(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
The blood, whether of AMD,1 trauma, or other etiology, causes severe damage to the photoreceptors2 and does it very early; the thicker3 the blood, the more the damage. Several options are available, including observation – justified if the blood is long standing, the hemorrhage is thin and small, or the visual acuity had been very poor prior to the bleeding.
36.1 The Nonsurgical Approach: Intravitreal Gas and tPA
The goal is to push the liquefied blood from under the fovea.
Inject up to 100 μg tPA into the vitreous cavity.
Inject up to 0.3 ml of pure perfluoropropane (C3F8) gas into the vitreous cavity.
Position the patient4 for 3 days.
36.2 Removal of the Clot In Toto
Technically, the blood clot is not as difficult to remove as it may appear, nor does it require as large a retinotomy as the clot’s dimensions would suggest. It is usually possible to remove the elastic clot in one piece and through a rather small retinotomy.
Complete the vitrectomy (especially, create a PVD).
Use diathermy to create a small retinotomy at a convenient location.5
The retinotomy should be far away from the major vessels in the area.
The retinotomy should be placed right above the clot in MIVS.6
If the clot proves to be too large, the retinotomy will stretch somewhat.
Use a small, blunt, angled,7 cannula or a soft-tipped flute needle to inject a little BSS over, and if possible under, the clot to separate it from the neuroretina above and the RPE beneath.8
The injection should be very slow and at low pressure.
It is difficult for the surgeon to precisely control both the position of the cannula’s tip and the attributes of the injection. It is best to use a tool (see below, Sect. 36.4) that allows the nurse to inject the fluid while the surgeon monitors the tip of the cannula.
Grab the clot with forceps and slowly retrieve it. Pausing during retrieval may help the retina to slide backward, separating from the clot.
Gently irrigate the subretinal space with BSS.
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