Diabetic Dense Premacular Hemorrhage

A Possible Indication for Prompt Vitrectomy

G. P. O'HANLEY, MD, FRCS(C), c. L. B. CANNY, MD, FRCS(C)

Abstract: A review was undertaken of nine eyes of nine patients who suffered tightly bound dense premacular hemorrhage as a complication of proliferative diabetic retinopathy. Patients who did not receive vitrectomy within four weeks of the onset of the hemorrhage all progressed to late macular traction and visual acuity no better than 6/30. Of the five patients who received vitrectomy within four weeks of the onset of the hemorrhage, none developed significant late macular traction and all achieved visual acuity of 6/12 or better. It is possible that the tightly bound dense premacular hemorrhage represents an indication for vitrectomy within one month of its onset. [Key words: diabetes, diabetic retinopathy, iris neovascularization, traction retinal detachment, vitrectomy, vitreous hemorrhage.] Ophthalmology 92:507-511,1985

Pars plana vitrectomy is a well recognized therapeutic modality for the treatment of the complications of diabetic retinopathy,1-4 particularly for unresolving vit­reous hemorrhage5,6 and/or tractional macular detach­ment. 7-11 The purpose of this report is to investigate a certain subgroup of diabetics with vitreous hemorrhage who appear to rapidly develop macular traction after preretinal hemorrhage. This particular subgroup is char­acterized by the presence of a dense preretinal hemor­rhage confined within an incomplete posterior vitreous detachment overlying the area centralis. This report will discuss the events surrounding nine such cases. Four cases (cases 1-4) were not operated on before four weeks, if at all, following the onset of the hemorrhage. The remaining five cases (cases 5-9) underwent pars plana vitrectomy within four weeks of onset of the dense premacular hemorrhage.

From the Department 01 Ophthalmology. University of Western OntariO, London, Ontario.

Presented at the 47th Annual Meeting of the Canadian Ophthalmological SOCiety-Retina Vitreous Working Party, Quebec, June 27, 1984.

Reprint requests to C. L. B. Canny, MD, Department 01 Ophthalmology, University Hospital, 339 Windermere Road. London. Ontario N6A 5A5.

RESULTS

Table 1 lists the clinical features of those eyes under­going vitrectomy more than one month, if at all, after their initial bleed and Table 2 those cases receiving pars plana vitrectomy within one month of their initial bleed. Case I will be described in detail as an example of delayed surgical intervention and case 7 as an example of those eyes treated promptly.

CASE REPORTS

Case 1. A 46-year-old man with diabetes of one years' duration presented with visual acuity of 6/7.5 in each eye. Funduscopic examination of the right eye revealed a small patch of neovascularization (NVE) in the midperiphery along with moderately severe arteriolosclerotic changes. The left fundus showed extensive fibrovascular proliferation along the superotemporal, inferotemporal, and inferonasal arcades. Mid­peripheral vascular obliteration was also seen. The patient was treated with bilateral panretinal photocoagulation. Four weeks following the final treatment to the left eye, the patient suffered a dense preretinal hemorrhage over the left area centralis (Fig 1). One week later the hemorrhage was somewhat increased. Two months later showed that the hemorrhage was beginning

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Fig 1. Top left. case 1. Left eye of a 46-year-old man with a dense premacular hemorrhage. No vitrectomy was done. Fig 2. Top right. case 1. Three years later than Figure I, showing extensive organization at the area centralis with counting fingers vision. Fig 3. Second row left. case 3. Left eye of a 53-year-old with asymmetric retinopathy and a dense pre macular hemorrhage of uncertain duration. Fig 4. Second row right. case 3. Left eye ten months postoperative with persistent foveal traction and 6/120 vision. Fig 5. Third row left. case 5. Left eye of a 36-year-old man with a dense premacular hemorrhage. Vitrectomy was done four weeks later. Fig 6. Third row right. case 5. Nineteen months postoperatively, no fibrous proliferation was seen. The best postoperative visual acuity was 6/1.5. Fig 7. Bottom left. case 7. Right eye of a 27-year-old woman with recent dense premacular hemorrhage and rapidly progressive fibrous proliferation. Vitrectomy was undertaken II days after the hemorrhage occurred. Fig 8. Bottom right, case 7. Six years postoperative showing slight foveal traction and foveal pigmentary changes associated with high myopia. The best postoperative visual acuity was 6/12.

