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Abstract
Pre-macular haemorrhage (PMH) can cause profound visual loss. Some surgeons prefer neodymium-doped yttrium aluminium garnet (Nd:YAG) hyaloidotomy as the first line of treatment due to being an easy technique and having a high success rate. However, the use of high energy close to the fovea can lead to various macular complications. We present a case of a patient who presented with PMH secondary to anaemic retinopathy. He underwent Nd:YAG laser hyaloidotomy, but developed a full-thickness macular hole. He further underwent vitrectomy and a type 1 closure was achieved. However, the visual gain was poor due to the large hole size and the collateral thermal damage. The hole may not close spontaneously, thus requiring surgical intervention. The surgical outcome of these holes depends on the size of the hole and the collateral thermal damage caused during the laser procedure.
- Macula
- Retina
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Background
Pre-macular haemorrhage (PMH) is defined as a circumscribed, boat-shaped collection of blood beneath the internal limiting membrane (ILM), or between the ILM and the posterior hyaloid, and/or both.1 It can lead to a sudden-onset unilateral or bilateral profound visual loss. It can occur secondary to valsalva retinopathy, retinal artery microaneurysm, proliferative diabetic retinopathy, retinal vein occlusion, Terson’s syndrome and haematological disorders such as aplastic anaemia and leukaemia.1
Spontaneous blood resolution along with a parallel visual recovery is seen in most of the cases. However, this may take weeks to months and can result in epiretinal membrane formation and toxic damage due to prolonged contact with haemoglobin and iron.1 The various treatment modalities include neodymium-doped yttrium aluminium garnet (Nd:YAG) membranotomy, pneumatic blood displacement and pars plana vitrectomy. Some surgeons prefer Nd:YAG membranotomy as the first treatment modality due to being an easy technique and having a high success rate. However, the use of high energy close to the fovea makes it prone to various macular complications.1–6
We report the management of a patient who developed full-thickness macular hole (FTMH) after Nd:YAG membranotomy.
Case presentation
A male in his 40s, photographer by profession, presented with bilateral sudden, painless visual loss for 10 days. He was a known case of megaloblastic anaemia. His best-corrected visual acuity (BCVA) was 20/120 in both eyes. Examination revealed round and normal reacting pupils with no relative afferent pupillary defect, and parallel visual axes. The intraocular pressures were 16 mm Hg in the right eye and 14 mm Hg in the left eye. Anterior segment examination was unremarkable in both eyes. Posterior segment examination in both eyes revealed a clear media, a normal optic disc and multiple preretinal blood collections around the optic disc in both eyes. The PMH measured around 3 disc-diameter (DD) in the right eye (figure 1A) and around 2 DD in the left eye (figure 1B).
At presentation. (A, B) Fundus images showing multiple preretinal blood collections around the optic nerve with pre-macular haemorrhage (PMH) measuring around 3 disc diameters (DD) in the right eye and around 2 DD PMH in the left eye; and (C, D) corresponding optical coherence tomography line scans through the macula showing that the blood collection in both eyes is beneath the internal limiting membrane.
Investigations
Optical coherence tomography (OCT) showed that the blood collection was present beneath the ILM. His blood haemoglobin level was 62g/L and platelet count was 55 x 109/L. Ocular treatment was deferred to his low haemoglobin and platelet counts. He underwent packed cell transfusion, intramuscular vitamin B12 injections and oral folic acid supplementation. Two weeks later, his platelet count improved to 46 x 109/L, while haemoglobin improved to 90g/L. The PMH did not show any signs of resolution in either eye.
Differential diagnosis
He was diagnosed as PMH secondary to anaemia.
Treatment
Owing to the nature of his professional demand, he preferred to undergo treatment in one eye for early visual rehabilitation. After explaining the available treatment options and their associated complications, he decided to undergo Nd:YAG laser membranotomy in his right eye. The procedure was performed with the help of pattern scanning laser machine (PASCAL, Topcon Medical Laser Systems, Santa Clara, California, USA) and area centralis lens (Volk Opticals, Mentor, Ohio, USA). The laser was operated in Q-switched mode. Two laser shots of 100 µm spot size, power 700 mW and exposure duration 0.1 s were applied at the surface of the PMH away from the fovea, following which the blood began to drain into the vitreous cavity. The left eye did not undergo any intervention.
Outcome and follow-up
One month later, his BCVA was 20/120 in the right eye and 20/20 in the left eye. Fundus examination of the right eye showed that the PMH treated with laser had resolved completely, while the other preretinal blood collections were still resolving. In addition, a FTMH was also noted. OCT showed a pre-macular cavity nasal to the hole as well as collateral outer retinal and retinal pigment epithelium (RPE) damage. The basal and minimum diameters of the hole were 1245 and 834 microns, respectively (figure 2A).
