Different responses to two consecutive Nd:YAG laser membranotomies at different locations in a 3-week-old sub-internal limiting membrane hemorrhage.

Case

A 20-year-old male soldier, with a history of a series of episodes of vomiting 22 days ago, presented with a central scotoma in his left eye. His visual acuity was hand movements OS. Fundus examination revealed a boat-shaped large premacular hemorrhage, and spectral-domain optical coherence tomography demonstrated a sub-internal limiting membrane (ILM) hemorrhage [Fig. 1]. Given the classical clinical presentation, a diagnosis of Valsalva retinopathy was made.

Figure 1

(a) Color fundus photograph of the left eye of a 20-year-old man with Valsalva retinopathy showing a massive premacular hemorrhage. Blood was partly settled resulting a fluid-blood level. (b) Infrared images with overlaid raster scans (red and yellow lines) demonstrating the positions of spectral domain optical coherence tomography cross-section (c and d). (c) Above the fluid blood level, the hyperreflective internal limiting membrane was distinct from turbid fluid with slight hyporeflection. (d) Below the fluid blood level, the internal limiting membrane was indistinct from the settled blood

Nd:YAG laser was applied in a single shot to the ILM surface, beginning at 1.7 mJ and titrated in 0.2–0.3 mJ steps, without effect. Finally, a single shot at 4.8 mJ led to successful photodisruption and some blood was noted flowing through the ILM opening. However, drainage was minimal due to clot formation. When the second shot at the same energy was applied at a different location on the dependent part of ILM covering thick hemorrhage to protect the underlying retina, blood began to drain smoothly into vitreous cavity [Fig. 2]. Four days postprocedure, the corrected vision was 20/25 with near-complete clearing of the premacular region. Three weeks later, his vision was 20/20 with further clearing of the vitreous hemorrhage [Fig. 3].

Figure 2

When one additional Nd:YAG laser shot was applied at a different location on the internal limiting membrane overlying the hemorrhage, blood gushed out into the vitreous cavity

Figure 3

(a) Fundus photograph 3 weeks after Nd:YAG membranotomy showing the resolution of the premacular hemorrhage. Long black and white arrows depicting the first and the second internal limiting membrane openings, respectively. (b) Infrared image with overlaid raster scans (blue and green lines) demonstrating the positions of spectral domain optical coherence tomography cross section (c and d). Short black and white arrows depicting the internal limiting membrane openings. (c) Detached internal limiting membrane and intact macula are noted. (d) Detached internal limiting membrane and two openings of internal limiting membrane without underlying retinal damage are noted. Black and white arrowheads depicting the first and the second internal limiting membrane openings, respectively

Discussion

Nd:YAG membranotomy is a valuable treatment option for sub-ILM hemorrhage.[123] A duration of over 3 weeks is known to be a critical factor for failure of clearance of sub-ILM hemorrhage.[45] In our patient with a 22-day-old hemorrhage, the responses to the two laser shots were totally different. It might be because the degree of blood clot formations was not homogenous within the hemorrhage. Some cumulative effect of the energy delivered by two laser shots might also have contributed to the disruption of partly coagulated blood, resulting in its successful drainage.

Conclusion

An additional laser shot successfully evacuated a sub-ILM hemorrhage. This result of different responses to laser shots could be taken into consideration while managing a sub-ILM hemorrhage of over 3 weeks’ duration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.