January 17, 2023
Authored by: Burton Wisotsky, MD
A 53 year old woman with a history of hypertension and hypercholesterolemia noted the sudden onset of flashing lights, floaters, and vision loss in the left eye two days before presentation. Ocular history is significant for moderate myopia with lattice degeneration. On examination, VA was OD: 20/20 and OS: 20/100. IOP’s were normal. DFE of the right eye showed mild peripheral lattice. In the left eye the view was hazy – photos and a B-scan were performed and are below:
There was a moderate vitreous hemorrhage. Differential diagnosis for acute vitreous hemorrhage in a nondiabetic patient include from most to least likely, hemorrhagic PVD with retinal tear, hemorrhagic PVD without retinal tear, BRVO with NVE, macroaneurysm, trauma, and other. The B-scan showed moderate vitreous haze and hemorrhage but no retinal detachment. It is imperative to get a good look at the retina despite the haze given that the most likely diagnosis is hemorrhagic PVD with retinal tear. If a tear is present and missed, there is a high likelihood of rapid progression to retinal detachment. Despite the haze, it was apparent that there was a moderate superior horseshoe retinal tear with early subretinal fluid. Although complicated due the hazy view, intervention is required immediately to seal the tear and reduce the risk of progressing to retinal detachment. Laser is the first choice, but the power must be increased to effectively get through the blood. If this is not possible, transscleral cryopexy can be applied even with difficult media. This can be highly effective but is a second option because it is uncomfortable and can induce inflammation, which can lead to macular fibrosis (ERM) or peripheral retinal fibrosis and redetachment (PVR). We proceeded with indirect laser and the treatment was successful.
Follow up visits were significant for gradual resolution of the vitreous hemorrhage. The retina remained stable – the tear was sealed by the laser and no additional tears were noted (see photos). Vision returned to 20/20 OU.
1 month post laser:
6 months post laser: