Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage

Early vitrectomy is indicated for both diffuse and dense vitreous haemorrhages of unknown aetiology

BACKGROUND

Early vitrectomy for complete fundus-obscuring vitreous haemorrhage (VH) allows for prompt diagnosis and treatment of the cause.

AIMS

To analyse the causes of VH of unknown aetiology, whether partially fundus-obscuring or dense, and to determine the outcomes of early vitrectomy.

METHODS

A retrospective review of patients who underwent early vitrectomy within 10 days of symptom-onset for partially fundus-obscuring or dense VH of unknown origin. Patients with evidence of proliferative diabetic retinopathy in either eye or any other preoperatively diagnosed aetiology of VH were excluded.

RESULTS

19 patients were included. Intraoperative diagnoses were: retinal tears without rhegmatogenous retinal detachment (RRD) (53%); peripheral localised RRD (32%); neovascularisation secondary to retinal vein occlusion (11%) and posterior vitreous detachment without a retinal break (5%). Patients with diffuse VH were as likely to have a retinal tear diagnosed as those with dense VH (88% vs 82%, respectively; p = 0.7). Mean VA improved from 1.26 LogMAR to 0.23 LogMAR postoperatively (p = 0.001). 1 patient (5%) developed a RRD one-year postoperatively.

CONCLUSIONS

In cases of diffuse or dense VH of unknown aetiology, an occult retinal tear should be suspected. Early vitrectomy should be strongly considered regardless of whether the fundal view is partially or completely obscured, to prevent progression to visually significant RRDs.

The BElfast Retinal Tear and detachment Score (BERT Score) in vitreous haemorrhage

OBJECTIVE

To establish if the BElfast Retinal Tear and detachment Score (BERT Score) can be used in triaging patients presenting with vitreous haemorrhage to allow safe differentiation between those with retinal tears and detachments, versus haemorrhagic posterior vitreous detachments.

METHODS

Retrospective audit of 122 patients presenting to eye casualty with vitreous haemorrhage excluding trauma and vascular causes. Twenty-two patients were excluded from the study as they had no follow-up. The BERT Score was applied to the remaining 100 patients.

RESULTS

Vitreous haemorrhages with a BERT score ≥4 points were more likely to have a retinal tear or detachment (P = 0.0056). The sensitivity was 84.6% (confidence interval (CI) 65.0-100.0%), specificity 34.5% (CI 24.5-44.5%), positive predictive value 16.2% (CI 7.4-24.9%) and negative predictive value 94% (CI 85.4-100.0%).

CONCLUSIONS

The BERT is a reliable scoring system to risk stratify patients with vitreous haemorrhage. Its high sensitivity and negative predictive value can help clinicians to detect high-risk patients.

Safety profile and surgical outcomes of early vitrectomy in eyes with unexplained fundus-obscuring vitreous haemorrhage

OBJECTIVES

To investigate the safety profile and the surgical outcomes in a large cohort of subjects undergoing early vitrectomy for unexplained fundus-obscuring vitreous haemorrhage (FOVH).

METHODS

Retrospective, single-centre case series of 186 consecutive eyes presenting between January 2018 and February 2020. Primary outcomes included change in best-corrected visual acuity (BCVA), rate of intra-operative retinal tears or retinal detachment (RD), baseline proliferative vitreoretinopathy (PVR), association of demographics with clinical outcomes, and rate of significant adverse events characterised by reoperation.

RESULTS

Main final diagnosis was haemorrhagic posterior vitreous detachment (76%) and the overall risk of a retinal tear with or without RD found at the time of surgery was 69%. Vitrectomy was completed within 24 h in 94% of eyes. Rate of RD was 18%; all cases were macula-sparing with no PVR. Mean change in BCVA from baseline to final follow-up was -1.53 ± 0.69 LogMAR, p < 0.001. Time from presentation to surgery was significantly associated with final BCVA (p = 0.036, beta co-efficient 0.097). There was a significant association between presence of RD and age <60 y (OR 0.94, 95%CI [0.90-0.98], p = 0.003). 4.8% required repeated vitrectomy for post-operative RD (4), epiretinal membrane formation (3), removal of oil (1), and recurrent FOVH (1). None of these reoperations were induced by complications during the first surgery.

CONCLUSION

There is a high rate of retinal breaks in cases with unexplained FOVH, and the risk of a concomitant RD is higher in younger subjects. Early vitrectomy within 24 h appears a safe first-line treatment and yields good clinical outcomes.

Early vitrectomy in eyes with non-diabetic vitreous hemorrhage

Background:

Optimal management of non-diabetic vitreous hemorrhage (NDVH) is controversial, and reliability of B-scan ultrasonography in detecting retinal tears (RTs) has been reported to be highly variable by previous literature.

Objectives:

To report outcomes of conservative versus surgical management of NDVH and reliability of B-scan ultrasonography in detecting RTs and rhegmatogenous retinal detachment (RRD).

Design:

Retrospective observational single-center cohort study.

Methods:

Ninety-six consecutive NDVH from 96 eyes (96 patients) with minimum follow-up duration of 12 months were included.

