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Vitreous hemorrhage associated with persistent hyaloid artery
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Vitreous hemorrhage associated with persistent hyaloid artery夽 ˜ b, C. Azrak a , E. Campos-Mollo a,∗ , M. Lledó-Riquelme a , F. Ardoy Ibanez J.J. Martinez Toldos a a b
Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, Spain Servicio de Radiología, Hospital General Universitario de Elche, Alicante, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Introduction: Hemorrhage from an entire persistent hyaloid artery (PHA) is an uncommon
Received 23 November 2010
anomaly.
Accepted 25 March 2011
Case report: A 52-year-old female presented with blurred vision in her amblyopic eye.
Available online 3 March 2012
Biomicroscopy revealed a blood filled PHA which was inserted in the posterior crystalloid. Ophthalmoscopy showed a mild vitreous hemorrhage. A tubular structure showing a hypo-
Keywords:
reflexivity inside the PHA was able to be analyzed using optical coherence tomography (OCT).
Persistent hyaloid artery
However, Doppler ultrasound did not detect the presence of active blood flow within it.
Hyaloid artery
Conclusions: The performance of non-invasive imaging tests such as the OCT and Doppler
Vitreous hemorrhage
ultrasound may be useful in the study of vitreous hemorrhage associated with PHA. © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
Hemorragia vítrea asociada a arteria hialoidea persistente r e s u m e n Palabras clave:
Introducción: La hemorragia vítrea secundaria a una arteria hialoidea persistente (AHP) ínte-
Arteria hialoidea persistente
gra es una anomalía infrecuente.
Arteria hialoidea
˜ Caso clínico: Una mujer de 52 anos presentó disminución de visión en su ojo ambliope. La
Hemorragia vítrea
biomicroscopia reveló una AHP rellena de sangre que se insertaba en la cristaloides posterior. En la oftalmoscopia se objetivó un hemovítreo leve. La tomografía de coherencia óptica (TCO) permitió analizar la estructura tubular de la AHP mostrando un interior hiporreflectivo. Sin embargo, el eco-doppler no detectó la presencia de flujo sanguíneo activo en su interior. Conclusiones: La realización de pruebas de imagen no invasivas que incluyen la TCO y el eco-doppler pueden ser útiles en el estudio de una hemorragia asociada a una AHP. © 2010 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L. Todos los derechos reservados.
夽 ∗
Please cite this article as: Azrak C, et al. Hemorragia vítrea asociada a arteria hialoidea persistente. Arch Soc Esp Oftalmol. 2011;86:331–4. Corresponding author. E-mail address: [email protected] (E. Campos-Mollo).
2173-5794/$ – see front matter © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
332
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
Introduction The embryonary hyaloid artery, a branch of the primitive dorsal ophthalmic artery, appears in the fifth week of gestation and reaches the lens to complete the tunica vasculosa lentis in the eleventh week. As of this time, the functions of this arteria are gradually substituted by other vessels and, under normal conditions, the embryonar vascular system is completely atrophied before birth.1,2 The remnants of the persistent hyaloid artery (PHA) are a development anomaly which is relatively common in the human eye. It is not unusual to find them in the optic disc (Bergmeister papilla) or in the posterior capsule of the lens (Mittendorf spot). The existence of a complete PHA from the optic disc up to the posterior Crystalloids is highly infrequent and even more so the presence of blood inside it.1–5 Consequently, vitreous hemorrhage originated in a PHA is an exceptional complication that has been documented on very few occasions.
Clinic case Female, 52, who referred spontaneous visual acuity (VA) reduction in her amblyope left eye (LE). She did not have a premature birth or family history related to ocular disease. In the first assessment, the best corrected VA was of one in the right eye (RE) (−1 cylinder 150◦ +3 sphere; axial length, 22.5 mm) and 0.025 in the left eye (LE) (−0.75 cylinder 25◦ −13.25 sphere; axial length, 25.3 mm). The biomicroscopy study of the LE identified a Mittendorf spot located in the inferior nasal quadrant of the lens posterior capsule and the anterior end of the PHA with hematic contents inside (Fig. 1). The opposite eye was normal. Horizontal corneal diameters were of 12 mm in both eyes (BE) and applanation tonometry was of 18 mm Hg in BE. An indirect ophthalmoscopy of the LE revealed a slight and diffuse intravitreal hemorrhage. The PHA path could be followed from the optic nerve to the posterior crystalloid (Fig. 2). The artery, fixed at both ends, moved freely following ocular movements. The posterior vitreous was partially detached from the retina. No peripheral retinal anomalies were found or signs of intraretinal traction or retina detachment. The RE fundus was normal. The hemorrhage gradually reabsorbed in the course of 1 week. The PHA could be distinguished clearly allowing for a better anatomic study. Optic coherence tomography (OCT) revealed the morphological characteristics of B. papilla (Fig. 3) from which the PHA arose in a tubular structure with a hyporeflective interior (Fig. 4). Mode B echography evidenced a hyperecogenic linear image vis-à-vis the vitreous which matched the PHA and a partial posterior vitreous detachment (Fig. 5a). An echography showed the normal blood flow of the central retinal artery and the posterior ciliary arteries, even though the presence of active blood flow in the PHA could not be determined (Fig. 5b). The hemogram and specific coagulation tests were normal. The hemovitreous reabsorbed completely and the patient recovered the 0.2 vision she had before the hemorrhage due to
Fig. 1 – Persistent hyaloid artery with blood content reaches the lens and enters the posterior capsule (Mittendorf spot). An arteriole emerges from the anterior end of the PHA (yellow arrow), an embryological remnant of the tunica vasculosa lentis. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
an ambliopy caused by anisometropy. There was no recurrence of bleeding in 6 months follow-up.
Discussion The functional consequences of a PHA include amblyopia, strabismus and nystagmus. It can be associated to the development of cataracts and less frequently vitreous hemorrhage can occur.4,5 Bleeding secondary to a PHA has been attributed to the rupture of hyaloid vessels produced by rapid ocular movements
Fig. 2 – Broad field retinography showing the entire path of the hyaloid artery from the papilla to the lens (Optomap, Optos plc, Dunferline, Scotland, United Kingdom).
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
333
Fig. 3 – Bergmeister’s papilla morphology and the origin of the hyaloid artery analyzed by 3D tomographic study (3D OCT-2000. Topcon Medical Systems, Oakland, USA).
during sleep, ocular traumatism or simply of spontaneous origin.1–5 In clinical assessments, it is important to differentiate PHA from the persistence of the hyperplasic primary vitreous. The latter is associated to microphthalmia, to the existence of a retrolental mass and to the stretching of ciliary processes.4 In our exploration we did not find any of these conditions. Supplementary tests could be useful to determine the causes and the origin of the bleeding. In our case, OCT revealed the tubular structure of the artery with a hypo-reflective lumen. Some publications refer to the identification of the hyaloid system remnants by means of OCT. However, in the literature we did not find any case in which this technique was applied specifically for PHA. The eco-doppler did not demonstrate the existence of active blood flow through the PHA. However, the biomicroscopy study allowed us to identify the presence of blood
Fig. 4 – Optic coherence tomography of the optic nerve showing an elevated tissue structure (Bergmeister’s papilla) and the tubular form of the PHA with a hypo-reflective interior (3D OCT-2000. Topcon Medical Systems, Oakland, USA).
