Vitreous Hemorrhage

Surgery for VH is usually rather straightforward, but it is not without caveats.

•Massive bleeding into the gel in a young person6 may make surgery very difficult (see below).

•In general, the older the hemorrhage, the more likely that its color changes from red to yellow. However, blood trapped between layers of vitreous gel may remain red for months (see below).

•Partial PVD can trick the surgeon into proceeding too fast, only to discover the hidden presence of strong VR adhesions (see Sect. 58.2). This is especially common in CRVO, and preoperative ultrasonography may be unable to warn the surgeon about the danger.

•The VH may be accompanied by intraretinal (a submembranous cyst7 in a patient with Terson syndrome) or subretinal blood (CNV). Even when the surgeon is unaware of the etiology, he must be prepared to deal with these conditions as well – one of the reasons for my resistance to agree with the statement that “PPV for VH is an easy surgery.”

Pearl

Multiple conditions may coexist in a single eye: a patient who has diabetes can also develop an RVO, or one with high blood pressure an RD. The VR surgeon should not assume, based on history or preoperative tests, that he knows the etiology of the VH in that particular eye; he must accept that all he has is a (strong) suspicion, but evidence will be provided only during surgery.

The issues raised above make it clear that the indication and timing of PPV remain somewhat controversial (except, as mentioned above, in the context of open-globe injury or the development of a retinal break). In all other cases, intensive consultation with the patient is necessary (see Chap. 5), but no artificial deadlines should be imposed (“if the bleeding does not resolve in 3 months,” see above). The risk of surgery is very small, possibly smaller than leaving the blood to persist for months, while the potential benefits are tangible.8

6This occurs most commonly in trauma.

7The blood is under the ILM.

8Instant visual rehabilitation for the patient and the possibility of treating the cause as well as the additional consequences of the condition: ME, EMP etc. The condition of the other eye has an obvious influence on the decision-making: early visual rehabilitation becomes more important if the fellow eye has poor vision.

62.2Surgical Technique

•If the bleeding is severe enough to prevent visualization of the retina, proceed in an anteroposterior direction.

–Start with vitrectomy in the middle of the vitreous cavity and rather close to the lens.

•Gradually proceed more posteriorly, and carefully create a PVD.

–Be prepared to encounter areas of unexpected, and unexpectedly strong, VR adhesions.

–There may be blood covering the posterior retina. If it can be easily vacuumed, you can be certain that a PVD is present. Conversely, if the blood resists evacuation, it is because vitreous gel is still present (see Sect. 25.2.7.1).

–If a large amount of blood has been trapped subhyaloidally,9 drain it once you made an opening in the posterior cortical vitreous. This will make the creation of the PVD easier.

•Be careful when removing blood-soaked vitreous gel in the periphery since the retina may be invisible initially.

•Deal with the pathology that caused the hemorrhage – although often this will not be found10 or is not directly amenable to treatment.11

62.3Severe Bleeding in a Young Patient

It may be impossible for the surgeon to visually distinguish a layer of vitreous from a detached retina (see Fig. 62.1).12

•The vitreous layer may have streaks of red blood; therefore, it resembles retina. Blood is trapped between the vitreous layers, and when the probe reaches such a pool and releases the blood, the surgeon’s impression is that he caused a fresh retinal hemorrhage.

•The retina may have occluded blood vessels and does not bleed when bitten into; therefore, it resembles vitreous. Large portions of the retina may be eaten with the probe before the surgeon realizes that the probe is now in the subretinal space. This is why the suggestion to “carefully remove the vitreous layer by layer via moving the probe in the frontal plane and gradually dig deeper”13 sounds reasonable at first, but in reality it is very dangerous.

9Rather common in diabetes.

10For example, hypertension or diabetes, where the exact source (location) of the bleeding remains unknown.

11For example, CRVO.

12There is such a mess inside the vitreous cavity that even ultrasonography cannot, with any certainty, answer the most important question: Is there an RD?

13I call this maneuver horizontal sweeping.