Results:

Seventy-two eyes (75%) underwent early pars plana vitrectomy (PPV), 19 (20%) were managed conservatively and 5 (5%) underwent late PPV. Initial mean best corrected visual acuities (BCVAs) were 1.95 ± 1.19, 1.19 ± 1.38, and 1.14 ± 1.04 logMAR respectively, the difference was statistically significant (p = 0.039). Mean final BCVAs were 0.92 ± 1.19, 0.59 ± 0.87, and 1.25 ± 1.89 logMAR, respectively, the difference was not significant (p = 0.447). When comparing initial and final BCVAs, the difference was significant only in the early PPV group (p = 0.00001) and was not significant in the conservative group (p = 0.066) and in the late PPV group (p = 0.46). Complications included RRD (n = 2) and re-bleed in vitrectomized cavity (n = 1) in the early surgical group, need for additional laser or cryoretinopexy to RTs (n = 2), retinal detachment (n = 1), neovascular glaucoma (n = 1), persistent vitreous hemorrhage (n = 2) in the conservative group. B-scan ultrasound showed preoperative 11.53% sensitivity and a 60.0% positive predictive value for diagnosing retinal tears (RTs) in NDVH.

Conclusion:

The benefit of early PPV in NDVH seems to outweigh the risks of surgery, especially in the context of low sensitivity of B-scan in identifying RTs, and significant improvement in final BCVA following surgery may occur. NDVH should be promptly referred to vitreoretinal services, as surgery may be a safer and more advisable option.

Vitrectomy vs. Combined Vitrectomy and Scleral Buckle for Repair of Primary Rhegmatogenous Retinal Detachment with Vitreous Hemorrhage

OBJECTIVE

To compare pars plana vitrectomy (PPV) to PPV with scleral buckle (PPV/SB) for repair of primary rhegmatogenous retinal detachment (RRD) with associated vitreous hemorrhage (VH).

DESIGN

Retrospective, observational study.

SUBJECTS

Patients with RRD and associated VH who underwent PPV or PPV/SB from January 1, 2010 through August 31, 2020 were analyzed.

METHODS, INTERVENTION, OR TESTING

We performed a single-institution, retrospective, observational study of 224 eyes with RRD and VH at the time of detachment. We excluded eyes with less than 6 months of follow up, prior history of retinal detachment repair with vitrectomy or scleral buckle, VH that resolved before surgical intervention, tractional or combined tractional and rhegmatogenous detachment.

MAIN OUTCOME MEASURES

Single surgery anatomic success (SSAS) at 6 months, defined as no recurrent retinal detachment requiring surgical intervention.

RESULTS

PPV and PPV/SB were performed on 138 eyes (62%) and 85 eyes (38%), respectively. The mean age was 61.9 years in PPV patients and 60.2 years in PPV/SB patients. Single-surgery anatomic success was achieved in 107 of 138 (77.5%) eyes that underwent PPV and in 78 of 85 (91.7%) eyes that underwent PPV/SB. The difference in SSAS between types of treatment was significant (p = 0.006). Mean visual acuity improvement in the PPV/SB group was 0.54 logMAR units greater than the PPV group (p = 0.126). The incidence of postoperative PVR in the PPV/SB group (11.7%) was lower than in the PPV group (19.5%) (p = 0.128). The rate of repeat PPV for non-RD reasons was similar for both groups (p = 0.437). Final reattachment status was achieved in 137 of 138 and 84 of 85 eyes in the PPV and PPV/SB groups, respectively. Final visual acuity improvement was significantly better in eyes with PPV/SB compared to PPV alone (logMAR 2.12 vs 1.26; p=0.011).

CONCLUSIONS

In RRD with VH patients, SSAS was superior in patients treated with PPV/SB compared with PPV alone. Although not significantly different, the PPV/SB group had better visual outcomes and a lower postoperative PVR rate.

Ocular Point-of-Care Ultrasound: Description of Intermediate Uveitis in an Adolescent Female

ABSTRACT

Ocular point-of-care ultrasound has been used to assess for intraocular pathology, including retinal and vitreous detachment. We describe a pediatric patient whose initial point-of-care ultrasound examination appeared to be consistent with bilateral posterior vitreous detachment but who was ultimately diagnosed with intermediate uveitis.

Prevalence of Vitreous & Retinal Disorders among Sudanese Diabetic Patients: A B-Scan Ultrasonography Study

Retina and vitreous abnormalities represent the most common eye disorders in diabetic patients; they may be associated with severe complications. Therefore, this study aimed to study the prevalence of vitreous and retinal pathologies in diabetic patients using B-Scan ultrasound (U/S). A total of two hundred and three Sudanese diabetic patients with long diabetic disease duration (mean 16.28 ± 4.830) years were enrolled in a descriptive-analytical study. 55% (n = 112) were males and 45% (n = 91) were females. The mean age of the participants was 62.28 ± 8.041(range between 30-79 years -old). The study was conducted in a Sudanese ophthalmologic hospital in Khartoum, during the period from 2016–2019. A Nidek (Echoscan US–4000) - B-scan ultrasound unit with 10 MHZ transducer was used. A high-frequency direct contact technique was applied. The inclusion criteria included adult diabetic patients. The vitreous and retina disorders were more prevalent in diabetic hypertensive participants 55 % (n = 112). The high frequency of the disorders was observed in age groups: 60–69 and 50–59 years-old. The most common disorder was retinal detachment which was detected in30.5% (n = 62) followed by vitreous changes in16.3% (n = 33). Posterior vitreous was observed in 15.8% (n = 32), vitreous hemorrhage seen in 15.3% (n = 31), both retinal detachment with vitreous hemorrhage were detected in 11.3%) (n = 23), retinal detachment with cataract were reported in 3.4% (n = 7), retinal detachment with Vitreous changes were seen in 3% (n = 6), and other changes were noted in 4.4% (n = 9) of the participants. There is no significant a statistical association between gender/diabetic duration and age with the disorders (P = 0.2, 0.43, and 0.5) respectively. Vitreous & Retinal disorders were more prevalent in diabetic hypertensive patients. The high frequency of the disorders was observed in the age group (50–70). The ultrasound is a useful method in diagnosing Vitreous & Retinal disorders among the diabetics.