Fig. 5 – Echography study (Toshiba Aplio xV, Toshiba Corporation, Tokyo, Japan): (a) Mode B echography showed a partial posterior vitreous detachment and the presence of the PHA. (b) Ocular globe echography was unable to determine the presence of active blood flow in the PHA.
content inside it. This suggests that the artery filled with blood passively and slowly. The angiograph could be useful to identify fluorescein leaks from the hyaloid system.3 However, our patient did not accept this test and it was impossible to determine with certainty the origin of the hemorrhage. Even so, the free mobility of the artery, the distribution of the hemorrhage and the absence of other findings after a complete retina exploration suggested that the bleeding presumably originated in the PHA. In our view, the hemorrhage could occur as a result of the traction on the posterior portion of the artery in the context of a partial posterior vitreous detachment. The vitreous hemorrhage of a PHA usually does not require treatment. However, if the hemovitreous persists, a pars plana vitrectomy might be required.2,5 Patients must be informed about the possible recurrence of the hemorrhage in order to be cautious even with slight ocular traumatism.2 In conclusion, this vascular development anomaly should be considered in a differential diagnostic of vitreous hemorrhage as an exceptional etiological possibility. Its study requires an in-depth exploration and the application of supplementary tests such as fluorescein angiography and ocular globe echography. In addition, in this case, OCT has allowed us to visualize the PHA lumen and thus could become a
334
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
very useful tool for the diagnostic study of this vascular anomaly.
Conflict of interests The authors have no conflict of interests to declare.
references
1. Delaney Jr WV. Prepapillary hemorrhage and persistent hyaloid artery. Am J Ophthalmol. 1980;90:419–21.
2. Cekic O, Totan Y, Batman C. Traumatic vitreous hemorrhage from a persistent hyaloid artery. J Pediatr Ophthalmol Strabismus. 2000;37:117–8. 3. Chen TL, Yarng SS. Vitreous hemorrhage from a persistent hyaloid artery. Retina. 1993;13:148–51. 4. Williamson W, Barac’h D, Poirier L, Coulon P, Verin P. Hémorragie intravitréenne associée à une persistance de l’artère hyaloïde. A propos d’un cas. J Fr Ophtalmol. 1994;17:361–4. 5. Goncalves A, Cruysberg JR, Draaijer RW, Sellar PW, Aandekerk AL, Deutman AF. Vitreous haemorrhage and other ocular complications of a persistent hyaloid artery. Doc Ophthalmol. 1996;92:55–9.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Vitreous hemorrhage associated with persistent hyaloid artery夽 ˜ b, C. Azrak a , E. Campos-Mollo a,∗ , M. Lledó-Riquelme a , F. Ardoy Ibanez J.J. Martinez Toldos a a b
Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, Spain Servicio de Radiología, Hospital General Universitario de Elche, Alicante, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Introduction: Hemorrhage from an entire persistent hyaloid artery (PHA) is an uncommon
Received 23 November 2010
anomaly.
Accepted 25 March 2011
Case report: A 52-year-old female presented with blurred vision in her amblyopic eye.
Available online 3 March 2012
Biomicroscopy revealed a blood filled PHA which was inserted in the posterior crystalloid. Ophthalmoscopy showed a mild vitreous hemorrhage. A tubular structure showing a hypo-
Keywords:
reflexivity inside the PHA was able to be analyzed using optical coherence tomography (OCT).
Persistent hyaloid artery
However, Doppler ultrasound did not detect the presence of active blood flow within it.
Hyaloid artery
Conclusions: The performance of non-invasive imaging tests such as the OCT and Doppler
Vitreous hemorrhage
ultrasound may be useful in the study of vitreous hemorrhage associated with PHA. © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
Hemorragia vítrea asociada a arteria hialoidea persistente r e s u m e n Palabras clave:
Introducción: La hemorragia vítrea secundaria a una arteria hialoidea persistente (AHP) ínte-
Arteria hialoidea persistente
gra es una anomalía infrecuente.
Arteria hialoidea
˜ Caso clínico: Una mujer de 52 anos presentó disminución de visión en su ojo ambliope. La
Hemorragia vítrea
biomicroscopia reveló una AHP rellena de sangre que se insertaba en la cristaloides posterior. En la oftalmoscopia se objetivó un hemovítreo leve. La tomografía de coherencia óptica (TCO) permitió analizar la estructura tubular de la AHP mostrando un interior hiporreflectivo. Sin embargo, el eco-doppler no detectó la presencia de flujo sanguíneo activo en su interior. Conclusiones: La realización de pruebas de imagen no invasivas que incluyen la TCO y el eco-doppler pueden ser útiles en el estudio de una hemorragia asociada a una AHP. © 2010 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L. Todos los derechos reservados.
