Nd-YAG laser membranotomy in posttraumatic subinternal limiting membrane hemorrhage.

Short Description

A 19-year-old female presented with the complaint of obstruction in the central vision in her right eye for 1 week following blunt trauma with kitchen utensil. On examination, the best-corrected visual acuity was 20/80 in her right and 20/20 in her left eye. The right eye showed dome-shaped premacular hemorrhage of >4 disc diameter (DD) size with well-demarcated yellow line at the borders [Figure 1a]. The peripheral retina in the right eye did not have any treatable retinal lesion. Spectral domain optical coherence tomography (SDOCT; Spectralis HRA + OCT, Heidelberg Engineering, Heidelberg, Germany) of the right eye showed detached internal limiting membrane (ILM) with underlying hemorrhage, i.e., sub-ILM hemorrhage [Figures 1b and 2a].

Figure 1

(a) Subinternal limiting membrane hemorrhage at macula with the characteristic yellow line (white arrow head). (b) Spectral domain optical coherence tomography scan reveals detached posterior hyaloid (yellow arrow), detached internal limiting membrane (white arrow), and hyperreflectivity at the level of ONL corresponding to the yellow line (arrowhead)

Figure 2

(a) Initial spectral domain optical coherence tomography shows detached internal limiting membrane (white arrow) with underlying blood (white star). (b) Posttreatment spectral domain optical coherence tomography shows break (arrowhead) in internal limiting membrane (white arrow). (c) Unattached internal limiting membrane (white arrow) at final follow-up with resolved blood (white star)

Nd-YAG laser (energy 4 mJ) was used to create an opening in the ILM at the most dependent part of the hemorrhage leading to release of blood in to vitreous. The patient was reviewed after 2 weeks, and examination revealed complete drainage of blood [Figure 3a and b]. SDOCT shows break in ILM through which blood had drained [Figure 2b]. The right eye vision improved to 20/20 by the end of 1 month. At 3 months, the vision in the right was maintained, but the ILM remained unattached along with the breakthrough which the hemorrhage had drained [Figure 2c].

Figure 3

(a) Cleared subinternal limiting membrane hemorrhage post-YAG membranotomy. (b) Spectral domain optical coherence tomography scan shows persistent yellow line and corresponding hyperreflective lesion (white arrowhead). Note the detached posterior hyaloid (yellow arrow) and persistently detached internal limiting membrane (white arrow)

Sub-ILM hemorrhage is collection of blood between ILM and retinal nerve fiber layer. It usually presents in the macular region as dome-like elevation and leads to significant visual morbidity.[1] While Valsalva maneuver and blunt trauma are common causes of sub-ILM hemorrhage in otherwise healthy individuals, it can be seen in various retinal diseases as well. Retinal artery macroaneurysm and proliferative diabetic retinopathy are conditions noted to have sub-ILM hemorrhage.[2]

Sub-ILM hemorrhage may resolve spontaneously without treatment over a period of weeks to months.[3] Vitrectomy with peeling of ILM to release the blood in the vitreous which is then removed with vitrectomy cutter is another method to treat nonresolving sub-ILM hemorrhage.[1] The fact that vitrectomy is an invasive procedure fuels the search for lesser invasive methods to treat sub-ILM hemorrhage and Nd:YAG laser fits in this place.

In the current case, we used Nd: YAG laser membranotomy for sub-ILM hemorrhage of >4DD and less than a month old. Similar to Suzuki et al.[4] who have reported SDOCT features of sub-ILM hemorrhage; our case had a well-demarcated yellow line with the corresponding hyperreflectivity at the level of the outer retina. The patient had complete functional recovery and no untoward event post-Nd:YAG membranotomy except for persistently unattached ILM. Persistently, detached ILM leading to wrinkling and epiretinal membrane formation have been reported in the past.[56] In our case, the persistently unattached ILM did not pose any threat to vision nor lead to the formation of the epiretinal membrane at the end of 3 months' follow-up. We recommend Nd:YAG laser membranotomy as relatively noninvasive alternative to vitrectomy for traumatic sub-ILM hemorrhage. Although regular follow-up would be required to assess the behavior of persistently detached ILM.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their 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

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Conflicts of interest

There are no conflicts of interest.