Factors Affecting Compliance to Anti-Vascular Endothelial Growth Factor Treatment of Diabetic Macular Edema in a Cohort of Jordanian Patients

Purpose

To determine compliance rates and characteristics and to investigate factors affecting patients’ adherence to treatment with anti-vascular endothelial growth factors (anti-VEGFs) for diabetic macular edema (DME) in a cohort of Jordanian patients.

Methods

A retrospective case series wherein the files of DME patients treated with anti-VEGFs were reviewed and analyzed for factors affecting treatment compliance was undertaken. Demographic, clinical and ocular characteristics were recorded. All patients were also interviewed by phone using a structured questionnaire. Univariate and multivariate analyses were performed to determine factors associated with compliance.

Results

A total of 117 patients (65 males 52 females) were included in this study with a mean age of 62.93 years (±9.75). Approximately, 85% of patients were compliant to their treatment and follow-up plan during the first year of management. Subjective perception of visual improvement after receiving three loading doses was the only independent variable with a unique statistically significant contribution to compliance. All other studied factors in this group of patients were not significantly associated with patient compliance.

Conclusion

VEGF suppression via the intravitreal route to treat DME is a long-term process that requires caregiver dedication but also proper patient compliance. Addressing real-life barriers in those patients may help guide future strategies to improve the treatment experience, lower the financial burden and contribute to better outcomes. Patients' perceptions of possible treatment outcomes at the short term may influence their long-term commitment to therapy.

A Proposed Method to Quantify Vitreous Hemorrhage by Ultrasound

Purpose

To propose a method for quantification of vitreous hemorrhages (VH) termed minimum image gain (MIG). Therefore, to obtain MIG measurements in patients with VH and to compare them to normal controls; to compare results between graders; and to obtain and compare MIG from two different ultrasound systems.

Methods

Retrospective and cross-sectional, observational, and comparative study performed in two parts: Part 1) Retrospective comparison of MIG in VH vs controls by two experienced graders, with intra/inter-observer variability: MIG technique is described. MIG is performed retrospectively in two groups, VH patients and normal controls. Groups are compared with independent samples t-test. Intra- and interobserver variability between graders was obtained. Part 2) Cross-sectional analysis of variability from nonexperienced graders and with different ultrasound systems: MIG is performed in cross-sectional measurements of VH patients, by two unexperienced graders, and with two ultrasound systems. Interobserver variability and Bland–Altman plot with levels of agreement (LoA) were obtained.

Results

Part 1: 50 patients with VH resulted in mean MIG: 52.8 dB; 34 controls resulted in mean MIG: 77.97 dB. Independent samples t-test resulted in a statistical significant difference. Intra- and inter-observer variability resulted in an almost perfect agreement between experienced graders. Part 2: 63 patients with VH, mean MIG: 56.19 dB. Inter-observer variability resulted in a very high agreement between unexperienced observers. LoA resulted in a statistical difference between the two ultrasound systems.

Conclusion

MIG may provide an objective and reproducible way to quantify vitreous hemorrhage density and potentially any vitreous humor opacity. Agreement is high even with unexperienced graders. However, the two ultrasound systems analyzed may not be interchangeable.

Comparison of Observation Versus Vitrectomy for Patients With Hemorrhagic Posterior Vitreous Detachment

BACKGROUND AND OBJECTIVE

Patients with hemorrhagic posterior vitreous detachments (HPVDs) have a high rate of retinal tears and often develop retinal detachments (RDs). This study aims to compare outcomes of 25-gauge pars plana vitrectomy (PPV) for HPVD versus an observational group.

PATIENTS AND METHODS

Retrospective cohort study of 109 consecutive eyes of 105 patients diagnosed with HPVD; 66 eyes underwent PPV and 43 eyes were observed.

RESULTS

Twenty-four eyes (36.4%) in the surgical group were found to have tears intraoperatively not seen preoperatively. The median time to vitreous hemorrhage (VH) resolution was significantly shorter for the PPV group, 14 days (interquartile range [IQR]: 7 days to 35 days), compared to those who were observed, 58.5 days (IQR: 30 days to 91 days) (P < .0001). RDs occurred more frequently among observational patients (11.63%) compared to 1.52% of surgical patients (P = .0344).

CONCLUSION

Twenty-five-gauge PPV for HPVD resulted in less RDs, diagnosis of occult retinal breaks intraoperatively, and shorter time to VH resolution. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e288-e293.].

COMPLIANCE AND ADHERENCE OF PATIENTS WITH DIABETIC MACULAR EDEMA TO INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN DAILY PRACTICE

PURPOSE

We assessed differences in compliance and adherence (lateness of patients, visual acuity, reasons for abstaining) between patients with diabetic macular edema (DME) and patients with age-related macular degeneration (AMD), both under anti-vascular endothelial growth factor therapy.

