Vitrectomy & complications..vitreous haemorrhages & related problems

vitreous haemorrhages what should you do subhyaloid haemorrhage tractional retinal detachments, early tractional retinal detachment involving macula extensive tractional retinal detachment epiretinal membrane Animation epiretinal membrane vitrectomy Animation vitrectomy vitrectomy for active retinopathy some cases new data concerning vitrectomy rubeotic glaucoma Animation rubeotic glaucoma Animation diabetic retinopathy

Related pages Notes for professionals rapid progression...4 cases vitreous haemorrhage, complications

Vitreous haemorrhages

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. In itself the haemorrhage is not serious and the blood usually clears.

side view 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 do not have 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.

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:

enlarge new vessels growing from retina	enlarge vitreous starts to shrink	enlarge blood vessel torn .. subhyaloid haemorrhage	enlarge haemorrhage spreads into the vitreous itself.. a vitreous haemorrhage

What should you do if you have a haemorrhage?

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).
• 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)

• don't panic
• rest for a day or two 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 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.
• 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 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

 

A Subhyaloid haemorrhage

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.

 

Minor tractional retinal detachment & vitreous haemorrhage

Bleeding into the vitreous may contribute to the vitreous shrinkage. See the photo tour and photos.

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.

 

 

Tractional retinal retachment involving macula

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.

 

 

An extensive tractional 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.

 

Epiretinal membrane

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.

 

 

 

 

 

Vitrectomy

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, surgery 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.

 

Vitrectomy for active retinopathy: a case

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

 

This case:

· 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
· Vitrectomy
· 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.

 

Cases: in Liverpool 2007 cases were presented:

• 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

New data on vitrectomy (Liverpool 2008)

• 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
• 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.

Rubeotic Glaucoma

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.