Skip to main content

Female with subILM hemorrhage

A 38 years old lady known for secondary hypertension due to adrenal gland dysfunction (as described by the patient) complains of sudden reduction of vision for the last two weeks in her left eye.


BCVA 20/80 in the left eye while 20/20 in the right eye has unremarkable anterior and posterior segment examinations.


Fundus image


The left eye anterior segment examination is unremarkable. The fundus exam showed radish elevated lesion (sub-ILM hemorrhage) in the fovea with mild vascular tortuosity, arteriolar constriction, and arteriovenous crossing.


Fundus image shows subILM hemorrhage
Fundus image shows subILM hemorrhage



Optical coherence tomography


OCT cross-section scan shows a hyperreflective mass in the sub ILM space, with shadow artifact hindering external retinal layers. Other retinal tissue findings on OCT are normal.

OCT cross-section shows subILM hemorrhage in the form of hyperreflective mass at the inner retinal layers
OCT cross-section shows subILM hemorrhage in the form of hyperreflective mass at the inner retinal layers 


Fluorescein fundus angiography


Fluorescein angiogram shows hypofluorescence in the sub-ILM hemorrhage area masking the underling macular tissues in all phases, and there are no signs of perifoveal vascular abnormalities.


Early phase of FFA shows blocked fluorescence due to subILM hemorrhage

Early phase of FFA shows blocked fluorescence due to subILM hemorrhage   

Mid phase of FFA shows blocked fluorescence due to subILM hemorrhage
Mid phase of FFA shows blocked fluorescence due to subILM hemorrhage   

Late phase of FFA shows blocked fluorescence due to subILM hemorrhage
Late phase of FFA shows blocked fluorescence due to subILM hemorrhage   


Routine blood analysis is unremarkable and has been sent for internal specialist consultation for control of hypertension.


Discussion


The sub ILM hemorrhage is due to rupture of perifoveal capillaries caused by rapid changes in intraocular venous pressure; thus can be caused in Valsalva maneuver, sneezing, or coughing. However, other reasons for sub-ILM hemorrhage could be blood dyscrasia.

Usually, it takes weeks to several months to be completely resolved. 

In cases where sub ILM hemorrhage is big enough to obscure the entire fovea, Yag laser, Intravitreal injection of tPA proceeded by pneumopexy, or simply intravitreal gas injection are indicated.

In this case, blood screening is unremarkable. The patient already suffers from blood hypertension, which is followed up by the internist. The hemorrhage's radish color is due to some blood cells becoming dehemoglobinized, and as it is not obscuring the entire macula, a decision was made to wait for spontaneous resolution.

In case it persists, then Intravitreal gas injection to displace the hemorrhage as YAG is not safe to be done due to its flat and close proximity to FAZ profile to avoid potential complications such as a macular hole.


Check clinical guidelines for hypertensive retinopathy

Labels:

Comments

  1. Laura BushSeptember 16, 2021 at 10:51 PM

    The information which you have provided is very good and essential for everyone. Keep sharing this kind of information. Thank you. houston retina specialists

    ReplyDelete

Post a Comment

Popular posts from this blog

Cellophane maculopathy

Caused by an epiretinal membrane, clinically, it appears as a sheen abnormal foveal reflex which features epiretinal membrane, due to inflammatory mediators and proliferation of glial cells secondary to a partial separation of posterior cortical vitreous. Fundus image shows cellophane maculopathy OCT features a hyperreflective band covering the inner retinal layers, causing minimal disturbance of inner retinal tissues. OCT cross-section shows epiretinal membrane  Cellophane maculopathy itself in individuals with good visual acuity may not need any interventions, but it is warranted to do a detailed peripheral retinal exam to rule out retinal tear or hole However, an epiretinal membrane may proliferate further and cause additional tangential traction. Thus, it may induce macular pucker or lamellar/pseudo hole and increase disturbance of inner retinal tissues, macular thickness, and reduction of vision. These patients may require pars plana vitrectomy to remove the epiretinal membrane an
10 comments
Read more

RPE tear, and it's OCT features in a nutshell

RPE tear can occur in vascularized PEDs due to a complication of intravitreal AntiVEGF treatment, which causes a rapid contraction of CNVm, inducing traction on the RPE surface and shrinking of RPE surface. On OCT, the RPE rip will indent the retina with increased hyperreflectivity in contracted RPE with underlying shadowing hinders choroidal view in contrast to the area where RPE where it ripped of which only Bruch's membrane is visible and increasing the visibility of the underlying choroid. RPE tear Thus two opposite forces, the regression of CNVm and remaining attached RPE, other causes such as laser or spontaneous can occur. However, the AntiVEGF treatment continued despite the RPE tear. Please check  Clinical guidelines for ARMD  and  course of clinical changes in RPE
2 comments
Read more

Diabetic macular edema with ischemic changes associated with very severe NPDR

A 51 years old male known to be diabetic for ten years with excellent glycemic control profile along with normal blood pressure presented with BCVA 20/100 in his left eye; he had a better vision of 20/30 in the same eye one year ago when he used to be on intravitreal injections of aflibercept, but he decided to discontinue intravitreal injection as been advised by another physician. Fundus image His fundus image shows cystic formation at the fovea with a sign of intraretinal dot and blots hemorrhages in the mid periphery with cotton wool spots and IRMA (Intra Retinal Microvascular Abnormalities). Fundus image showing macular edema with intraretinal hemorrhage and cotton wool spots Optical coherence tomography His OCT scan shows thickened central macular tissues with disorganization of inner retinal layers and non-empty cystic formation as it is classic findings of diabetic macular edema with some empty cystic formation; however, the ellipsoid zone looks intact. OCT cross-section for ce
2 comments
Read more