METHODS

We included 136 patients with DME (36% women, 65 years, 22 visits, 13.9 injections, and 29.9 months of follow-up) and 109 patients with AMD (59% women, 76 years, 20 visits, 14.7 injections, and 22.3 months of follow-up) (minimum follow-up of 12 months and at least 5 injections). We assessed missed appointments (lateness >14 days) and therapy break-offs (lateness >100 days). All delayed patients were called and interviewed for abstaining reasons.

RESULTS

Forty-six percent of patients with DME and 22% of patients with AMD had at least one break-off. Thirty-five percent of patients with DME and 50% of patients with AMD were always on schedule. In patients with DME, there was significant correlation (P = 0.017) between the number of break-offs and change of visual acuity. In 60% DME and 38% AMD of break-off cases, visual acuity was worse than the before break-off. The most common reason for abstaining was comorbidities (33% AMD and 20% DME).

CONCLUSION

There are significant differences between patients with AMD and DME regarding compliance and adherence, which also affects outcome. Strategies to tie patients with DME to costly intravitreal therapy need to be developed to improve outcomes and efficacy.

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

VISUALIZATION FROM INTRAOPERATIVE SWEPT-SOURCE MICROSCOPE-INTEGRATED OPTICAL COHERENCE TOMOGRAPHY IN VITRECTOMY FOR COMPLICATIONS OF PROLIFERATIVE DIABETIC RETINOPATHY

PURPOSE

To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated optical coherence tomography in vitrectomy for proliferative diabetic retinopathy complications.

METHODS

In this prospective study, we analyzed a subgroup of patients with proliferative diabetic retinopathy complications who required vitrectomy and who were imaged by the research swept-source microscope-integrated optical coherence tomography system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy-associated pathologies and reviewing the intraoperatively documented surgeon feedback.

RESULTS

Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes), and vitreous hemorrhage (2 eyes). Useful, good-quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple diabetic retinopathy complications could be imaged. Swept-source microscope-integrated optical coherence tomography provided surgical guidance, e.g., in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%), acceptable images were captured, but they were not useful due to high tractional retinal detachment elevation which was challenging for imaging.

CONCLUSION

Swept-source microscope-integrated optical coherence tomography can provide important guidance during surgery for proliferative diabetic retinopathy complications through intraoperative identification of different complications and facilitation of intraoperative decision making.

Use of ophthalmic B-scan ultrasonography in determining the causes of low vision in patients with diabetic retinopathy

Purpose

To determine the causes of low vision among Sudanese patients with diabetic retinopathy (DR) by using ophthalmic B-scan ultrasonography.

Materials and methods

A total of 100 patients with DR at different grades, were recruited prospectively between September 2016 and January 2018. Nidek (Echoscan US-4000) ultrasound unit was used to determine the causes of low vision in diabetic patients according to their glycated haemoglobin (HbA1c) and early treatment of diabetic retinopathy scale (ETDRS) severity levels.

Results

Vitreous hemorrhage (VH) 42(66.6%), asteroid hyalosis (AH) 12(14.3%), and partial retinal detachment (PRD) 9(19%) were the main cause of low vision in patients presenting with moderately regulated HbA1c and graded with either minimal or mild nonproliferative retinopathy (NPDR). While VH 15(40.5%), total retinal detachment (TRD) 12(32.4%), posterior vitreous detachment (PVD) 7(19%), and choroidal detachment (CD) 3(8.1%), were dominant in patients with poorly regulated HbA1c and graded either as moderate NPDR; severe NPDR; and proliferative retinopathy (PR).

Conclusions

Ophthalmic B-mode ultrasound is a rapid, noninvasive imaging technique that can be used with minimum discomfort in ophthalmological practice for the detection and evaluation of DR complications that predict the visual outcome.

Ultrasonography in Emergency Department; a Diagnostic Tool for Better Examination and Decision-Making

Context:

The aim of this study is to evaluate the applications of ultrasonography (US) as a diagnostic tool in emergency settings.

Evidence acquisition:

In the present review article, search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane were searched for the applications of US in emergencies. Finally, related articles which were published between 2000 and 2017, were selected and by reviewing them an attempt was made to evaluate various applications of US for examining and facilitating decision-making in emergency department (ED).

Results:

As a diagnostic tool, US can be of diagnostic help in emergency settings for the specialists and the treatment team regarding trauma, measuring intracranial pressure (ICP), hemothorax pneumothorax, abscess and its drainage, deep vein thrombosis (DVT), dyspnea, acute abdomen, appendicitis and biliary problems, renal colic and renal stones, shock, foreign object, bone fracture, peripheral nerve block, establishing central and peripheral venous access, lumbar puncture (LP), and confirmation of nasogastric tube (NGT) and endotracheal tube (ETT) placement.

Conclusion:

The results of this review study showed that US can be of help to EMPs as a diagnostic tool in a wide range of diseases and clinical conditions, which in turn can result in a decrease in the time needed for diagnosis and treatment, and therefore improve both the quality and quantity of the service provided in ED.

Accuracy of B-scan ultrasonography in acute fundus obscuring vitreous hemorrhage using a standardized scanning protocol and a dedicated ophthalmic ultrasonographer

Purpose

To assess the accuracy of B-scan ultrasound (U/S) in diagnosing cases of acute fundus obscuring vitreous hemorrhage (FOVH) using a standardized scan protocol and dedicated ophthalmic ultrasonographer.

