Vitrectomy & complications..vitreous haemorrhages & related problems
A vitreous haemorrhage is the term given to bleeding into the middle chamber
of the eye (the 'vitreous'). It can develop if you have proliferative retinopathy
when the 'new' blood vessels burst and bleed. If you have had plenty
of laser In itself the haemorrhage is not serious and the blood usually clears.
If you have not had enough laser, then you are at high risk of developing complications as below (tractional retinal detachment), and vitrectomy surgery with 'endo' laser is usually needed.
Enlarge new blood vessels grow on the surface of the retina into the gel and can bleed.
view from the front
enlarge ....this is what the doctor sees
If you have proliferative retinopathy and have had not enough laser, the 'new' blood vessels may grow forward from the retina in to the 'vitreous' gel. See vitrectomy animation and Animation and photo.
The vitreous gel may start to shrink, and pull on the growing new vessels, and may make them bleed. The bleeding usually causes a 'spiders web' to appear in the vision, swirling around as the eye is moved. This can cause a serious retinal detachment and loss of vision.
The blood is eventually reabsorbed by the body's cells, and itself causes no damage. A dense haemorrhage caused by a severe bleed still usually clears itself, but problems may arise as below:
new vessels growing from retina
vitreous starts to shrink
blood vessel torn .. subhyaloid haemorrhage
haemorrhage spreads into the vitreous itself.. a vitreous
It is common to have such haemorrhages in proliferative retinopathy:
if you have had a lot of laser, i.e. 6000 burns on each eye, such bleeding is not usually serious, but more laser is often needed.
if you have had no laser, the bleeding suggests that quite a lot of laser may be needed, reasonable soon (how soon: this depends on how severe the condition is, perhaps within 2-4 weeks). This may mean you will need a vitrectomy to remove the blood so that laser can be carried out.
if you have had perhaps 3000 burns, more laser is needed (how soon: again this depends on how severe the condition is).
If you have a haemorrhage (it is impossible to give specific advice; these are general principles)
rest for few hours day sitting upright in a chair during the day, have extra pillows to keep your head high at night
let your eye clinic know (unless the bleeding is small, and have had frequent haemorrhages, and have had 8000 or so burns on the eye, and have had a recent examination)
If you have had no laser or very little laser then you need to see an ophthalmologist with in a few days, as you may need a vitrectomy.
if your sight is badly affected it is safer to have your eye examined by your ophthalmologist, although usually there is no immediate treatment. Laser is usually arranged at a later date when it is likely much of the blood will have cleared. If you have had no or very little laser, then a vitrectomy (and endo laser) is often necessary.
Have your blood pressure checked. It needs to be less than 130/80 if you have no protein in your urine, less than 125/75 if there is protein. you may need extra medication. The lower the blood pressure, the less the bleeding.
Do not lift anything really heavy. This depends on how much you lift normally, but paving stones or very heavy suitcases are not ideal. Once you have had plenty of laser and the vessels have shrunk back it is fine to start lifting again as normal.
Avastin is ideally it is given a week before vitrectomy surgery, but it may cause retinal detachment if surgery is delayed. Spaide.
Sometimes Avsin can avoid the need for vitrectomy completely (Need to check before the injection, with ultrasound, that there is no tractional retinal detachment).
Vitreous haemorrhage is due to vitreous traction,
66% only needs laser if that is active with IRMAs, blots, blot haemorrhages, & venous dilatation
33% inactive, no laser..these blleds are simply due to vitreous raction on inactive new vessels
For a none-clearing haemorrhage
Usually use Avastin 1 week before
6 weeks of haemorrhage..think about vitrectomy
(ultrasound to exclude a retinal detahment)
30% of type 1 need vitrectomy...not a sign of failure
Florid NVE...good results with vitrectomy: vitrectomy at first sign of haemorrhage, before fibrosis
If there is a smaller vitreous haemorrhage it may settle behind the vitreous gel and in front of the retina. This is called a subhyaloid haemorrhage. See a large photo
These haemorrhages usually clear without any problems, but sometimes more laser is needed to treat any fresh new vessel growth. At the beginning they may interfere with your sight, but many people do not know they have one.
Laser treatment (yellow arrow) can be effective:
A premacular haemorrhage can be lasered successfully Retina 2012. Sight improved over a few weeks.
- Laser was aimed inferiorly (cross).
- Yag laser, area centralis,
- >6mj, several shots.
- no immediate visible response to the laser, but the haemorrhage dispersed as below over 3 weeks.
Left...after laser, right before laser Enlarge
enlarge Early tractional detachment: the scar tissue in the vitreous shrinks (black) , wrinkling the retina(red)
If the shrinkage is mild the retina may become slightly lifted or wrinkled.
