Photograph showing diffuse subretinal hemorrhage one weeks following vitrectomy and drainage of choroidal hemorrhage induced by blunt trauma.There is a low, residual choroidal hemorrhage in the far temporal periphery (not illustrated), but this is markedly diminished
He underwent surgery to drain the hemorrhage. The conjunctiva was opened temporally, and a circumferential sclerotomy was performed just anterior to the muscle insertions. Copious dark red blood egressed. The sclerotomy was not sutured. A scleral buckle was not placed and a vitrectomy was not performed.
Postoperatively, the retina remained reattached and the vitreous hemorrhage cleared completely. The residual choroidal gradually resolved as did the subretinal fluid. Cystoid macular edema occurred within the first month but responded, ultimately, to intravitreal triamcinolone. There was increasing corneal edema that required a DSEK. The visual acuity was 20/80 18 months after the initial injury.
One might have considered a more conservative approach with continued observation, but due to the height of the choroidal hemorrhage, the profound visual loss, and the patient’s strong motivation to intercede at that point in time, the drainage was performed as described. Another consideration for the approach would have considered a primary vitrectomy in conjunction with the drainage. In retrospect, the vitreous hemorrhage and subretinal fluid (which seemed to have been secondary to the choroidal hemorrhage) resolved without consequence. The corneal decompensation likely was attributable in part to the trauma but probably was largely due to preexisting compromise from what was, evidently, a complicated previous cataract extraction.
Timing of vitrectomy after primary repair
A 29-year-old male was involved in an altercation and sustained an injury to his left eye from some broken glass. The visual acuity was hand motions, and there was not an afferent pupillary defect. There was a laceration evident that extended from about 3 mm posterior to the temporal limbus posteriorly. The cornea was fairly clear and there did not appear to be any lens rupture, but there was blood lining the posterior lens surface. There was moderate vitreous hemorrhage which blocked the view posteriorly. An X-ray did not depict any intraocular foreign body. A primary closure with silk sutures was affected the next morning. The posterior extent of the laceration was about 3 mm behind the line of the muscle insertions.
One week later, the visual acuity was 1/200 with still moderate vitreous hemorrhage. The ultrasound test did not show retinal detachment. A vitrectomy was performed in conjunction with an encircling scleral buckling procedure with a 240 band and a lensectomy (preserving the peripheral anterior capsule). The visual acuity had improved to 20/40 by 2 months postoperatively (with aphakic correction). A secondary PC IOL was planned.
In this case there are several points of controversy. Whenever the vitreous base has been affected by a rupture or laceration (Fig. 3.2a), the risk of subsequent retinal detachment is high (as the experimental and clinical studies cited above have demonstrated). While it would have been very reasonable to perform the vitrectomy commensurate with the laceration repair, this surgeon prefers a staged approach about 10 days later so that the posterior vitreous detachment could either occur or more easily be induced. Such trauma more commonly involves a younger population without preexisting vitreous separation. Removal of the posterior hyaloid is important to minimize postoperative cellular proliferation that could lead to retinal detachment. Placement of an encircling scleral buckle neutralizes some of the cicatricial vitreous changes consequent to such an injury (Fig. 3.2b). The lens was removed in this case to facilitate maximal vitreous base removal and to maximize visualization. The peripheral anterior capsule was preserved to allow future placement of a posterior chamber IOL into the sulcus.
Schematic depicting vitreous traction towards anterior laceration site (a). Vitrectomy and scleralbuckling procedure were performed (b).If vitreous traction is not addressed early, secondary “anterior loop” traction may ensue causing severe cicatricial changes (c) (Permission from Michels RG, et al. Retinal Detachment. CV Mosby 1990)
While there might be debate about whether the vitrectomy should be done concurrent with the primary closure or up to 10 days later, there is uniform agreement that waiting in the hopes that the vitreous hemorrhage would clear, or only if it did not clear after several weeks, is contraindicated due to the expectation that contraction of the vitreous base during that time would lead to a complex retinal detachment (Fig. 3.2c).
Traumatic macular hole (Fig. 3.3)
A 32-year-old male was struck by a random rock on the right side of his head and brow. One week later, he realized loss of central vision. He was seen 2 weeks later with 20/80 due to a small macular hole (Fig. 3.3). The lens was clear and stable. The only other definite sign of trauma was a self-healed retinal dialysis inferotemporally, but there might have been mild RPE disturbance in the 1-disk-diameter radius around the fovea suggesting previous commotio retinae. There was a posterior vitreous detachment.
Optical coherence tomograph of a traumatically induced full-thickness macular hole (a) with the map showing elevation and thickening of adjacent foveal tissue (b)
A vitrectomy with ILM peel and fluid–gas exchange was performed. No chromodyes or triamcinolone was used. Medium-acting gas was used since the patient had to fly home as soon as possible.
A concern in traumatic macular holes is the possibility of permanent visual loss due to collateral injury, such as cataract, commotio retinae, or optic neuropathy. Treatment of traumatic macular holes is identical in approach as for idiopathic macular holes.
Blunt trauma (Fig. 3.4)
A 16-year-old was struck by a paintball after removing his protective eyewear after completing a “war games” contest. He had sudden and severe loss of vision. He was seen the next day with recorded light perception vision and intraocular pressure of 26 mmHg. There was a moderately hazy view to the posterior pole due to some vitreous hemorrhage. The media had improved sufficiently by weeks later to allow view of a submacular hemorrhage (Fig. 3.4). This cleared spontaneously over the next 3 months yielding 20/15 visual acuity. There were no other collateral injuries, for example, to the vitreous base or lens.
Fundus photograph of submacular hemorrhage (a), better appreciated for its extent on the red free photography (b).The OCT shows the subretinal hemorrhage (c).Three weeks later the fundus (d) and OCT (e) have improved
Subretinal hemorrhage itself is not generally an indication for surgical intervention since, especially in young patients, there is a good capacity for spontaneous resolution, as occurred in this patient . This case does demonstrate the importance of compulsive use of protective eyewear in this growing recreational pastime of paintball contests .
Secondary RD after trauma (SB, SO, options for management – like PVR: retinotomy, lens, etc.) (Fig. 3.5)
A 49-year-old man suffered an injury to his left eye when a tennis ball hit his eye directly. He had a su dden and severe loss of vision. He was seen the next day with vision of 3/200 and a moderate circulating hyphema; there did not appear to be any retinal detachment by ophthalmoscopy (limited by media opacities) or ultrasound examination. One week later, the hyphema had cleared sufficiently to allow detection of a subretinal hemorrhage underlying the fovea and extending inferiorly (Fig. 3.5). There was a 3-clock-hour tear with bridging vessels in the mid-periphery associated with hemorrhage and subretinal fluid extending around the tear and inferiorly.