Methods

Consecutive patients presenting with acute FOVH of unknown cause, between January 2013 and December 2014, were prospectively recruited. Patients underwent a scan performed by a dedicated ultrasonographer, utilizing a systematic scan sequence and using an ocular specific U/S device. The U/S findings were compared to the findings during vitrectomy or after spontaneous hemorrhage clearance.

Results

Fifty-eight eyes (58 patients) were included. An underlying rhegmatogenous retinal detachment (RRD) and retinal tears without RRD were reported in nine and 14 patients, respectively. Nineteen of these patients underwent vitrectomy, and the other four underwent laser retinopexy or cryopexy alone. An additional six patients with suspected but uncertain retinal tears underwent vitrectomy, during which tears were confirmed in three, two had retinal vessel avulsions, and one had retinal new vessels. There was “complete” agreement between the B-scan findings and clinical findings in 78% of patients, “partial” agreement in 19%, and agreement was not tested in 3%. When the agreement was “partial”, the disagreements did not affect patient management. The sensitivity was 100% for the detection of RRD, and for the detection of new retinal tears in patients without retinal detachment.

Conclusion

B-scan U/S scan was highly sensitive in identifying the pathology in acute FOVH. Our results show an improvement from previously reported results, likely related to the standardized scan protocol and dedicated ophthalmic ultrasonographer.

Objective Quantification of Retinal Shortening: Sonographic Evidence of Intraretinal Proliferative Vitreoretinopathy

BACKGROUND AND OBJECTIVE

To evaluate retinal shortening with ultrasound (USG) in patients with retinal detachment (RD).

PATIENTS AND METHODS

This was a pilot, prospective, investigative study. Ten consecutive patients undergoing surgery for total RD with anterior or posterior proliferative vitreoretinopathy (PVR) graded more than grade C1 were included. Longitudinal USG B-scan was done for all patients to calculate retinal-to-choroidal length ratio (RCR). Quadrant-based RCRs and mean RCRs were calculated. All patients were followed for a minimum period of 3 months for unexplained recurrent retinal detachment.

RESULTS

Mean duration of RD was 14.2 months and a mean of 2.8 retinal quadrants had epiretinal PVR, subretinal PVR, or both. Mean RCR was 0.81 and was the least in superior temporal quadrant. Seven patients developed recurrent RD, five at the first weekly visit. All of these patients had an RCR of less than 0.8 in at least one quadrant, whereas none of the remaining three patients had a quadrantic RCR of less than 0.8 (P = .008). Mean RCR was less than 0.8 in four of seven patients with recurrent RD (P = .2) CONCLUSION: Retinal shortening can be measured objectively with USG based RCRs. Low RCR in any retinal quadrant is a serious concern deserving appropriate patient counseling. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:746-750.].

Early Vitrectomy for Spontaneous, Fundus-Obscuring Vitreous Hemorrhage

PURPOSE

To examine the visual outcomes of early intervention in the setting of fundus-obscuring vitreous hemorrhage (VH) presumed to be due to posterior vitreous detachment.

DESIGN

Retrospective comparative case series.

METHODS

All eyes that presented with a fundus-obscuring VH, defined as vision of 20/400 or worse and requiring a B-scan at presentation from 2003 to 2013, were evaluated. Eyes with any history of retinopathy, macular degeneration, recent trauma, presentation greater than 2 weeks after onset of symptoms, or follow-up of less than 2 months were excluded. The main outcome measure studied was final best-corrected visual acuity (BCVA) as dependent on the time to surgery.

RESULTS

Ninety-two eyes met inclusion criteria with a mean follow-up of 490 days. Initial BCVA was logMAR 2.218 (Snellen equivalent 20/3000-20/4000, range 20/400-light perception); final BCVA was 0.318 (Snellen equivalent of 20/40-20/50, range 20/20-light perception, P < .001). Fifty-six patients (60.8%) had either a retinal tear or a retinal detachment. Patients who underwent surgery within 1 week had no significant improvement over all others; however, a significant improvement was found when comparing early vs delayed surgery groups (P < .05). There was a significantly increased risk of developing a macula-off retinal detachment in patients who did not undergo surgery within 1 week of presentation.

CONCLUSIONS

Early surgical intervention results in similar visual outcomes compared to a conservative approach. However, early intervention significantly reduces the incidence of severe vision loss related to macula-involving retinal detachment. This study highlights the importance of close follow-up given the high risk of retinal detachment in fundus-obscuring vitreous hemorrhage.

Efficacy of High Frequency Ultrasound in Localization and Characterization of Orbital Lesions

BACKGROUND

The complicated anatomy of orbit and the wide spectrum of pathological conditions present a formidable challenge for early diagnosis, which is critical for management. Ultrasonography provides a detailed cross sectional anatomy of the entire globe with excellent topographic visualization and real time display of the moving organ.

OBJECTIVES OF THE STUDY

To evaluate the efficacy of high frequency Ultrasound in localization of orbital diseases and to characterize various orbital pathologies sonologically.

