www.diabeticretinopathy.org.uk

Vitrectomy & complications..vitreous

haemorrhages & related problems

David Kinshuck

Vitreous haemorrhages

A vitreous haemorrhage is the term given to bleeding into the middle chamber of the eye (the 'vitreous'). It can develop if you have proliferative retinopathy when the 'new' blood vessels burst and bleed. If you have had  plenty of laser In itself the haemorrhage is not serious and the blood usually clears.
If you have not had enough laser, then you are at high risk of developing complications as below (tractional retinal detachment), and vitrectomy surgery with 'endo' laser is usually needed. Outcomes can be predicted Retina14 .

 

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side view: new blood vessels grow on the surface of the retina into the gel and can bleed Enlarge

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view from the front enlarge ....this is what the doctor sees

 

If you have proliferative retinopathy and have had not enough laser, the 'new' blood vessels may grow forward from the retina in to the 'vitreous' gel. See vitrectomy animation  and    Animation and photo.

The vitreous gel may start to shrink, and pull on the growing new vessels, and may make them bleed. The bleeding usually causes a 'spiders web' to appear in the vision, swirling around as the eye is moved. This can cause a serious retinal detachment and loss of vision.

The blood is eventually reabsorbed by the body's cells, and itself causes no damage. A dense haemorrhage caused by a severe bleed still usually clears itself, but problems may arise as below:

 

early new vessel growth new vessels growing from retina enlarge
new vessels and detachment of the posterior vitreous face vitreous starts to shrink  enlarge
the vitreous detachment pulls the new vessels blood vessel torn .. subhyaloid haemorrhage enlarge
a vitreous gel haemorrhage haemorrhage spreads into the vitreous itself.. a vitreous haemorrhage enlarge

 

 

 

What should you do if you have a haemorrhage,
and do you need surgery?

It is common to have such haemorrhages in proliferative retinopathy:

If you have a haemorrhage (it is impossible to give specific advice; these are general principles)

A Subhyaloid haemorrhage

If there is a smaller vitreous haemorrhage it may settle behind the vitreous gel and in front of the retina. This is called a subhyaloid haemorrhage. See a large photo

These haemorrhages usually clear without any problems, but sometimes more laser is needed to treat any fresh new vessel growth. At the beginning they may interfere with your sight, but many people do not know they have one.

 

 

Hyaloidotomy

subhyaloid haemorrhage..blood just behind rear face of vitrous and in front of retina

A premacular haemorrhage can be lasered successfully Retina 2012. Sight improved over a few weeks.

yag laser hyaloidotomy improves sight

after laser Enlarge

Laser treatment can be effective...before laser

 

Another patient:

yaglaser hyaloidotomy to treat a subhyaloid haemorrhage

after laser

Laser treatment (yellow arrow) can be effective...before laser

 

Minor tractional retinal detachment & vitreous haemorrhage

an early tractional retinal detachment..scar tissue in the vitreous pulls and wrinkles the retinaenlarge Early tractional detachment: the scar tissue in the vitreous shrinks (black) , wrinkling the retina(red)

Bleeding into the vitreous may contribute to the vitreous shrinkage. See the photo tour and photos.

If the shrinkage is mild the retina may become slightly lifted or wrinkled.
Fortunately the wrinkling is usually away from the macula, and the sight should be good. Surgery is not needed.

 

 

 

Tractional retinal retachment involving macula

wrinkling of the central retina causes loss of sightenlarge The scar tissue pulls on the central area of the retina (the macula) and affects the vision

If this happens in the macular area (the macula is described in 'mechanisms') your sight may be affected: objects may appear tilted or bent. An operation (vitrectomy, as below, may be needed).
Shown here is a small 'traction detachment', a type of retinal detachment. See animation of epiretinal mebrane peel.

 

 

 

An extensive tractional retinal detachment

an extensive tractional retinal detachmentenlarge The vitreous shrinkage is very severe, pulling the retina (a large 'retinal detachment')

If the condition is very severe, your sight may be extremely bad. Vitrectomy surgery is usually helpful, but your sight may be permanently damaged. See photo. Patients with tractional retinal detachment and fibrovascular proliferation behind the equator do well with vitrectomies. Many patients with some fibrovascular proliferation anterior to the equator do well, but vitrectomy does not help those with rubeosis or rubeotic glaucoma (when this occurs with fibrovascular proliferation anterior to the equator as well). Vitrectomy animation.

 

Epiretinal membrane

enlarge The scar tissue on the retinal surface,  wrinkles the retina

If the scar tissue is near the surface of the retina, it looks like a thin membrane. It is called an 'epiretinal membrane'. It causes wrinkling of the retina, and this may be removed surgically if the sight is reduced.

Vitrectomy

2 port vitrectomy to remove a vitrous haemorrhageenlarge  Vitrectomy surgery

 

A vitrectomy carried out by an experienced surgeon is usually successful, but is not discussed here in detail. The operation usually produces a cataract in the period after the operation: this needs a cataract operation.Three small holes are placed in the side of the eye, for instruments like a special light, tiny scissors, and a vitreous 'cutter'. The blood is sucked out with one of the probes, and if thickened membranes like those illustrated above are present, they are peeled off the retina then sucked out. If the vitreous shrinks and pulls the retina substantially, a vitrectomy may be needed (as in the two paragraphs above). Similarly, if there is a dense haemorrhage, vitrectomy may be needed.

An ultrasound test may tell the surgeon whether the retina is in place or not (it can detach hidden behind the haemorrhage). This is a very simple test using a scanning probe placed over your eye.

Vitrectomy surgery is often needed if there is a vitreous haemorrhage in an eye that has had very little laser Eye 2011.    Good results..getting even better Drive UK study  Eye 2012   Retina 2012.

Follow up for glaucoma is needed in the years after surgery Retina14 .

 

Vitrectomy for active retinopathy: a case

Retinopathy that is not controlled by laser may respond to vitrectomy with excellent results. I have seen such cases presented at meetings, by Dr Ellis (2003). Florid retinopathy that progresses despite laser may be completely stabilised by vitrectomy. He presented this case, as an example:

graph of HbA1c of patient with florid retinopathy needing vitrectomy

the HbA1 fluctations of this patient lead to rapdily prgressive retinopathy, with lots of new vessels and retinal traction and haemorrhage

This patient:

This is reviewed in the literature here , here, and a search here. Laser before the vitrectomy surgery nevertheless improves outcomes and is important: it must be carrried out where possible. In future, anti-VEGF treatment is likely to be offered instead of vitrectomy, as risks are lower.

 

Cases: in Liverpool 2007 cases were presented:

Data on vitrectomy

Rubeotic Glaucoma

This is a very nasty type of glaucoma that can occur in diabetes. It occurs when 'new vessels' grow and stop fluid draining out of the eye. Treatment involves a lot of laser. See a more detailed page and an animation.