夽 ∗
Please cite this article as: Azrak C, et al. Hemorragia vítrea asociada a arteria hialoidea persistente. Arch Soc Esp Oftalmol. 2011;86:331–4. Corresponding author. E-mail address: [email protected] (E. Campos-Mollo).
2173-5794/$ – see front matter © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
332
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
Introduction The embryonary hyaloid artery, a branch of the primitive dorsal ophthalmic artery, appears in the fifth week of gestation and reaches the lens to complete the tunica vasculosa lentis in the eleventh week. As of this time, the functions of this arteria are gradually substituted by other vessels and, under normal conditions, the embryonar vascular system is completely atrophied before birth.1,2 The remnants of the persistent hyaloid artery (PHA) are a development anomaly which is relatively common in the human eye. It is not unusual to find them in the optic disc (Bergmeister papilla) or in the posterior capsule of the lens (Mittendorf spot). The existence of a complete PHA from the optic disc up to the posterior Crystalloids is highly infrequent and even more so the presence of blood inside it.1–5 Consequently, vitreous hemorrhage originated in a PHA is an exceptional complication that has been documented on very few occasions.
Clinic case Female, 52, who referred spontaneous visual acuity (VA) reduction in her amblyope left eye (LE). She did not have a premature birth or family history related to ocular disease. In the first assessment, the best corrected VA was of one in the right eye (RE) (−1 cylinder 150◦ +3 sphere; axial length, 22.5 mm) and 0.025 in the left eye (LE) (−0.75 cylinder 25◦ −13.25 sphere; axial length, 25.3 mm). The biomicroscopy study of the LE identified a Mittendorf spot located in the inferior nasal quadrant of the lens posterior capsule and the anterior end of the PHA with hematic contents inside (Fig. 1). The opposite eye was normal. Horizontal corneal diameters were of 12 mm in both eyes (BE) and applanation tonometry was of 18 mm Hg in BE. An indirect ophthalmoscopy of the LE revealed a slight and diffuse intravitreal hemorrhage. The PHA path could be followed from the optic nerve to the posterior crystalloid (Fig. 2). The artery, fixed at both ends, moved freely following ocular movements. The posterior vitreous was partially detached from the retina. No peripheral retinal anomalies were found or signs of intraretinal traction or retina detachment. The RE fundus was normal. The hemorrhage gradually reabsorbed in the course of 1 week. The PHA could be distinguished clearly allowing for a better anatomic study. Optic coherence tomography (OCT) revealed the morphological characteristics of B. papilla (Fig. 3) from which the PHA arose in a tubular structure with a hyporeflective interior (Fig. 4). Mode B echography evidenced a hyperecogenic linear image vis-à-vis the vitreous which matched the PHA and a partial posterior vitreous detachment (Fig. 5a). An echography showed the normal blood flow of the central retinal artery and the posterior ciliary arteries, even though the presence of active blood flow in the PHA could not be determined (Fig. 5b). The hemogram and specific coagulation tests were normal. The hemovitreous reabsorbed completely and the patient recovered the 0.2 vision she had before the hemorrhage due to
Fig. 1 – Persistent hyaloid artery with blood content reaches the lens and enters the posterior capsule (Mittendorf spot). An arteriole emerges from the anterior end of the PHA (yellow arrow), an embryological remnant of the tunica vasculosa lentis. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
an ambliopy caused by anisometropy. There was no recurrence of bleeding in 6 months follow-up.
Discussion The functional consequences of a PHA include amblyopia, strabismus and nystagmus. It can be associated to the development of cataracts and less frequently vitreous hemorrhage can occur.4,5 Bleeding secondary to a PHA has been attributed to the rupture of hyaloid vessels produced by rapid ocular movements
Fig. 2 – Broad field retinography showing the entire path of the hyaloid artery from the papilla to the lens (Optomap, Optos plc, Dunferline, Scotland, United Kingdom).