MATERIALS AND METHODS

Hundred eyes of 85 patients were examined with ultrasound using linear high frequency probe (5 to 17 MHz) of PHILPS IU22 ultrasound system. Sonological diagnosis was made based on location, acoustic characteristics, kinetic properties and Doppler flow dynamics. Final diagnosis was made based on clinical & laboratory findings/higher cross-sectional imaging/surgery & histopathology (as applicable). Diagnostic accuracy of ultrasonography was evaluated and compared with final diagnosis.

RESULTS

The distinction between ocular and extraocular pathologies was made in 100% of cases. The overall sensitivity, specificity, NPV and accuracy of ultrasonography were 94.2%, 98.8%, 92.2% & 94.9% respectively for diagnosis of ocular pathologies and 94.2%, 99.2%, 95.9% & 95.2% respectively for extra ocular pathologies.

CONCLUSION

Ultrasonography is a readily available, simple, cost effective, non ionizing and non invasive modality with overall high diagnostic accuracy in localising and characterising orbital pathologies. It has higher spatial and temporal resolution compared to CT/MRI. However, CT/MRI may be indicated in certain cases for the evaluation of calcifications, bony involvement, extension to adjacent structures and intracranial extension.

Predictors of visual outcome in traumatic cataract

Traumatic cataract resulting from open- or closed-globe ocular trauma is one of the most common causes of blindness. Visual outcome is unpredictable because this is not determined solely by the lens. There is a lack of a standard classification, investigations, and treatment guidelines related to the outcome, with considerable debate regarding predictive models. We review the predictors of visual outcome following surgical treatment of traumatic cataracts, which may act as a guide to clinicians.

Sports medicine ultrasound (US) beyond the musculoskeletal system: use in the abdomen, solid organs, lung, heart and eye

The use of point-of-care ultrasound (US) by non-radiologists is not new and the expansion into sports medicine practice is relatively young. US has been used extensively to evaluate the musculoskeletal system including the diagnosis of muscle, tendon and bone injuries. However, as sports medicine practitioners we are responsible for the care of the entire athlete. There are many other non-musculoskeletal applications of US in the evaluation and treatment of the athlete. This paper highlights the use of US in the athlete to diagnose pulmonary, cardiac, solid organ, intra-abdominal and eye injuries.

Controversies in traumatic cataract classification and management: a review

Traumatic cataract is one of the important causes of blindness after ocular trauma, either open or close globe. Visual outcome is unpredictable because it is not only lens that decides visual outcome. There is no standard classification, investigation, or treatment guidelines for the same. There are controversies regarding predictive models. We would like to highlight these controversies and try to reach certain guidelines that may help clinicians to manage traumatic cataracts.

Vitreous hemorrhage in children and adolescents in India

PURPOSE

To report the clinical profile, etiologies, treatment modalities, and outcomes for vitreous hemorrhage in patients <18 years of age in India.

METHODS

The medical records of patients presenting with vitreous hemorrhage between January 2000 and January 2010 were retrospectively reviewed.

RESULTS

A total of 261 eyes of 246 patients (201 males) were included. Of these patients, 231 (94%) were unilateral. Trauma was the leading cause of injury in 179 eyes (68.5%); blunt trauma was more common than penetrating trauma in both males (64.7%) and females (57.7%). Wooden sticks were the most common cause of trauma (20.7%). Spontaneous causes accounted for 82 (31.5%) eyes, including 33 eyes (40%) with Eales disease, and 16 eyes (19.7%) with sequelae of retinopathy of prematurity. Trauma was most common cause of vitreous hemorrhage in all age groups, except in children <4 years of age, in whom spontaneous hemorrhage predominated. Overall, the most common management was surgery, performed in 173 (66.2%) eyes; 63 (24.1%) eyes were observed. Male sex, age >8 years, unilateral presentation, surgical treatment (P < 0.001), and blunt trauma (P = 0.047) were associated with severe visual loss. Mean follow-up was 636.5 ± 802.0 days overall, 597.0 ± 749.0 days for eyes observed and 638.8 ± 802.6 days for eyes that underwent surgery.

CONCLUSIONS

Posttraumatic vitreous hemorrhage comprises almost two-thirds of children and adolescents presenting with vitreous hemorrhage. Blunt trauma is more common than penetrating trauma. Male sex, age >8 years, unilateral presentation, and surgical treatment were all significantly associated with severe visual loss.

Controversies in ocular trauma classification and management: review

Ocular trauma is a topic of unresolved controversies and there are continuous controversial and debatable management strategies for open-globe injuries (OGIs). International classification of ocular trauma proposed almost 15 years ago needs to be reviewed and to be more robust in predicting the outcome in the setting of OGIs. Anterior segment trauma involves controversies related to patching for corneal abrasion, corneal laceration repair, and medical management of hyphema. Timing of cataract surgery and intraocular lens implantation in the setting of trauma is still debated worldwide. There are unresolved issues regarding the management of OGIs involving the posterior segment. Timing of vitrectomy has been and will continue to be debated by proponents of early versus delayed intervention. The use of prophylactic cryotherapy and scleral buckle is still practiced differently throughout the world. The role of intravitreal antibiotics in posterior segment trauma in the absence of infection is still debated. Similarly, the use of vitrectomy versus vitreous tap in the setting of traumatic endophthalmitis is not fully resolved. In optic neuropathy, the role of intravenous methylprednisolone versus conservative management is always debated and still there are no evidence-based guidelines about the beneficial role of pulse steroid therapy. The role of optic canal decompression in the setting of acute traumatic optic neuropathy is also not conclusive. Orbital and adnexal trauma has been shown to adversely affect the outcome of OGI patients but both lids and orbital injury are not taken as preoperative variables in international ocular trauma classification. The timing of intervention in blow-out fracture is still debated. The pediatric age group, owing to the high risk of amblyopia and intraocular inflammation as well as strong vitreoretinal adhesions, has to be managed by different principles. Although the risk of sympathetic ophthalmia is very rare, it is always one of the key debated issues while managing traumatized eyes with no light perception vision. Prospective, controlled clinical studies are not possible in the OGI setting and this article reviews pertinent data regarding these management issues and controversies, and provides recommendations for treatment based on the available published data and the authors' personal experience.

