Original Article
Role of Nd: YAG
Laser in the Management of Premacular Subhyloid Hemorrhage
Irum Raza, Chaudhary Nasir Ahmad, Tehseen Mahmood Mahju
Pak J Ophthalmol 2017, Vol. 33, No. 2
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See end of article for authors affiliations …..……………………….. Correspondence to: Irum Raza DOMS, FCPS Vitreo-retina Fellow Department of Ophthalmology, King Edward Medical College &
Mayo Hospital, Lahore. E-mail: eyemiss@ymail.com |
Purpose:
To evaluate the role of early Nd:YAG laser hyaloidotomy in the
management of premacular subhyaloid hemorrhage. Study
Design: prospective interventional case series. Place
and Duration of Study: Ophthalmology department, King
Edward medical university and Mayo hospital, Lahore from 1st July, 2015 to
31st December, 2015. Material
and Methods: There were total 20 patients of premacular
subhyaloid hemorrhage who underwent Nd:YAG laser hyaloidotomy. All were
followed up on 2nd day, 1st week and 2nd
week. Detailed examination was done to note the improvement of vision,
clearance of macula, absorption of hemorrhage and any complication occurred.
Data was analyzed by SPSS version 20 and presented in the form of tables. Results:
Among included patients, 8 were males (40%) and 12 were females
(60%). Mean and standard deviation for patients' age was 36.55 ± 14.50 with
range of 20-65 years. Maximum patients (50%) were from the younger age group
of 20-35 years. Most common etiology of hemorrhage was PDR (40%). Macula was
cleared in 15 patients (75%) but visual acuity was improved in only 13
patients (65%) because of underlying maculopathies. The mean amount of energy
of laser used was 7.67 ± 2.55 with a range of 4-12 mJ. The hemorrhage took 4
weeks on average to be absorbed from vitreous. Complication in the form of
taut epimacular membrane was noted in only one patient. Conclusion: Nd:YAG laser hyaloidotomy is a safe,
cheap, non-invasive and early visual rehabilitory procedure.
Key words: Nd:YAG laser, hyaloidotomy, premacular subhyaloid hemorrhage. |
Premacular subhyaloid hemorrhage is an ocular condition in which
blood accumulates in front of macula behind the posterior vitreous face. It can
be caused by proliferative diabetic retinopathy (PDR), hypertensive
retinopathy, retinal artery macroaneurysm, blood dyscrasias, age-related
macular degeneration (AMD) and valsalva maculopathy1. It causes
profound sudden loss of vision.
It is a self-limiting condition and can resolve on its own.
However spontaneous resorption of the blood entrapped in the subhyaloid space
is slow and may result in long-lasting visual hampering2. If it persists
for longer period, can lead to pigmentary damage to the macula, toxic damage to
the retina due to the prolonged contact with iron and haemoglobin, epimacular
membrane formation or even macular traction3.
Various management options for this entity include observation,
Neodymium:YAG (Nd:YAG) laser hyaloidotomy and pars plana vitrectomy.4
As it is associated with permanent macular changes before the hemorrhage gets
spontaneously resolved and management of
underlying cause with potential risks of damage to ocular structures is
instituted, early intervention becomes crucial. Although pars plana vitrectomy
is likely to have the best anatomic outcome, the well known complications limit
its immediate adoption in the majority of scenarios. Nd:YAG laser hyaloidotomy
is a non-invasive, cheap, and safe method, which enables the drainage of the
premacular subhyaloid haemorrhage into the vitreous, facilitates absorption of
blood cells and improves the vision immediately by the clearance of the
obstructed premacular area5. It is found to be efficacious
in 93.33% cases6.
The
rationale of this study was to establish the early role of Nd:YAG laser in the
management of premacular subhyaloid hemorrhage so as to avoid the permanent
macular damages which may occur in case of conservative observational approach.
MATERIALS
AND METHODS
This prospective interventional case series
was carried out in Ophthalmology department, King Edward medical university and
Mayo hospital, Lahore from 1st July, 2015 to 31st December, 2015. There
were total 20 patients of premacular subhyaloid hemorrhage. They were selected
with the help of non probability purposive sampling technique. Inclusion
criteria were onset of symptoms within 2 weeks, 3-5 disc diameters of
hemorrhage and phakic patients with excellent posterior segment view. While
exclusion criteria was previous treatment for any maculopathy, associated
vitreous hemorrhage and visual acuity better than 6/60.