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O'HANLEY AND CANNY • DENSE PRE MACULAR HEMORRHAGE

Table 1. Dense Premacular Hemorrhage Later than One Month after Vitrectomy

Clinical Feature

Age (years) Duralion of diabetes (years) Follow-up (months) Preoperative visual acuity Panrelinal photocoagulation Best Postoperative Visual Acuity Last acuity Panretinal photocoagulation-hemorrhage interval Hemorrhage-vitrectomy interval Degree of surface membrane proliferation Late macular traction

* See Figures 1 and 2. t See Figures 3 and 4. t Applied after hemorrhage and before vitrectomy. CF = count fingers; HM = hand motions.

1*

47 2

37 CF 3' Yes

CF 3' 3 weeks 3+ years Very severe Yes

to show fibrous proliferation. Eight months following the hemorrhage there was resorption of the hemorrhage within an elevated fibrous mass temporal to the fovea which appeared unchanged at 15 months following the onset of the dense premacular hemorrhage. Visual acuity at that time was 6/15. Twenty-seven months following the initial hemorrhage, while the patient was out of the country, he experienced a marked decrease in central vision in his left eye. When he returned for further examination, some 32 months following the initial hemorrhage, the vision in the left eye was count fingers at 3 feet. Funduscopic examination of the left eye revealed a large tractional detachment of the macula. The area of involvement was so extensive as to preclude operative intervention. At follow-up examination 37 months following the initial hem­orrhage, the areas of traction had become more discrete such that vitrectomy has been offered but declined to date (Fig 2).

Cases 3 and 5. See Figures 3 through 6. Case 7. The index case in this series was a 27-year-old

2

17 13 29 6/120 Not 6/30 6/30

"14 weeks Moderate Yes

Case No.

53 30 21

3t

CF 6" Not 6/120 CF 2'

7+ weeks Moderate Yes

63 20 14 CF Yes 6/60 HM

4

9 months 5 weeks Severe Yes

woman with diabetes of 25 years' duration who on initial examination had vision of counting fingers in the right eye and 6/12 in the left eye when corrected for her high myopia. Funduscopic examination of the right eye revealed vitreous hemorrhage inferiorly with a large boat-shaped preretinal hem­orrhage along and beneath the inferotemporal arcade. In addition, there was an incomplete posterior vitreous detachment with diffuse preretinal hemorrhage overlying the entire area centralis. Disk neovascularization (NVD) was present. Fun­duscopic examination of the left eye revealed similar, less pronounced changes. Vitreous hemorrhage was present inferi­and a small preretinal hemorrhage beneath the inferotemporal arcade. Numerous patches of surface NVE were seen as well as fine NVD. The patient was treated with left panretinal photocoagulation. One week after the initial examination she suffered marked deterioration in the right eye because of an increase in pre macular hemorrhage which had reduced the vision to light perception only (Fig 7). The temporal vascular

Table 2. Dense Premacular Hemorrhage Earlier than One Month after Vitrectomy

Case No.

Clinical Feature 5* 6 7t 8 9

Age (years) 36 27 27 27 31 Duration of diabetes (years) 13 22 25 24 15 Follow-up (months) 19 20 78 10 37 Preoperative visual acuity CF CF LP HM HM Preoperative panretinal photocoagulation Yes Yes No Yes Yes Best Postoperative visual acuity 6/7.5 6/6 6/12 6/7.5 6/7.5 Last acuity 6{18 6{7.5 6/18 6/7.5 HM Pametinal photocoagulation-hemorrhage interval 7 months 8 months 8 months 1 week Hemorrhage-vitrectomy interval 4 weeks 3 weeks 11 days 6 days 3 days Oegree of surface membrane proliferation Mild Mild Moderate Mild Mild Late macular traction No No Mild No No

* See Figures 5 and 6. t See Figures 7 and 8. CF = count fingers; LF = light perception; HM = hand motions.

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arcades were becoming drawn into the area centralis by fibrous proliferation. Eleven days following this hemorrhage, the patient underwent a pars plana vitrectomy with membrane stripping from the optic disk and superotemporal arcade. One month postoperatively, the patient's visual acuity was· 6/60 with evidence of some traction inferior to the fovea. One year postoperatively visual acuity in the right eye was 6/21. Two years postoperatively the patient's visual acuity was 6/15 with bilateral foveal pigment epithelial changes present thought to be on the basis of high myopia. Three years postoperatively visual acuity was 6/12, and on final examination six years postoperatively 6/18 in the right eye with mild macular traction and foveal retinal pigment epithelial changes present (Fig 8).

