purpose of this study, we defined total vitreous hemorrhage as hemorrhage so dense that it obscured all retinal detail when the patient was first examined.

    The patients were selected from the files of the Retina Services of the Shaare

    Accepted for publication Jan. 5, 1983. From the Retina Service, Department of Ophthal

    mology, Shaare Zedek Medical Center, Jerusalem, Israel.

    Reprint requests to Morton H. Seelenfreund, M.D., Retina Service, Shaare Zedek Medical Center, Jerusalem, ... 293, Israel.

    Zedek Medical Center in Jerusalem and Mount Sinai Hospital Medical Center in New York as well as our private office records. We excluded cases of trauma.

    We reviewed approximately 2,000 consecutive cases of retinal tears and detachment and found ten (0.005%) that included initial vitreous hemorrhages that totally obscured all retinal detail.

    There were six men and four women, ranging in age from 43 to 69 years (mean age, 59 years). None of the patients had a history of severe myopia, ocular trauma, or previous ocular surgery. All ten patients noted sudden loss of vision in the involved eye, and each patient was examined within 48 hours after the onset of symptoms. Initial visual acuities ranged from 20/200 to hand movements. The follow-up periods ranged from two to eight years (Table).

    RESULTS

    The amount of time needed for the vitreous to clear so that the retinal tears could be visualized varied from one to 14 days (mean, 4.3 days).

    Type and location of tearsIn all ten cases the tears were moderate to large

    AMERICAN JOURNAL OF OPHTHALMOLOGY 95:659-662, 1983 659

  • TABL

    E SU

    MM

    ARY

    OF

    CLI

    NIC

    AL

    DA

    TA

    Day

    s Un

    t

    Day

    s U

    ntil

    Visu

    al A

    cuity

    * Pa

    tient

    No.

    , Se

    x, A

    ge (y

    rs)

    1,

    F,5

    5 2,

    M, 6

    9

    3, M

    , 60

    4,

    F,6

    4 5,

    M, 6

    3

    6, M

    , 60

    7, M

    , 63

    8, M

    , 43

    9, F

    , 52

    10,

    F,

    58

    Refra

    ctiv

    e Er

    ror

    -1.7

    5 N

    one

    + 1.

    50

    -1.0

    0 N

    one

    Non

    e N

    one

    +1.2

    5

    -1.5

    0

    -2.0

    0

    Tear

    s W

    ere

    Visi

    ble

    14 2 3 2 2 7 3 1 3 6

    Loca

    tion

    of T

    ear*

    Tem

    pora

    l, on

    equ

    ator

    Te

    mpo

    ral,

    on e

    quat

    or

    Tem

    pora

    l, on

    equ

    ator

    Te

    mpo

    ral,

    on e

    quat

    or

    Tem

    pora

    l, on

    equ

    ator

    Tem

    pora

    l, on

    equ

    ator

    Te

    mpo

    ral,

    on e

    quat

    or

    Nas

    al, o

    n eq

    uato

    r

    Tem

    pora

    l, an

    terio

    r to

    equ

    ator

    N

    asal

    , ant

    erio

    r to

    equ

    ator

    Surg

    ical

    Pro

    cedu

    re

    360-

    degr

    ee b

    and

    Trap

    door

    Trap

    door

    Tr

    apdo

    or

    Impl

    ant

    + 36

    0-de

    gree

    ban

    d Tr

    apdo

    or

    Impl

    ant

    + 36

    0-de

    gree

    ban

    d Im

    plan

    t +

    360-

    degr

    ee b

    and

    Impl

    ant

    + 36

    0-de

    gree

    ban

    d Im

    plan

    t +

    360-

    degr

    ee b

    and

    Vitr

    eous

    Cle

    ared

    C

    ompl

    etel

    y

    28

    56

    28

    28

    60

    30

    60

    30

    21

    30

    Pre

    oper

    ativ

    e

    HM

    . H

    M.

    20/2

    00

    H. M

    . L.

    P.

    20/2

    00

    H. M

    .

    CF

    .

    CF

    .

    H. M

    .

    Post

    oper

    ativ

    e

    CF

    . 20

    /40

    20/3

    0 20

    /30

    20/2

    0

    20/2

    0 20

    /40

    20/2

    00

    20/3

    0

    20/4

    0

    Follo

    w-u

    p

    Para

    mac

    ular

    sta

    r H

    emor

    rhag

    e at

    5

    mos

    U

    neve

    ntfu

    l U

    neve

    ntfu

    l H

    emor

    rhag

    e at

    7

    mos

    U

    neve

    ntfu

    l U

    neve

    ntfu

    l

    Mac

    ular

    puc

    ker

    Une

    vent

    ful

    Hem

    orrh

    age

    at

    2 yr

    s

    *All

    tear

    s w

    ere

    in th

    e su

    perio

    r qu

    adra

    nts.

    f H.M

    ., ha

    nd m

    ovem

    ents

    ; CF

    ., co

    untin

    g fin

    gers

    ; L.P

    ., lig

    ht p

    erce

    ptio

    n.

  • VOL. 95, NO. 5 VITREOUS HEMORRHAGE 661

    and horseshoe-shaped. They were all in the superior quadrants located just anterior to the equator (four cases) or on the equator (six cases). In Cases 1, 2, 5, and 8, a large vessel bridging the tear could be identified as the probable origin of the vitreous hemorrhage.