Predictive factors for final outcome of severely traumatized eyes with no light perception

Background

An eye injury that causes no light perception (NLP) typically carries an unfavorable prognosis, and NLP because of trauma is a common indication for enucleation. With advances in vitreoretinal surgical techniques, however, the indication for enucleation is no longer determined by posttrauma NLP vision alone. There are limited studies in the literature to analyse the outcome of NLP eyes following open globe injury. The current study was aimed to evaluate the outcome of surgical repair of severely traumatized eyes with no light perception vision as preoperative visual acuity. Secondary objective was to possibly predict the factors affecting the final vision outcome in this eyes.

Methods

Retrospective case analysis of patients with surgical repair of open globe injury over last ten years at a tertiary referral eye care centre in Singapore.

Results

Out of one hundred and seventy two eyes with open globe injury 27 (15.7%) eyes had no light perception (NLP). After surgical repair, final visual acuity remained NLP in 18 (66.7%) eyes. Final vision improved to Light perception/ Hand movement (LP/HM) in 2(7.4%) eyes, 1/200 to 19/200(11.1%) in 3 eyes and 20/50-20/200(14.8%) in 4 eyes. The median follow up was 18.9 months (range: 4–60 months). The factors contributing to poor postoperative outcome were presence of RAPD (p = 0.014), wound extending into zone III (p = 0.023) and associated vitreoretinal trauma (p = 0.008).

Conclusions

One third of eyes had ambulatory vision or better though two third of eyes still remained NLP. Pre-operative visual acuity of NLP should not be an indication for primary enucleation or evisceration for severely traumatized eyes. Presence of afferent papillary defect, wound extending posterior to rectus insertion and associated vitreoretinal trauma can adversely affect the outcome in severely traumatized eyes with NLP. Timely intervention and state of art surgery may restore useful vision in severely traumatized eyes.

[Ocular trauma. Blunt ocular trauma]

Ocular traumas represent a major public health problem with poorly understood ramifications at both the individual and community levels. Any of the ocular structures can be damaged in the case of closed globe injury. These lesions, often multiple, may appear immediately or in a delayed fashion. Classifications have been developed recently in order to better inform the patient of the visual prognosis. However, significant efforts are still needed, on the one hand, to assess and develop new therapies, and on the other hand, to implement effective policies to prevent ocular trauma.

Early vitrectomy for vitreous hemorrhage associated with retinal tears

PURPOSE

To evaluate outcome of early surgery in vitreous hemorrhage, presumably associated with retinal tears.

DESIGN

Retrospective, noncomparative interventional case series.

METHODS

We included 40 consecutive cases in 39 patients treated with early vitrectomy for vitreous hemorrhage. Main outcome measures were incidence of tears identified preoperatively and intraoperatively, visual acuity, and complications.

RESULTS

Vitrectomy took place after a mean delay of 2.7 days after presentation. A total of 69 tears were found in 40 eyes; 53.7% of tears were identified preoperatively by funduscopy or ultrasound (U/S) and the remaining 46.3% of tears were only identified during vitrectomy. Visual acuity improved significantly from 1/60 to 0.8. The sensitivity of U/S tear detection was 55.9%. A history of predisposing factors was not related to the risk of presence of unsupported tears. In 2 cases a retinal detachment developed between the U/S evaluation and vitrectomy. Postoperative complications were cataract (30%), macular pucker (2.5%), and retinal detachment (5.0%).

CONCLUSIONS

Our findings illustrate the potential dangers of a conservative approach to vitreous hemorrhage and show that early vitrectomy has good outcome with acceptable complication rates. Prospective studies on optimal treatment of vitreous hemorrhage associated with tears are needed.

Bedside ocular ultrasound for the detection of retinal detachment in the emergency department

OBJECTIVES

Acute retinal detachments (RD) can be difficult to diagnose and may require emergent intervention. This study was designed to assess the performance of emergency department ocular ultrasound (EOUS) for the diagnosis of RD.

METHODS

This was a prospective, observational study using a convenience sample of emergency department (ED) patients. Physicians performed EOUS for the diagnosis of RD prior to evaluation by an ophthalmologist. The criterion standard was the diagnosis of a RD by the ophthalmologist who was blinded to the results of EOUS.

RESULTS

Fifteen physicians evaluated 48 patients with acute visual changes. Eighteen patients (38%) had RDs and all were correctly identified (true positives). Of the 30 patients (62%) without RD, 25 patients were correctly identified (true negatives), and five patients with vitreous hemorrhages were misidentified as having RDs (false positives). Therefore, the sensitivity and specificity of EOUS for RD were 100% (95% confidence interval [CI] = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively.

