DOI: 10.18410/jebmh/2015/584
ORIGINAL ARTICLE
ND YAG POSTERIOR HYALOIDOTOMY: A SAFE AND COSTEFFECTIVE APPROACH FOR THE MANAGEMENT OF PRE-MACULAR
HAEMORRHAGE IN VALSALVA RETINOPATHY
Shashidhar S1, Manasa Penumetcha2
HOW TO CITE THIS ARTICLE:
Shashidhar S, Manasa Penumetcha. ”ND YAG Posterior Hyaloidotomy: A Safe and Cost-Effective Approach
for the Management of Pre-Macular Haemorrhage in Valsalva Retinopathy”. Journal of Evidence based
Medicine and Healthcare; Volume 2, Issue 28, July 13, 2015; Page: 4107-4113,
DOI: 10.18410/jebmh/2015/584
ABSTRACT: AIM: To assess the safety and efficacy of Nd YAG posterior hyaloidotomy or
membranotomy as a treatment modality for pre-macular haemorrhage in valsalva retinopathy.
METHODS: This is a retrospective study of 10 eyes of 10 patients who underwent Nd YAG
posterior hyaloidotomy for pre-macular haemorrhage in valsalva retinopathy from January 2006
to November 2014. Post procedure results were assessed in terms of clearance of pre macular
haemorrhage, improvement in visual acuity, complications of procedure if any. RESULTS: 10
eyes of 10 patients with valsalva retinopathy were studied. These patients presented within 4
weeks of onset of symptoms. The pre-macular haemorrhage of more than 3DD seen in
association with valsalva retinopathy were included and drained into the vitreous cavity using Nd
YAG laser. It was observed that 9 out of 10 patients had a vision of 6/12 or better (90%) out of
which 7 had 6/6 vision (70%). No patients had any complications. CONCLUSION: Nd YAG laser
posterior hyaloidotomy or membranotomy can be considered to be a safe, inexpensive, nonsurgical treatment option for the management of pre macular haemorrhage valsalva retinopathy.
KEYWORDS: Nd YAG-Neodimium yittrium aluminium garnett, ILM-Internal Limiting membrane,
Valsalva retinopathy.
INTRODUCTION: Valsalva retinopathy was first described by Thomas Duane in 1972 as “A
particular form of retinopathy which was pre-retinal and hemorrhagic in nature, secondary to a
sudden increase in intrathoracic pressure”.1
Following a valsalva manoeuvre, that is forcible exhalation effort against a closed glottis
there is a sudden rise in intrathoracic pressure leading to a reduced venous return to the heart,
decreasing the stroke volume subsequently increasing the venous system pressure. This is
transmitted or transferred to the eye as a sudden increase in the intraocular venous pressure
causing the retinal capillaries to spontaneously rupture.2,3,4,5,6
Individuals with history of vascular diseases such as diabetes, hypertension, sickle cell
disease, anemia, idiopathic thrombocytopenic purpura and other blood dyscrasias and patients
with history of ocular venous occlusion are at increased risk for retinopathy to occur following
valsalva manoeuvre.7,8,9
Valsalva retinopathy is characterized by sudden painless loss of vision or central scotoma.
Affected individuals are generally healthy with normal eyes and positive history of valsalva stress
like strenuous exertion, emesis, violent coughing, sexual intercourse, labour, blowing musical
instruments, compression injuries. The classical sign is a small, solitary, well-circumscribed preJ of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 28/July 13, 2015
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DOI: 10.18410/jebmh/2015/584
ORIGINAL ARTICLE
retinal haemorrhage at the macula which is not associated with retinal, choroidal or any systemic
disease. In some instances, the solitary haemorrhage may be fairly large.10
The anatomical location of the pre-macular haemorrhage is described as sub internal
limiting membrane, subhyaloid, or a combination of both. However it is usually not possible to
distinguish clinically between a subhyaloid and sub-ILM haemorrhage.10,11,12
In majority of cases it resolves spontaneously without compromising visual acuity
however, even a small pre-macular haemorrhage may take several months to clear.13
Various available modalities of management are: 1. Observation for small haemorrhage. 2.
Posterior hyaloidotomy/Membranotomy using Nd YAG laser or double frequency YAG laser.
3. 3-Port pars plana vitrectomy. 4. Injection of tissue plasminogen activator with pneumatic
displacement of subhyaloid haemorrhage.
