Purpose
To evaluate outcome of early surgery in vitreous hemorrhage, presumably associated with retinal tears.
Design
Retrospective, noncomparative interventional case series.
Methods
We included 40 consecutive cases in 39 patients treated with early vitrectomy for vitreous hemorrhage. Main outcome measures were incidence of tears identified preoperatively and intraoperatively, visual acuity, and complications.
Results
Vitrectomy took place after a mean delay of 2.7 days after presentation. A total of 69 tears were found in 40 eyes; 53.7% of tears were identified preoperatively by funduscopy or ultrasound (U/S) and the remaining 46.3% of tears were only identified during vitrectomy. Visual acuity improved significantly from 1/60 to 0.8. The sensitivity of U/S tear detection was 55.9%. A history of predisposing factors was not related to the risk of presence of unsupported tears. In 2 cases a retinal detachment developed between the U/S evaluation and vitrectomy. Postoperative complications were cataract (30%), macular pucker (2.5%), and retinal detachment (5.0%).
Conclusions
Our findings illustrate the potential dangers of a conservative approach to vitreous hemorrhage and show that early vitrectomy has good outcome with acceptable complication rates. Prospective studies on optimal treatment of vitreous hemorrhage associated with tears are needed.
A patient presenting with a fundus-obscuring vitreous hemorrhage, presumably caused by a retinal tear, poses a serious clinical dilemma. Many clinicians prefer a conservative approach. Positioning the head upright to allow blood to settle down in the eye, combined with immobilization and bilateral patching, enhances resolution of blood. These measures promote clearance of blood in the superior part of the eye, enabling visualization and treatment of superior retinal tears. The trade-off of a conservative approach is the risk of progression to a rhegmatogenous retinal detachment (RRD) before clearing of the vitreous hemorrhage allows full evaluation of the fundus and treatment of retinal tears.
If the vitreous hemorrhage is too dense to allow funduscopic evaluation, ultrasound (U/S) investigation of the eye can identify retinal tears, pointing to a rhegmatogenous origin. It has been shown, however, that U/S detection rate of retinal tears is suboptimal, especially if tears are small, and this has also been our clinical impression. This makes assessment of risk of progression to RRD unreliable, undermining the conservative approach. For this reason, some have favored a more aggressive strategy. This paper describes our experiences and outcome of vitrectomy in an early stage of the disease.
Methods
Medical records of consecutive patients who underwent early vitrectomy for a vitreous hemorrhage between February 1, 2007 and February 1, 2009 were reviewed. We included cases of vitrectomy for vitreous hemorrhage with presence or suspicion of retinal tears, that had a follow-up of at least 3 months. We excluded cases with other causes of vitreous hemorrhage like trauma and vascular disease and eyes in which a retinal detachment was seen on funduscopy or U/S. If a tear was visible at funduscopy, we attempted to laser the defect if we assessed the hemorrhage to be penetrable by laser. If it was not possible to get a satisfactory laser barrage, the tear was considered unsupported and the patient was advised to undergo vitrectomy. If no tear was found because the hemorrhage was too dense to allow proper funduscopic evaluation of the periphery of the retina, a U/S investigation was performed. If a tear was found at U/S investigation, we advised the patient to have surgery. If no tear was found, we discussed options with the patient and advised a vitrectomy if predisposing factors were identified. In certain cases without the presence of predisposing factors, still a mutual decision was made to opt for vitrectomy. After a decision was made to operate, the patient was scheduled for surgery within 7 days, but an attempt was always made to perform surgery as fast as possible. The time between decision and actual surgery was recorded as “delay.”
All patients were operated at the Academic Medical Center, Amsterdam, a tertiary academic referral center. The operations were performed by 1 of 3 surgeons (H.S.T., M.M., or H.M.B.). Data were retrieved from an electronic patient file, containing structured operation notes and standardized fundus drawings with detailed localization of encountered and treated tears.
All operations were performed with the Alcon Accurus 600 DS (Alcon Laboratories, Fort Worth, Texas, USA), BIOM wide-angle viewing system (Binocular Indirect Ophthalmo Microscope; Oculus Inc, Wetzlar, Germany). Operations were performed with either a 20-gauge or 25-gauge platform, depending on the surgeon’s preference. In 20-gauge cases infusion pressure was set at 20 mm Hg with cutting rate varying between 1000 and 2500 cuts/minute. In 25-gauge procedures infusion pressure was set at 30 mm Hg, cutting rate varied between 1000 and 1500 cuts/minute, and light was provided by a xenon light source (Photon 2; Synergetics, O’Fallon, Missouri, USA). In combined procedures, we always started with phacoemulsification of the lens, implantation of an intraocular lens, and suturing of the cataract wound. During vitrectomy, a preexisting posterior vitreous detachment was encountered intraoperatively in all eyes. Core vitrectomy was performed, followed by vitrectomy of the periphery. The extent of peripheral vitrectomy depended on lens status of the eye, with less complete vitrectomy in phakic eyes. Extensive internal search was performed in all cases using visualization with the BIOM system and scleral indentation. All tears were treated with external cryo application. We also retreated the tears that were already supported by earlier laser barrage. If tears were detected, an air or gas tamponade was used.