(A, B) Right eye 1 month after laser hyaloidotomy. Fundus image showing resolved pre-macular haemorrhage and full-thickness macular hole (A) and corresponding optical coherence tomography (OCT) line scans showing a full-thickness macular hole with pre-macular cavity nasal to the hole and collateral outer retinal and RPE damage; and (C, D) right eye 1 month after vitrectomy. Fundus image showing a closed macular hole (C), OCT line scans showing type 1 closure with outer retinal defect.
Due to the large size of the hole and professional demand, he underwent vitrectomy. A type 1 closure was achieved post-surgery and his BCVA improved to 20/80 (figure 2B).
Discussion
Nd:YAG laser was initially manufactured for treating anterior segment pathologies such as capsulotomy for posterior capsule opacification in pseudophakic eyes and iridotomy in angle closure glaucoma. It has also been successfully used for the treatment of PMH. However, it can rarely lead to macular complications.1–6 It has been proposed that PMH <3 DD should not be treated with laser hyaloidotomy due to the absence of adequate ‘cushion’ and can lead to inadvertent retinal damage.4 7 We had to treat the patient due to his professional demand and the absence of spontaneous resolution.
The patient developed a FMTH after Nd:YAG hyaloidotomy. Only three similar cases have previously been described where a FTMH developed after Nd:YAG hyaloidotomy.2 3 8 Three other cases have been described where retinal hole(s) developed away from the fovea after Nd:YAG hyaloidotomy (table 1).2–6 Such a macular hole can form due to several reasons. First, the direct photodisruptive effect can lead to hole formation, especially in the absence of adequate ‘cushion’ to dampen the impact, that is, in case of small haemorrhages. Second, the thickened ILM may create a tangential traction on the retina leading to hole formation.2–6 Third, the pre-macular cavity formed after the laser hyaloidotomy can produce a tangential traction leading to hole formation.9 We believe thickened ILM and pre-macular cavity contributed to hole formation in our case.
List of previous reports related to development of retinal hole after Nd:YAG laser treatment for pre-macular haemorrhage (PMH)
The management of such holes is controversial. The parafoveal holes can be observed as the visual acuity is good in these cases. Tian et al reported spontaneous closure of FTMH 12 weeks after Nd:YAG hyaloidotomy in a pregnant female.8 However, Gurung performed vitrectomy as the number of holes slowly increased to five.5 Suren et al showed that even the fovea-involving macular holes can undergo spontaneous closure with good visual outcome. However, this took nearly 6 months. They proposed that a decrease in the tangential traction and glial cell proliferation led to spontaneous hole closure.3 On the contrary, Ulbig et al treated the patient with an early vitrectomy.2 After discussion with our patient, he also underwent vitrectomy. A type 1 anatomical closure was achieved after the surgery. However, the visual gain was poor due to the large hole size as well as the iatrogenic collateral thermal damage. Wang et al and Alsulaiman et al reported that the eyes with a good preoperative visual acuity and absence of severe RPE or choroidal damage have better postoperative prognosis.10 11
To the best of our knowledge, the surgical outcomes of FTMH secondary to Nd:YAG hyaloidotomy have never been reported earlier. The outcome depends on the hole size as well as the collateral thermal damage caused during the laser therapy. However, it is imperative to understand that the small haemorrhages can be observed as they undergo spontaneous resolution.
Patient’s perspective
I have been diagnosed with megaloblastic anaemia for many years. However, I did not take the medications regularly. I have been explained that the visual loss occurred secondary to anaemia and could have been prevented. I then underwent laser to remove the blood that came in front of my retina. Subsequently, I developed a hole in my macula, which is an extremely rare complication related to the laser treatment.
Learning points
Avoid neodymium-doped yttrium aluminum aluminium garnet (Nd:YAG) laser hyaloidotomy in eyes with small pre-macular haemorrhage (<3 disc diameter).
Full-thickness macular hole is a potential complication of Nd:YAG laser hyaloidotomy.
Unlike traumatic macular hole, the one secondary to Nd:YAG laser hyaloidotomy may not close spontaneously, necessitating surgical intervention.
The surgical outcome of macular holes secondary to Nd:YAG laser hyaloidotomy depends on the collateral thermal damage caused by the laser.
Ethics statements
Patient consent for publication
Footnotes
Contributors NBK contributed to acquisition of data or analysis and interpretation of data and the drafting of the article or revising it critically for important intellectual content. PK and CM contributed to the conception and design, acquisition of data or analysis and interpretation of data and the drafting of the article or revising it critically for important intellectual content. ORN contributed to acquisition of data or analysis and interpretation of data and the drafting of the article or revising it critically for important intellectual content.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.