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      Characterization of retinal hemorrhages delimited by the internal limiting membrane

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          Abstract

          Clinically, hemorrhages at the vitreoretinal interface have been termed as ‘pre-retinal’ in location. However, there is a careful distinction to be made between sub-hyaloid and sub-internal limiting membrane (ILM) planes of blood collection. In the past half-century, a body of literature has accrued on sub-internal limiting membrane hemorrhage. We characterize the etiopathological, clinical, anatomical, and imaging characteristics of this entity (often misconstrued as sub-hyaloid hemorrhage). Management decisions are briefly described, and a unifying term of sub-internal limiting membrane macular hemorrhage is proposed to aid in further research.

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          Oxygen toxicity, oxygen radicals, transition metals and disease.

          B Halliwell, J Gutteridge (1984)
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            Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.

            P Tornambe, C Regillo, M. Johnson … (1999)
            To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. Retrospective, noncomparative case series. From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.
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              Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid-gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration.

              Christopher L Haupert, Brooks W McCuen, Glenn J Jaffe … (2001)
              To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration. Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 microg), and fluid-gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity. In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P =.004) but not between preoperative and final visual acuity (P =.16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye. This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Ophthalmol
                Journal ID (iso-abbrev): Indian J Ophthalmol
                Journal ID (publisher-id): IJO
                Journal ID (publisher-id): Indian J Ophthalmol
                Title: Indian Journal of Ophthalmology
                Publisher: Wolters Kluwer - Medknow (India )
                ISSN (Print): 0301-4738
                ISSN (Electronic): 1998-3689
                Publication date (Print): January 2024
                Publication date (Electronic): 22 December 2023
                Volume: 72
                Issue: Suppl 1
                Pages: S3-S10
                Affiliations
                [1]Anant Bajaj Retina Institute, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
                [1 ]Anant Bajaj Retina Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
                [2 ]Dr Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
                Author notes
                Correspondence to: Dr. Srikanta Kumar Padhy, Faculty, Anant Bajaj Retina Institute, L V Prasad Eye Institute, Bhubaneswar, Odisha, India. E-mail: srikantkumar.padhy19@ 123456gmail.com
                Article
                Publisher ID: IJO-72-3
                DOI: 10.4103/IJO.IJO_266_23
                PMC ID: 10833172
                PubMed ID: 38131534
                SO-VID: b572dbe5-c8aa-4a23-afcb-e6b7b64aeaf6
                Copyright © Copyright: © 2023 Indian Journal of Ophthalmology
                License:

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Date received : 28 January 2023
                Date revision received : 03 August 2023
                Date accepted : 14 August 2023
                Categories
                Subject: Review Article

                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: ilm peeling,membranotomy,nd-yag laser,sub-hyaloid hemorrhage,sub-internal limiting membrane macular hemorrhage
                Data availability:
                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: ilm peeling, membranotomy, nd-yag laser, sub-hyaloid hemorrhage, sub-internal limiting membrane macular hemorrhage

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