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
333
Fig. 3 – Bergmeister’s papilla morphology and the origin of the hyaloid artery analyzed by 3D tomographic study (3D OCT-2000. Topcon Medical Systems, Oakland, USA).
during sleep, ocular traumatism or simply of spontaneous origin.1–5 In clinical assessments, it is important to differentiate PHA from the persistence of the hyperplasic primary vitreous. The latter is associated to microphthalmia, to the existence of a retrolental mass and to the stretching of ciliary processes.4 In our exploration we did not find any of these conditions. Supplementary tests could be useful to determine the causes and the origin of the bleeding. In our case, OCT revealed the tubular structure of the artery with a hypo-reflective lumen. Some publications refer to the identification of the hyaloid system remnants by means of OCT. However, in the literature we did not find any case in which this technique was applied specifically for PHA. The eco-doppler did not demonstrate the existence of active blood flow through the PHA. However, the biomicroscopy study allowed us to identify the presence of blood
Fig. 4 – Optic coherence tomography of the optic nerve showing an elevated tissue structure (Bergmeister’s papilla) and the tubular form of the PHA with a hypo-reflective interior (3D OCT-2000. Topcon Medical Systems, Oakland, USA).
Fig. 5 – Echography study (Toshiba Aplio xV, Toshiba Corporation, Tokyo, Japan): (a) Mode B echography showed a partial posterior vitreous detachment and the presence of the PHA. (b) Ocular globe echography was unable to determine the presence of active blood flow in the PHA.
content inside it. This suggests that the artery filled with blood passively and slowly. The angiograph could be useful to identify fluorescein leaks from the hyaloid system.3 However, our patient did not accept this test and it was impossible to determine with certainty the origin of the hemorrhage. Even so, the free mobility of the artery, the distribution of the hemorrhage and the absence of other findings after a complete retina exploration suggested that the bleeding presumably originated in the PHA. In our view, the hemorrhage could occur as a result of the traction on the posterior portion of the artery in the context of a partial posterior vitreous detachment. The vitreous hemorrhage of a PHA usually does not require treatment. However, if the hemovitreous persists, a pars plana vitrectomy might be required.2,5 Patients must be informed about the possible recurrence of the hemorrhage in order to be cautious even with slight ocular traumatism.2 In conclusion, this vascular development anomaly should be considered in a differential diagnostic of vitreous hemorrhage as an exceptional etiological possibility. Its study requires an in-depth exploration and the application of supplementary tests such as fluorescein angiography and ocular globe echography. In addition, in this case, OCT has allowed us to visualize the PHA lumen and thus could become a
334
a r c h s o c e s p o f t a l m o l . 2 0 1 1;8 6(1 0):331–334
very useful tool for the diagnostic study of this vascular anomaly.
Conflict of interests The authors have no conflict of interests to declare.
references
1. Delaney Jr WV. Prepapillary hemorrhage and persistent hyaloid artery. Am J Ophthalmol. 1980;90:419–21.
2. Cekic O, Totan Y, Batman C. Traumatic vitreous hemorrhage from a persistent hyaloid artery. J Pediatr Ophthalmol Strabismus. 2000;37:117–8. 3. Chen TL, Yarng SS. Vitreous hemorrhage from a persistent hyaloid artery. Retina. 1993;13:148–51. 4. Williamson W, Barac’h D, Poirier L, Coulon P, Verin P. Hémorragie intravitréenne associée à une persistance de l’artère hyaloïde. A propos d’un cas. J Fr Ophtalmol. 1994;17:361–4. 5. Goncalves A, Cruysberg JR, Draaijer RW, Sellar PW, Aandekerk AL, Deutman AF. Vitreous haemorrhage and other ocular complications of a persistent hyaloid artery. Doc Ophthalmol. 1996;92:55–9.