Nd YAG laser treatment is a non-invasive method which enables the drainage of extensive
pre-macular haemorrhage into the vitreous cavity and facilitates the absorption of blood leading
to a faster improvement in visual acuity by clearing the macular area.
There are several reports presenting results of Nd YAG laser treatment in patients with
pre macular haemorrhage for various aeitiologies like proliferative diabetic retinopathy, valsalva
retinopathy, macroaneurysm, retinal vein occlusion and Tersons syndrome.14,15,16
In this study 10 patients of valsalva retinopathy with pre-macular haemorrhage more than
3 disc diameters in size and duration less than 4 weeks were included.
MATERIALS AND METHODS: It is a retrospective study including 10 eyes of 10 patients from
January 2006 to November 2014.
Inclusion criteria were patients with pre-macular haemorrhage because of valsalva
retinopathy with duration of presentation being less than 4 weeks. Exclusion criteria considered
was premacular haemorrhage due to other causes, media opacities like cataract, vitreous
haemorrhage etc. that would interfere with the procedure and any other causes which would
have influence on the final visual outcome.
Pre and post treatment evaluation was included in the form of best corrected visual
acuity, detailed anterior and posterior segment evaluation.
Horizontal and vertical diameter of pre-macular haemorrhage was measured in
comparison with disc using calipers in digital imaging system.
Nd YAG laser was applied through a slit lamp using the Goldmann three mirror. Laser
settings used were single burst, Q switched mode started with 2mJ with increments of 1mJ.
Maximum energy used was upto 7mJ and cumulative energy never exceeded 15-18mJ. Site of
laser application was the most dependent part of the haemorrhage avoiding the fovea and major
blood vessels. For larger haemorrhages 2 openings were made for complete clearance of the
haemorrhage.
2 out of 10 eyes needed repeat procedure on day 3 in view of blockage of the opening.
Follow up was done on day 3, 1st week, 2nd week, 1st month, 3rd month, 6th month and
yearly thereafter for 2 years.
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OUTCOME MEASURES: All patients were studied for decrease of pre-macular haemorrhage,
improvement of visual symptoms and complications of the procedure if any.
RESULTS:
Sl.
No.
Age/Sex
1
2
3
4
5
6
7
8
9
10
25yrs/F
28yrs/M
28yrs/F
44yrs/M
30yrsF
20yrs/M
25yrs/M
25yrs/M
32yrs/M
45yrs/M
Size of
haemorrhage
3.75DD
3.25DD
6.5DD
5.25DD
4.75DD
3.5DD
3DD
3.5DD
4DD
3DD
Duration of
presentation
1 Week
3 Days
3 Days
5 Days
5 Days
2 Weeks
4 Weeks
10 Days
1 Week
2 Weeks
Table 1
Pre laser
vision
Total Energy
used
Post laser
vision
HM+
HM+
HM+
HM+
HM+
HM+
CFCF
CFCF
CFCF
CFCF
8mJ
6mJ
4mJ
5mJ
4.5mJ
8mJ
10mJ
8mJ
13mJ
14mJ
6/6.
6/6.
6/6p.
6/18.
6/6.
6/6.
6/12.
6/6p
6/6.
6/12.
The study included 10 Eyes of 10 patients in the age group of 20-45yrs average age being
30.2yrs. 7 patients were males while 3 were females. Right eye was affected in 7 out of 10
patients. Size of pre-retinal haemorrhage was between 3.00DD to 6.5DD. Duration of visual
symptoms was less than 1 week in 4 patients, 1-2 weeks in 3 patients and 2-4 weeks in 3
patients.
Following the procedure entrapped blood was released into vitreous cavity and macular
area was cleared by 1st week in most patients and in all patients by 3-4 weeks. Initial few days
following the intervention patients complained of floaters which subsided in all except 1 patient. 2
out of 10 patients needed a repeat procedure on day 3 of follow up.
Visual acuity at presentation ranged from hand movements to counting fingers at 1meter.
Visual acuity improved to 6/6 in 7 patients 6/12 in 2 patients and 6/18 in one patient who had
vitreous haze at 1month follow up.
No complications like retinal or choroidal haemorrhage, retinal detachment, macular hole
were seen in our study.