    Surgical procedureAll ten patients underwent surgery within two days after a definite tear or tears could be seen, without waiting for further clearing of the vitreous.

    In five cases a silicone implant plus a 360-degree encircling band was used and in one case just a 360-degree encircling band was placed. In these six cases biomi-croscopy disclosed evidence of continuous vitreous traction on the tears. In the remaining four cases, in which there was little or no remaining vitreous traction, trapdoor procedures using Ophthalmic Gelfilm were used.1

    Follow-upBy three to eight weeks after surgery, the vitreous was clear enough for the entire retina to be examined in each case. In all ten cases, no other tears were found.

    In Case 2, there was another hemorrhage six months postoperatively. The apparent origin of this hemorrhage was a vessel on the flap of the tear. The hemorrhage resolved with no further problems during a four-year follow-up period. Other hemorrhages occurred seven months postoperatively (Case 5) and two years postoperatively (Case 10). In neither case could the origin of the hemorrhage be identified and no new tears were found.

    In all ten cases the tears remained sealed during the follow-up periods and no reoperations were required.

    Visual acuityEight of the patients regained visual acuities of 20/40 or better. In Case 1 a star figure developed close to the macula, causing traction on the macula and decreasing the patient's visual acuity to counting fingers. In Case

    8 a macular pucker developed, decreasing the patient's visual acuity to 20/200.

    DISCUSSION

    Except for traumatic injuries and bleeding from preretinal vascular formation, vitreous hemorrhages are most often associated with retinal hole formation.2-3 This problem is related to vitreous liquefaction and contraction.4 The adhesion of the posterior hyaloid surface to retinal vessels is particularly strong and may be reinforced by the prolongation of vitreous fibrillae into the retina itself.5 The retinal vessels may tear during posterior vitreous separation, leading to subsequent vitreous hemorrhage.6'7 The hemorrhage is usually sparse because the peripheral vessels are small, and in the area of the adhesion they share in the degenerated state of the retina.6 Only occasionally is the bleeding profuse.

    If there is a formed vitreous, the hemorrhage often appears in the form of curls or linear streaks and at first it may not spread widely in the vitreous cavity. If, however, the vitreous is fluid, the blood rapidly diffuses throughout the vitreous cavity.5

    In our cases, the vitreous was mostly liquefied. This permitted rapid diffusion of blood throughout the vitreous cavity, totally obscuring all retinal details. The presence of liquefied vitreous also helps to explain the fairly rapid settling of the blood when bedrest was prescribed.

    The treatment of patients with large or total vitreous hemorrhages should include hospitalization, strict bedrest with sedation, elevation of the head at a 30- to 45-degree angle, and binocular patching.6 This permits more rapid settling of the blood so that the superior retina can be examined. With this regimen, it took an average of 4.3 days for the blood to settle enough so that the tears could be seen in the superonasal and the super-otemporal quadrants.

  • 662 AMERICAN JOURNAL OF OPHTHALMOLOGY MAY, 1983

    Once definite tears can be seen we believe surgery should be performed as soon as possible. It is not necessary to wait for the blood to clear entirely so that all of the retina can be seen. In many cases it was eight weeks until the inferior retina could be examined adequately. During that time the retinal tears could have progressed to full retinal detachments with a much poorer visual prognosis. Early surgery is also indicated because the superior-quadrant tears are probably the only ones. We found no tears inferiorly when the lower vitreous had cleared.

    The high incidence of postoperative hemorrhage (three of ten cases) indicated that there may be further vitreous contraction as much as two years after the initial hemorrhage. This possibility, the adherence of vitreous to the retinal flap, tenting of the tear, and the presence of a meridional fold connected to the tear suggest that a permanent encircling silicone band be used to help relieve the vitreous traction.

    Ultrasonography was not used in these cases because the vitreous cleared rapidly enough to make the diagnosis evident.

    However, if bedrest does not produce clearing of the vitreous, ultrasonography may assist in the diagnosis and subsequent course of treatment.6

    Vitrectomy was not necessary in these cases. However, if the hemorrhage fails to clear, or if ultrasonography shows the beginning of a retinal detachment at any time, vitrectomy should be performed so that the retina can be repaired.

    REFERENCES 1. Seelenfreund, M. H., and Freilich, D. B.: In

    dications and methods for use of absorbable implants in retinal surgery. Perspect. Ophthalmol. 4:303, 1980.

    2. Morse, P. H,, Aminlari, A., and Scheie, H. G.: Spontaneous vitreous hemorrhage. Arch. Ophthalmol. 92:297, 1974.

    3. Wise, G. N., Dollery, C. T., and Henkind, P.: The Retinal Circulation. New York, Harper and Row, 1971, pp. 171-174.

    4. Duke-Elder, S., and Dobree, J. H.: Diseases of the Retina. In Duke-Elder, S. (ed.): System of Ophthalmology, vol. 10. St. Louis, C. V. Mosby, 1967, pp. 779-789.

    5. Duke-Elder, S.: Diseases of the Lens and Vitreous; Glaucoma and Hypotony. In System of Ophthalmology, vol. 11, section 1. St. Louis, C. V. Mosby, 1969, pp. 363-367.

    6. Tolentino, F. I., Schepens, C. L., and Freeman, H. M.: Vitreo-Retinal Disorders. Philadelphia, W. B. Saunders, 1976, pp. 413-470.

    7. Morse, P. H.: Vitreo-Retinal Disease. Chicago, Year Book Medical Publishers, 1979, pp. 78 and 79.

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