Fortunately the wrinkling is usually away from the macula, and the sight should be good. Surgery is not needed.
enlarge The scar tissue pulls on the central area of the retina (the macula) and affects the vision
If this happens in the macular area (the macula is described in 'mechanisms')
your sight may be affected: objects may appear tilted or bent. An operation
(vitrectomy, as below, may be needed).
Shown here is a small 'traction detachment', a type of retinal detachment. See animation of epiretinal mebrane peel.
enlarge The vitreous shrinkage is very severe, pulling the retina (a large 'retinal detachment')
If the condition is very severe, your sight may be extremely bad. Vitrectomy surgery is usually helpful, but your sight may be permanently damaged. See photo. Patients with tractional retinal detachment and fibrovascular proliferation behind the equator do well with vitrectomies. Many patients with some fibrovascular proliferation anterior to the equator do well, but vitrectomy does not help those with rubeosis or rubeotic glaucoma (when this occurs with fibrovascular proliferation anterior to the equator as well). Vitrectomy animation.
enlarge The scar tissue on the retinal surface, wrinkles the retina
If the scar tissue is near the surface of the retina, it looks like a thin membrane. It is called an 'epiretinal membrane'. It causes wrinkling of the retina, and this may be removed surgically if the sight is reduced.
enlarge Vitrectomy surgery
A vitrectomy carried out by an experienced surgeon is usually successful, but is not discussed here in detail. The operation usually produces a cataract in the period after the operation: this needs a cataract operation.Three small holes are placed in the side of the eye, for instruments like a special light, tiny scissors, and a vitreous 'cutter'. The blood is sucked out with one of the probes, and if thickened membranes like those illustrated above are present, they are peeled off the retina then sucked out. If the vitreous shrinks and pulls the retina substantially, a vitrectomy may be needed (as in the two paragraphs above). Similarly, if there is a dense haemorrhage, vitrectomy may be needed.
An ultrasound test may tell the surgeon whether the retina is in place or not (it can detach hidden behind the haemorrhage). This is a very simple test using a scanning probe placed over your eye.
Retinopathy that is not controlled by laser may respond to vitrectomy with excellent results. I have seen such cases presented at meetings, by Dr Ellis (2003). Florid retinopathy that progresses despite laser may be completely stabilised by vitrectomy. He presented this case, as an example:
the HbA1 fluctations of this patient lead to rapdily prgressive retinopathy, with lots of new vessels and retinal traction and haemorrhage
· Diabetes diagnosed
· Treated, good control for a while
· Parents divorced (common in families with children with diabetes)
· Poor control as a teenager
· Poor attendance in clinic (poor attendance is related to poor prognosis)
· Got a job
· Started to control diabetes well
· Proliferative retinopathy develops
· Remains extremely florid despite laser, even gets worse
· Excellent result: no evident active retinopathy
This is reviewed in the literature here , here, and a search here. Laser before the vitrectomy surgery nevertheless improves outcomes and is important: it must be carrried out where possible. In future, avastin or macugen are likely to be offered instead of vitrectomy, as risks are lower.
- all had rapid improvement of their diabetic control which was previously poor
- the retinopathy progressed from very early/none to very florid proliferation in 3 months
- one patient was pregnant
- all developed florid retinopathy
- all were offered very intensive laser
- some needed vitrectomy
- one eye was lost (rubeotic glaucoma), the fellow eye (with vitrectomy) maintained 6/9
- none were offered Avastin, but in separate discussions many people thought that intravitreal Avastin would have helped if given early at around the time of laser
- see details
- Patients with proliferative retinopathy have a 33% risk of a vitreous haemorrhage at some time.
- About 25% of these haemorrhagesare recurrent or severe and need a vitrectomy.
- After vitrectomy about 20% bleed needing a washout
- After vitrectomy,
- 33% have vision better than 6/18
- 3% develop rubeotic glaucoma
- 12% develop a cataract
- outcomes are naturally worse if there is an ischaemic macula, or if the fellow eye has poor sight.
- Vitrectomy can be considered
- after 6 week with a vitreous haemorrhage
- after lots of laser with recurrent haemorrhage, vitrectomy is preferable to even more laser (to maintain visual field)
- for florid new vessels that do not respond to loser (as above)
- if there is a tractional retinal detachment either with a hole or of it involves the macula.
- macular oedema only if there is definite vitreo-retinal traction. If there is no traction it will generally not help
- if there is a vitreous haemorrhage thet prevents laser in a patient who has not had laser/or has had very little laser.
- Vitrectomy timing: refer
- 6 weeks after a haemorrhage,
- earlier if there is a severe haemorrhage, or if the fellow eye is blind, or if there is not enough laser, a ochre membrane, retrohyaloid haemorrhage, or pseudophakia.
This is a very nasty type of glaucoma that can occur in diabetes. It occurs when 'new vessels' grow and stop fluid draining out of the eye. Treatment involves a lot of laser. See a more detailed page and an animation.