Posterior hyaloidotmy or membranotomy was 100% successful in our study and no
patient needed other additional procedures.
DISCUSSION: The pre-macular haemorrhage is located at the vitreoretinal interface, the most
common site being posterior pole at the pre-macular bursa. Sudden increase in intraocular
venous pressure following valsalva manoeuvre results in a spontaneous rupture of retinal
perifoveal capillaries resulting in a pre-macular haemorrhage.
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ORIGINAL ARTICLE
Small haemorrhages tend to resolve spontaneously without leaving any visual disturbance.
A slowly resolving large subhyaloid or sub internal limiting membrane haemorrhage would
prolong the contact of retina with haemoglobin and iron which has the possibility of damaging the
retina in the form of macular pigmentary changes and epiretinal membranes leading to reduction
in visual function which may be irreversible.17,18 The exact location of the pre-macular
haemorrhage is still unclear. It is difficult to determine the location of the pre-macular
haemorrhage biomicroscopically, but presence of glistening light reflex and fine striae on the
surface of haemorrhage seen clinically is indicative of sub ILM haemorrhage. Shukla et al19
reported the optical coherence tomography (OCT) results of two patients of valsalva retinopathy
and the OCT demonstrated two distinct membranes: highly reflective being internal limiting
membrane and overlying patchy membrane with low optical reflectivity consistant with posterior
hyaloids. The study concluded that the plane of pre-macular haemorrhage in Valsalva retinopathy
is probably under ILM. It also indicated that only when both ILM and the posterior hyaloid are
visible on OCT can the location of blood be ascertained. In our study OCT was done in a few
patients after the procedure which shows reflective membranes one in vitreous cavity and other
on the retinal surface (Fig 3a, 3b).
In 1988 Faulborn first described the application of Q-switched Nd YAG laser to subhyaloid
haemorrhage.14
Ulbig et al20 studied 21 eyes with pre-macular subhyaloid haemorrhage of various causes.
Visual acuity improved in 16 out of 21 eyes within 1 month, 7 patients required additional
vitrectomy due to vitreous haemorrhage, macular hole was reported in one of the patients with
size of subhyaloid haemorrhage being 1DD. There was failure in draining a clotted haemorrhage
of 35 days duration into the vitreous cavity. Following this the author advocated laser therapy in
patients with size of haemorrhage more than 3 DD and used energy level below 9mJ and a
shorter duration of presentation.
In our study minimum size of haemorrhage was 3 DD and the laser energy used was 2mJ
at the start, with an increment of 1mJ and never exceeded beyond 7mJ.
In our study laser procedure was 100% successful in releasing the trapped blood and the
visual acuity was 6/12 or better, which is in 90% patients.
CONCLUSION: In accordance with other studies the improvement in visual acuity was faster
and safer in our study. The procedure should be considered in young and healthy patients as
they belong to the working population for whom rapid restoration of visual acuity is important.
Therefore Nd YAG laser Posterior hyaloidotomy or membranotomy can be considered as an ideal
mode of management provided the size of haemorrhage is more than 3DD and of shorter
duration. It is a safe, inexpensive, nonsurgical treatment option.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 28/July 13, 2015
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ORIGINAL ARTICLE
COLOR PLATES:
Fig. 1: Pre-macular haemorrhage in Valsalva retinopathy in 30-yr old
female patient managed with Nd- YAG laser hyaloidotomy
Fig. 2a: Immediate
post-laser fundus
Fig. 2b: Day 3 follow-up
of same patient
Fig. 3a: Pre laser OCT
Fig. 3b: Post laser OCT
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ORIGINAL ARTICLE
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ORIGINAL ARTICLE
AUTHORS:
1. Shashidhar S.
2. Manasa Penumetcha
PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of
Ophthalmology, Minto Ophthalmic
Hospital & Regional Institute of
Ophthalmology.
2. Resident, Department of
Ophthalmology, Bangalore Medical
College & Research Institute.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Shashidhar S,
A. V. Road,
Opposite Central Police Station,
Chamarajpete, Bangalore-560002,
Karnataka, India.
E-mail: swamyshashidhar@gmail.com
Date
Date
Date
Date
of
of
of
of
Submission: 06/07/2015.
Peer Review: 07/07/2015.
Acceptance: 11/07/2015.
Publishing: 13/07/2015.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 28/July 13, 2015
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