DISCUSSION

The cases just described were obtained from a review of the over 300 vitrectomies performed by one of the authors (CLBC) between August 1977 and May 1984. This includes a group of 131 primary procedures in 105 diabetic patients. 12 Excluding case 1, in whom a vitrec~ tomy has not been performed, this indicates that only about 6% of primary vitrectomies for the complications of diabetes were done for the relief of a dense premacular hemorrhage or its sequelae. The cases included in this series were those found preoperatively to have a collection of hemorrhage tightly trapped between the retina and posterior vitreous face of an incomplete posterior vitreous detachment. This generally causes the hemorrhage to take on a rounded rather than navicular shape. The hemorrhages were so dense as to completely obliterate the underlying fundus details. Vision was therefore reduced generally to a level of count fingers or less.

In a retrospective study, as compared to a controlled clinical trial, there are a number of differences between the two treatment groups that may have played a role in the visual and technical outcome. The group whose surgery was delayed was older, with a mean age of 45 years compared to 30 years for the group treated promptly. The role that age played in this series of patients is unknown, but increasing age may reduce the ability of the macula to recover from any insult. There was no difference between the treatment groups with respect to duration of diabetes and length of follow-up.

All but one case had panretinal photocoagulation (PRP) before vitrectomy with six of the nine cases having PRP before their premacular hemorrhage; two had PRP less than three weeks before their hemorrhage. Does previous PRP promote the vitreous detachment and help a more fibrous response while surpressing endothelial growth?

A number of surgically important features are note­worthy in this group of patients, highlighting the differ­ences between those approached promptly and those treated after a delay of five weeks or more. Without exception, in all patients operated on within four weeks of the onset of the dense premacular hemorrhage, the only area of vitreous detachment was the preretinal

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hemorrhage itself. There was no preretinal space devoid of hemorrhage. Once the preretinal space was entered, the hemorrhage was usually found to be clotted rather than liquid and could be lifted en bloc from the surface of the retina and aspirated. In those cases treated promptly, the partially organized posterior vitreous face was easily peeled from the retina without major hem­orrhage or retinal traction. The posterior Vitreous often separated spontaneously from the retina once the peeling was started. In contrast, those cases operated on after a delay of five weeks or more required extensive membrane peeling and segmentation; invariab.ly some of the mem­branes could not be safely separated from the retina and variable degrees· of surface retinal traction remained.

Conclusions are difficult to draw from such a small retrospective series. The patients who underwent vitrec­tomy within one month of the onset of the dense premacular hemorrhage were, in general, a group in whom the surgery was technically less difficult because membranes on the surface of the retina were much less severe. None of the patients who had vitrectomy within four weeks of the onset of the dense premacular hem­orrhage developed late macular traction.

A possible mechanism by which these results can be explained is as follows. ~lood between the internal limiting membrane and the posterior surface of the vitreous face can serve as both a scaffold and a stimulus for the elaboration of fibrous tissue in that area. This fibrous tissue is more likely to be elaborated within the confines of a dense, tightly bound hemorrhage which is unable to flow and contains a greater amount of blood breakdown products than would a small boat-shaped hemorrhage within the same sized posterior vitreous detachment. Should such fibrous tissues be elaborated on the surface of the fovea, a permanent reduction in vision is likely, either from surface wrinkling or frank tractional macular detachment.

The current major indications for vitrectomy for the relief of the complications of proliferative diabetic reti­nopathy are unresolving hemorrhage after four to six months and progressive tractional retinal detachment. Cases 2, 3, and 4 illustrate that given a dense premacular hemorrhage, observation of the patient until such time as a tractional macula.r detachment occurs can result in the inability to adequately relieve that traction and significantly improve visual acuity. It would seem a more reasonable approach, and indeed technically sim­pler, to prevent that formation of the fibrous traction by removing the scaffold and stimulus before it develops. It appears that not just "early,,,13,14 but "prompt" vi-trectomy is required for patients with a tightly bound dense premacular hemorrhage.

ACKNOWLEDGMENTS

The authors thank Dr. Miriam Ridley for providing us with further information regarding one of these patients, and Mar-

O'HANLEY AND CANNY • DENSE PREMACULAR HEMORRHAGE

ibeth Drury and Susan Jung for assistance in the preparation of the manuscript.

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