We read with interest the article “Early Vitrectomy for Spontaneous, Fundus-Obscuring Vitreous Hemorrhage” by Melamud and associates. As the authors rightly point out, there is a potential morbidity attached to delay in treatment from macula-off retinal detachment. There is evidence to suggest that patients undergoing laser retinopexy for retinal tears are at risk of a poorer outcome, with need for more treatment and progression to retinal detachment in the presence of vitreous hemorrhage.
At the annual meeting of the 2014 British and Eire Association of Vitreo-Retinal Surgeons (BEAVRS) opinions were sought through live voting on how best to manage patients with fundus-obscuring vitreous hemorrhage with no obvious underlying cause (presumed PVD induced and ultrasound B-scan normal). Two questions were posed: when should patients be referred to vitreoretinal (VR) services and when should a vitrectomy be performed? The first question stemmed from the fact that most patients are seen in a casualty setting at the first visit by non-VR specialists and occasionally observed for a period of time before referral.
Forty-five percent of delegates at the meeting feel that such patients should be referred on day 1 of presentation; 21% and 20% preferred observation for 2–3 and 4–7 days respectively, prior to referral; and 14% would observe for over 1 week prior to referral. Undoubtedly review by the VR specialist as soon as possible is the best management. The group of clinicians electing to wait for over 1 week may result from the assumption that with a normal ultrasound B-scan, no intervention would be undertaken.
With regard to when to perform a vitrectomy for non clearing hemorrhage, 36% of delegates would operate on the next available list, 23% within 1 week, 22% within 1–2 weeks, and 19% would wait over 2 weeks. While this may be a true representation of the perceived urgency by vitreoretinal surgeons, this may also reflect different patterns of work with varied availability of emergency VR theatres.
As described in the paper, in the absence of an emergency, 7 days provides a reasonable timeframe within which to plan the surgery. This may be recommended for most patients; however, there will be some clinicians who elect to observe for longer. This may stem from confidence in their ability to perform comprehensive ocular ultrasound, or may be due to accessibility and geographic distance to VR centers. While not ideal, this may simply represent the real-life nature of VR cover.
BEAVRS represents a snapshot of British and Irish vitreoretinal opinion, with the majority of delegates being consultants with a subspecialist interest in VR. Doctors in training, VR fellows, and international VR surgeons were also in attendance.
In summary, the opinions garnered from the survey performed at BEAVRS reflect the findings from the study, with the majority of British and Irish VR surgeons preferring to perform a vitrectomy for fundus-obscuring vitreous hemorrhage within 7 days of presentation.