Preoperative parameters retrieved were patient characteristics, visual acuity, lens status, predisposing factors, and number and location of tears detected preoperatively by means of funduscopy and by means of ultrasound. Intraoperative parameters were type of surgery, type of anesthesia, number and location of tears detected intraoperatively, intraoperative complications, and mode of tamponade. Postoperatively we collected visual acuity and postoperative complications. Total number of tears is defined as the number of tears found intraoperatively. We only considered tears with persistent vitreous traction. Operculated tears, round holes in lattice, and other degenerative tears were always treated during vitrectomy but not included in our analysis. Supported tears are defined as tears that were treated adequately by any means of retinopexy before operation. New tears are defined as tears that were encountered intraoperatively and had not been identified by means of funduscopy or U/S preoperatively. New retinal detachments are defined as presence of retinal detachment as encountered intraoperatively, which had not been present at the last preoperative funduscopic or ultrasonographic evaluation. Unsupported tears are defined as those tears that were identified during surgery but were not, or not adequately, treated.
Statistical analysis was performed using SPSS software for Windows version 16.0 (SPSS Inc, Chicago, Illinois, USA).
Results
Forty eyes from 39 patients were included. Baseline patient and ocular characteristics are summarized in Table 1 . The mean follow-up was 19.1 months (range 6-34 months). Predisposing factors were present in 16 of 40 cases. Of the 24 cases without predisposing factors, only 5 mentioned sensation of flashes. Of 40 eyes, tears were visible by funduscopy in 13 cases but we were not able to adequately secure these tears with laser photocoagulation because of the density of the hemorrhage. In 17 eyes 1 or more defects were identified with U/S and in 10 eyes no tears could be found on U/S.
| Gender | |
| Female | 19 (47.5%) |
| Male | 21 (52.5%) |
| Mean age: yrs (range) | 61.1 (37-86) |
| Eye | |
| OD | 16 (40.0%) |
| OS | 24 (60.0%) |
| Predisposing factors | |
| None | 19 (47.5%) |
| Flashes | 5 (12.5%) |
| Previous tear | 10 (25.0%) |
| Previous RRD | 3 (7.5%) |
| Tear fellow eye | 2 (5.0%) |
| RRD fellow eye | 1 (2.5%) |
| Tear detection | |
| U/S no tears | 10 (25.0%) |
| U/S tears | 17 (42.5%) |
| Visual | 13 (32.5%) |
| Total # identified tears | 38 (95.0%) |
| Lens status | |
| Phakic | 30 (75.0%) |
| Pseudophakic | 10 (25.0%) |
| Mean delay: days (range) | 2.7 (0-11) |
Intraoperative details are depicted in Table 2 . All 40 cases underwent vitrectomy for removal of blood and treatment of defects. Sixteen of 40 cases were operated with the conventional 20-gauge system and the remaining 24 cases with the sutureless 25-gauge platform. In all cases, a preexistent posterior vitreous detachment (PVD) was present over the posterior pole. Separation of the posterior vitreous membrane and retina in more peripheral areas varied but was not recorded systematically. Delay between decision to treat and actual treatment was on average 2.7 days. There were no differences in retinal tear incidence or complications between the 20-gauge and the 25-gauge cases.
| Anesthesia | |
| General | 5 (12.5%) |
| Local | 35 (87.5%) |
| Type of operation | |
| Vitrectomy | 36 (90.0%) |
| Vitrectomy + phaco | 4 (10.0%) |
| Vitrectomy platform | |
| 20-gauge | 16 (40.0%) |
| 25-gauge | 24 (60.0%) |
| Total # tears | 69 |
| # unsupported tears | 62 (89.9%) |
| # supported tears | 7 (10.1%) |
| # new tears | 32 (46.4%) |
| # new RRD | 2 (2.9%) |
| Location of tears (cases) | |
| Superior | 17 (42.5%) |
| Inferior | 3 (7.5%) |
| Superior + inferior | 13 (32.5%) |
| Tamponade | |
| No (BSS) | 2 (5.0%) |
| Air | 22 (55.0%) |
| SF6 | 15 (37.5%) |
| C3F8 (0.5cc) | 1 (2.5%) |
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