Sub-internal limiting membrane hemorrhage treated with intravitreal tissue plasminogen activator followed by octafluoropropane gas injection

Characterization of retinal hemorrhages delimited by the internal limiting membrane

Clinically, hemorrhages at the vitreoretinal interface have been termed as 'pre-retinal' in location. However, there is a careful distinction to be made between sub-hyaloid and sub-internal limiting membrane (ILM) planes of blood collection. In the past half-century, a body of literature has accrued on sub-internal limiting membrane hemorrhage. We characterize the etiopathological, clinical, anatomical, and imaging characteristics of this entity (often misconstrued as sub-hyaloid hemorrhage). Management decisions are briefly described, and a unifying term of sub-internal limiting membrane macular hemorrhage is proposed to aid in further research.

A Case of Acute Promyelocytic Leukemia With Retinal Hemorrhages Beneath Internal Limiting Membrane During Clinical Remission

Leukemia is a systematic cancer of the blood and blood-forming tissues that affects multiple organs. Acute myeloid leukemia (AML) is the most common type of leukemia that affects adults. Ophthalmic manifestations of leukemia could be observed in both acute and chronic leukemias. Around 35.4% of leukemia patients present with leukemic retinopathy. In this report, we discuss the case of a patient who was diagnosed with acute promyelocytic leukemia (APL) and went on to develop leukemic retinopathy during chemotherapy.

A 35-year-old male was diagnosed with APL and received induction therapy with daunorubicin, and all-trans retinoic acid (ATRA) in a seven + three regimen. During the remission phase, he presented with a complaint of decreased vision of the right eye for about three weeks after the initiation of the therapy. On examination, the best-corrected visual acuity (BCVA) was found to be 6/60 in the right eye and 6/6 in the left eye. Fundus examination showed intraretinal hemorrhages in the posterior pole of both eyes. Fundus photography of the right eye showed resolved macular bleeding, temporal retinal bleeding, fresh inferonasal, and supraoptic retinal hemorrhage. For the left eye, however, it showed a small hemorrhagic spot temporal to the macula. Optical coherence tomography (OCT) was performed on both eyes, which showed sub-inner limiting membrane (sub-ILM) hemorrhage in the right macula with normal OCT of the left eye.

There are multiple reported ocular manifestations of leukemic retinopathy including flame-shaped hemorrhage, cotton wool spots, and Roth spots. In patients with APL, thrombocytopenia and intracranial hemorrhage are the proposed underlying mechanism of retinal hemorrhage. Terson’s syndrome, which is an intracranial hemorrhage with associated retinal hemorrhage, has been reported to occur during ATRA induction therapy. Sub-ILM hemorrhage is relatively uncommon, and it has been associated with multiple primary pathologies such as Valsalva retinopathy, Terson’s syndrome, and bleeding dyscrasias.

Retinal hemorrhage is a serious complication in leukemic patients; it could be the presenting complaint or even manifest after the initiation of therapy. Early detection and frequent follow-ups are crucial for its management.

Bilateral and multiple sub-internal limiting membrane hemorrhages in a familial retinal arteriolar tortuosity patient by Valsalva-like mechanism: an observational case report

Background

Bilateral and multiple Valsalva-related sub-internal limiting membrane (ILM) hemorrhages in a familial retinal arteriolar tortuosity (FRAT) patient is rare, and we treated this patient by both observation and Neodymium yttrium aluminum garnet (Nd: YAG) laser membranotomy methods.

Case presentation

A 13-year-old female student presented with sudden visual loss and central scotoma in both eyes after running 800 m at the school gym. The examination revealed six sub-ILM hemorrhages with the biggest hemorrhage measuring approximately 1.5-disc diameters (DD) in the right eye and two sub-ILM hemorrhages with the biggest one measuring 5.5 DD in the left eye. The patient was diagnosed as having Valsalva retinopathy associated with FRAT. Nd: YAG laser membranotomy was performed at the biggest hemorrhages and the rest hemorrhages were treated with observation in both eyes. The visual acuity recovered to 20/16 in the right eye and 20/20 in the left eye. Epiretinal membrane (ERM) formation was observed in the left eye.

Conclusions

Nd: YAG laser could be considered for treating premacular hemorrhage in FRAT patient especially when a quick vision recovery was needed. This is the first reported case of a FRAT patient suffering from bilateral and multiple Valsalva-related sub-ILM hemorrhages which were treated by both observation and Nd: YAG laser treatment.

Spontaneous Macular Hole Closure after Valsalva Retinopathy and Nd:YAG Laser Treatment

Purpose

The purpose of this report is to present a case who had spontaneous macular hole closure after Nd:YAG laser membranotomy applied to premacular haemorrhage associated with Valsalva retinopathy.

Methods

Case report.

Results

A 19-year-old young male patient presented to our clinic with sudden vision loss in his right eye, which had occurred 2 weeks before, following push-up and sit-up exercise. The patient was found to have premacular haemorrhage associated with Valsalva retinopathy. Nd:YAG laser membranotomy was performed. During his follow-up at week 1, full-thickness MH was observed and he was put under observation. At month 6, his vision acuity improved, laser coagulation sites in the fundus disappeared, and macular hole closed spontaneously.

Conclusion

Macular hole that develops after Nd:YAG laser treatment of Valsalva retinopathy may spontaneously be closed like in our case. However, there is a need for further research to understand the mechanism of closure.

[Laser membranotomy in the management of acute premacular hemorrhage : Case report and overview on the approach]

Acute premacular bleeding is often associated with vasoproliferative retinal changes, vascular anomalies or a Valsalva maneuver. The diagnosis is made during the funduscopic examination and can if necessary be confirmed with optical coherence tomography (OCT). This article presents a case example with a sub-inner limiting membrane (ILM)/sub-hyaloidal bleeding. Furthermore, we present various treatment options and give an overview on the use of the Nd:YAG laser for laser membranotomy as a minimally invasive treatment option with a low complication profile.