(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
62.1 General Considerations
Blood in the vitreous cavity, regardless of the cause of the bleeding, interferes with vision and prevents the ophthalmologist from having a direct view of the retina. The VH1 may cause a long list of secondary complications ranging from siderosis to ghost cell glaucoma and even PVR.
Removal is nevertheless rarely urgent unless the bleeding is caused by a torn retinal vessel bridging retinal tear,2 or the VH is related to open-globe trauma.3 Conversely, the risk of PPV is low enough today that this alone should not serve as a contraindication to early surgery.4
Bleeding may also occur in a vitrectomized eye5; in such cases the blood usually, but not always, absorbs faster than as if the gel were still present.
Pearl
People with an incurable systemic disease must understand that vitrectomy (and removal of the blood) may reduce the risk of a postoperative bleeding, but it does not eliminate it. To reduce the risk to the minimum, oil should be implanted (see Sect. 35.4).
Surgery for VH is usually rather straightforward, but it is not without caveats.
Massive bleeding into the gel in a young person6 may make surgery very difficult (see below).
In general, the older the hemorrhage, the more likely that its color changes from red to yellow. However, blood trapped between layers of vitreous gel may remain red for months (see below).
Partial PVD can trick the surgeon into proceeding too fast, only to discover the hidden presence of strong VR adhesions (see Sect. 58.2). This is especially common in CRVO, and preoperative ultrasonography may be unable to warn the surgeon about the danger.
The VH may be accompanied by intraretinal (a submembranous cyst7 in a patient with Terson syndrome) or subretinal blood (CNV). Even when the surgeon is unaware of the etiology, he must be prepared to deal with these conditions as well – one of the reasons for my resistance to agree with the statement that “PPV for VH is an easy surgery.”
Pearl
Multiple conditions may coexist in a single eye: a patient who has diabetes can also develop an RVO, or one with high blood pressure an RD. The VR surgeon should not assume, based on history or preoperative tests, that he knows the etiology of the VH in that particular eye; he must accept that all he has is a (strong) suspicion, but evidence will be provided only during surgery.
The issues raised above make it clear that the indication and timing of PPV remain somewhat controversial (except, as mentioned above, in the context of open-globe injury or the development of a retinal break). In all other cases, intensive consultation with the patient is necessary (see Chap. 5), but no artificial deadlines should be imposed (“if the bleeding does not resolve in 3 months,” see above). The risk of surgery is very small, possibly smaller than leaving the blood to persist for months, while the potential benefits are tangible.8
62.2 Surgical Technique
If the bleeding is severe enough to prevent visualization of the retina, proceed in an anteroposterior direction.
Start with vitrectomy in the middle of the vitreous cavity and rather close to the lens.
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