Proper permission was taken from institutional ethical committee
to conduct this study. Patients were selected from out-door patient department
(OPD) of Ophthalmology department of Mayo hospital, Lahore. A formal informed
consent was taken from the patients after brief description of method, duration
and possible outcome failure of treatment. They were ensured about the safety
of procedure and also that the confidentiality of data would be maintained.
After fulfilling the inclusion and exclusion criteria, patients were enrolled
in this study. After enrollment, the detailed history was taken about the onset
of reduced vision. Systemic inquiry was carried out in detail. Pre and
post-treatment best corrected visual acuity, slit-lamp examination, intraocular
pressure and fundoscopy were done. Special attention was paid to note any
possible etiology. Once diagnosis was made, patients underwent Nd:YAG laser
hyaloidotomy with the help of triple-mirror contact lens. Initially energy was
set at 3 milli joules (mJ) and was increased depending upon the reaction. Laser
was applied at anterior dependent surface of hemorrhage away from fovea. End
point was when anterior surface of hemorrhage was ruptured and blood trickled
into the vitreous.
Patients were called for follow ups on 2nd day, 1st
week and 2nd week. On each visit, visual acuity was assessed and
detailed fundus examination was done to find out underlying pathology and any
complication occurred during procedure.
All the recordings were made in the proforma designed (copy
attached).
All the data was entered and analyzed with the help of computer
software SPSS version 20 to find out frequencies and percentages of study
variables i.e. gender, etiology of haemorrhage. Descriptive statistics were
applied to calculate mean and standard deviation for the age of the patients
and amount of energy of laser applied.
Confounding variables like age, gender and etiology were
controlled by stratification.
RESULTS
Total 20 patients were included in study. The mean and standard
deviation of age was 36.55 ± 14.50 while the age range was 20-65 years. Patients
were divided into three different age groups. This division and its effect on
the final outcome are shown in table 1. This table shows that most of the
patients belonged to younger age group and the patients who didn’t showed
improvement were from the older age group.
Table 1: Age of patients and its
effect on outcome.
|
Age Group |
No.
of Patients |
Improvement
of Visual Acuity |
Clearance
of Macula |
|
20-35 years |
10 (50%) |
8 (80%) |
8 (80%) |
|
36-50 years |
8 (40%) |
4 (50%) |
6 (75%) |
|
51-65 years |
2 (10%) |
1 (50%) |
1 (50%) |
Table 2: Gender distribution and
its effect on outcome.
|
Gender |
No.
of Patients |
Improvement
of Visual Acuity |
Clearance
of Macula |
|
Male |
8 (40%) |
5 (62.5%) |
6 (75%) |
|
Female |
12 (60%) |
8 (66.67%) |
9 (75%) |
Table 3: Etiology of hemorrhage
and its effect on outcome.
|
Etiology |
No.
of Patients |
Improvement
of Visual Acuity |
Clearance
of Macula |
|
PDR |
8 (40%) |
4 (50%) |
6 (75%) |
|
Valsalva maneuver |
4 (20%) |
4 (100%) |
4 (100%) |
|
Trauma |
3 (15%) |
2 (66.67%) |
2 (66.67%) |
|
Blood dyscrasias |
2 (10%) |
1 (50%) |
1 (50%) |
|
AMD |
1 (5%) |
0 (0%) |
0 (0%) |
|
CRVO |
1 (5%) |
1 (100%) |
1 (100%) |
|
Idiopathic |
1 (5%) |
1 (100%) |
1 (100%) |
Gender distribution of patients is shown in table 2 with its
effect on final outcome. Male:female ratio in this study was 1:1.5. Visual
acuity was labeled as improved when there was at least 3 steps improvement
according to Snellen’s system of visual acuity assessment. Percentage of
improvement of visual acuity was better in females but macular clearance was
equal in both genders.
Table 3 describes in detail the etiology of subhyaloid hemorrhage
and its response to the Nd:YAG laser. PDR was the most common etiology. Only
50% patients of PDR showed improvement of visually acuity. Other maculopathies
were found in the remaining cases. They were managed according to the nature of
maculopathy. Cases of valsalva maneuver, CRVO and idiopathic etiology gave
excellent response.
Efficacy of procedure was defined in terms of macular clearance of
hemorrhage and it’s trickling in to the vitreous. According to this definition,
procedure was found effective in 15 out of 20 (75%) cases. Surprisingly the
dispersed hemorrhage took very late i.e. 4 weeks on average to be cleared from
vitreous.
Complication
was noted in only one case of trauma where hemorrhage dispersed into vitreous
and led to formation of taut membrane. This case was then dealt surgically.