CONCLUSIONS

Emergency department ocular ultrasound is sensitive for the diagnosis of RD and may have a role in excluding RD in patients presenting to the ED.

Association between severity of vitreous haemorrhage and visual outcome in primary rhegmatogenous retinal detachment

PURPOSE

To elucidate the relationship between the severity of vitreous haemorrhage (VH) and visual outcome in primary rhegmatogenous retinal detachment (RRD) without previous vitreoretinal surgery.

METHODS

We carried out a retrospective review of patients presenting with RRD and VH between January 1993 and December 2002. Diabetic retinopathy, retinal vessel occlusion and open-globe injury patients were excluded. Study patients were separated into group 1 (eyes with mild to moderate VH) and group 2 (eyes with severe VH).

RESULTS

Our sample included 71 eyes of 71 patients (mean age 48.0 years, range 7-78 years) (median follow-up period 19 months, range 12-140 months), of which 21 had mild, 17 had moderate and 33 had severe VH. The mean visual acuity (VA) in logMAR (logarithm of minimum angle of resolution) of the 38 eyes in group 1 improved from 1.90 (Snellen equivalent [SE] 20/1589) to 0.68 (SE 20/96). In the 33 eyes in group 2, mean logMAR VA improved from 2.42 (SE 20/5261) to 1.63 (SE 20/853). Group 2 patients were significantly older (p = 0.002), had longer duration of preoperative haemorrhage (p = 0.004), lower presenting VA (p < 0.001), worse final VA (p < 0.001), and a higher incidence of severe (grade C) proliferative vitreoretinopathy (PVR) (p = 0.002). More eyes in group 2 required silicone oil tamponade, although this was not statistically significant (p = 0.133). The overall recurrence rate of retinal detachment after primary surgery was around 21% in both groups.

CONCLUSIONS

Rhegmatogenous retinal detachment with severe VH is associated with longer duration of preoperative haemorrhage, a higher incidence of severe PVR and worse visual outcome. Close follow-up and aggressive surgical interventions are suggested in these patients.

The predictive value of echography in diabetic vitreous hemorrhage

PURPOSE

To identify echographic signs that are predictive for the prognosis of diabetic vitreous hemorrhage (VH).

METHODS

Sixty eyes of 58 diabetic patients with VH were divided into two groups: group I contained 32 eyes with nonclearing diabetic VH which underwent pars plana vitrectomies. Group II contained 28 eyes which cleared spontaneously with time. The echographic signs were classified according to blood density, blood location and to the presence of vitreoretinal traction.

RESULTS

The two groups showed statistically significant differences (P < 0.01) in the frequencies of the same echographic signs. In group I, a high or moderate density of blood in the vitreous cavity (71.5% of eyes), partial posterior vitreous detachment with one or more vitreoretinal or papillary traction sites (67.8%) and blood located in the vitreous gel (62.5%) were the main echographic signs associated with nonclearing diabetic VH. In group II, a low density of blood in the vitreous cavity (75%), total posterior vitreous detachment without a vitreoretinal or papillary traction site (68.8%) and blood in the subvitreal space (46.5%) were the main echographic signs associated with a diabetic VH that will clear with time. The presence of blood in both the vitreous gel and in the subvitreal space occurred at the same frequency (near 28%).

CONCLUSIONS

Ultrasonographic examination of a diabetic VH can be predictive for the ultimate prognosis of the intraocular blood. The echographic signs found to be associated with spontaneous clearing of the hemorrhage are a low density of hemorrhage, complete vitreous detachment and blood in the subvitreal space.

Early vitrectomy for fundus-obscuring dense vitreous haemorrhage from presumptive retinal tears

BACKGROUND

Published literature on the management of patients with fundus-obscuring dense vitreous haemorrhage due to presumptive retinal tears is sparse and advocates waiting for spontaneous resolution. Surgery is indicated only when a definite retinal tear or retinal detachment is identified.

METHODS

A retrospective review of all patients who underwent early vitrectomy for vitreous haemorrhage associated with posterior vitreous detachment was carried out. A comparison of initial visual acuity versus final visual acuity after vitrectomy was performed. The number of eyes that were found to have retinal tears and retinal detachment were documented. Initial and final Snellen acuities were used for statistical analysis. Categorical data were analysed using Fisher's exact test and statistical significance was considered to be p < 0.05.

RESULTS

Sixteen eyes were identified and all these patients presented or were referred soon after the onset of vitreous haemorrhage. Associated ocular pathology (choroidal neovascular membrane, retinal branch vein occlu-sion, macroaneurysm) was suspected to be the source of the haemorrhage in 4 eyes. Vitrectomy was carried out in 12 eyes soon after presentation (mean time 6.3 days, range 1-28 days). Nineteen retinal breaks were seen in these eyes and 5 eyes had more than two breaks. None of the eyes were found to have proliferative vitreoretinopathy at the time of surgery. Two eyes needed repeat surgery for new retinal breaks. Excluding the eyes found to have an ocular pathology as the cause of vitreous haemorrhage, the mean visual acuity improved from hand movements to 6/12 (p < 0.001).

CONCLUSIONS

Early vitrectomy for spontaneous dense fundus-obscuring vitreous haemorrhage and posterior vitreous detachment is safe. Since the number of patients in this study was small, a prospective randomised controlled study comparing early versus late vitrectomy is needed to see whether early surgery also prevents proliferative vitreoretinopathy formation.