DISCUSSION
Premacular subhyaloid hemorrhage
results in an acute and profound decrease in vision7,8,9. Different
etiologies including vasoproliferative diseases (e.g., diabetic retinopathy),
vascular anomalies (e.g., retinal macroaneurysms), or rare conditions like
valsalva maneuver, terson syndrome and leukemias can cause these hemorrhages2,10,11,12.
Each cause can lead to a hemorrhage into the vitreoretinal interface. Still
attached, posterior hyaloid membrane results in formation of a premacular
hemorrhagic bubble, which will cause decreased vision and/or a central scotoma.
It can resolve on its own but observation may result in unwanted sequelae
leading to permanent damage to macula. That is why, early removal of the
hemorrhage is important13. Various therapeutic options include the
intravitreal administration of SF6
gas, Nd:YAG laser hyaloidotomy or a pars plana vitrectomy14,15,16.
Opening the posterior hyaloid membrane by laser (referred to as hyaloidotomy)
presents a minimally invasive technique introduced for the first time in 1988
by Faulborn17. One year later it was also used by Gabel. Since that,
it has become a popular method due to its non-invasiveness. We also used this
in our study.
In this study, we performed
this method on 20 patients of premacular subhyaloid hemorrhage. Etiologies
included PDR, trauma, valsalva maneuver and miscellaneous causes. The
percentage of these etiologies is almost similar to those found in study of Murtaza
et al6 with exception of trauma. This is possible as both these
studies were performed in same country.
The hyaloidotomy was successful
and blood trickled into vitreous from where it was cleared within 4 weeks. Our
final follow up of study was at 2nd week. That is why, our results
are contrary to findings of Ahmedabadi18 and Murtaza, et al6.
Other possible reason may be relatively younger ages of our patients in which
blood dispersed into vitreous is absorbed slowly because of less liquefaction.
More number of diabetic patients in our study can also make the difference as
blood is absorbed very slowly in diabetic patients due to aggressive nature of
disease process.
Visual acuity was found to be
improved in 13 cases (65%) according to the defined criterion. It is lower than
that (75%) found in study of Ulbig et al19. It is because the final
follow-up of patients in their study was longer than that in our study. One
patient had visual acuity of 6/6 (5%) while vision of 10 patients (50%) was
between 6/9-6/12. This is similar to that of Faisal and colleagues6
(56.66%) and Renni et al10 (66.67%). This is however in comparison
to results of study of Shashidhar et al20 (92.85%). This comparison
has emerged due to the difference in etiologies of premacular subhyaoid
hemorrhage. Most of patients in our study were that of PDR and trauma where as
these were the least common etiologies in Shashidhar’s study. There were other
macular changes besides subhyaloid hemorrhage in our patients which had limited
the final visual acuity.
Final outcome was assessed on
the basis of displacement of hemorrhage away from the macula and its clear
visualization which may or may not be associated with improved vision. Our
results are less than other studies6,10,12,16. The only possible
reason is the shorter duration of study and earlier follow up than those of
others.
This short duration study showed that Nd:YAG laser hyaloidotmy is
effective in macular clearance and improvement of vision if no associated
maculopathy is present.
CONCLUSIONS
Early Nd:YAG laser treatment should be considered
for recent premacular subhyaloid hemorrhages. Its benefits include early visual
rehabilitation, visualization of the underlying fundus, early access for
macular photocoagulation, the avoidance of surgical vitrectomy and
avoidance of potential toxic macular changes. Long term follow ups of laser
treated cases are important. Randomization with deferral of procedure or
vitrectomy can exactly map out merits and demerits. Additionally, comparison
with intravitreal anti-VEGF (vascular endothelial growth factors) injections
can also highlight its marvelous effects.
Author’s Affiliation
Dr. Irum
Raza
DOMS,
FCPS
Vitreo-retina
Fellow
Department
of Ophthalmology, King Edward Medical College & Mayo Hospital, Lahore.
Dr. Chaudhary
Nasir Ahmad
FCPS,
Fellowship Vitreo-retina
Assistant
Professor
Department
of Ophthalmology, King Edward Medical College & Mayo Hospital, Lahore.
Dr. Tehseen
Mahmood Mahju
MS
(Ophth), Fellowship Vitreo-retina
Senior
Registrar Department of Ophthalmology, King Edward Medical College & Mayo
Hospital, Lahore.
Role of
Authors
Dr.
Irum Raza
Patients’
selection, data collection and analysis.
Dr.
Chaudhary Nasir Ahmad
Literature
search and references.
Dr.
Tehseen Mahmood Mahju
Research
design and research supervision.
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