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Subretinal Blood in Retinal Separation
S U B R E T I N A L B L O O D IN R E T I N A L S E P A R A T I O N W I L L I A M V . DELANEY, JR., M . D . Syracuse, New
The ominous prognosis of blood between the neural and pigmented layers of the retina in the macular region is well known to retinal surgeons. For this reason, great care is taken to avoid bleeding from choroidal perforation, excessive diathermy, or sudden ocular decompression. Schepens and associates described a technique of careful selection and inspection of the choroidal puncture site when releasing subretinal fluid, with positioning of the patient to avoid drainage of blood to the macula if hemorrhage occurs. In cryopexy, which, unlike diathermy, does not thrombose choroidal vessels, a cutdown for fluid through thawed tissue is avoided when possible. 1
In this report two patients are described, each of whom, on initial examination prior to any surgery, had subretinal blood accompanying his detachment. Neither had any unusual medical problems and neither regained better than 20/400 vision, despite successful reattachment of the retina. T o my knowledge, spontaneous subretinal bleeding as a complication of retinal detachment has never been reported. CASE
York
was 9.0 mm Hg in the right eye and 10.9 mm Hg in the left (Schip'tz). Advanced arcus senilis and cortical spoke cataracts were present bilaterally. The retina was threequarters detached. Two small round holes were present at the 11:30-o'clock meridian; no operculae were seen. An area of lattice degeneration was present at the 8-o'clock position. Venous blood was observed beneath the nasal and macular retina (fig. 1 ) . In addition, grayish-yellow material was present at the margin of the macular blood, thought to be absorbing blood. No preretinal membrane was discernible by slitlamp. No gross intravitreal blood could be seen but cells were present. The left eye had a small area of temporal lattice degeneration. The left macula was normal. MEDICAL FINDINGS
The patient's medical history was unremarkable. His neck skin was loose, but there was insufficient evidence for a diagnosis of pseudoxanthoma elasticum. Blood pressure
1
OCULAR FINDINGS
Mr. P. O., an 81-year-old white man. noted poor vision in the right eye V/z weeks prior to admission. His vision had been normal when checked by his family physician one month previously. He denied floaters or lightning streaks. On admission, the patient's vision in the right eye was counting fingers at one foot with a +0.75 sph +0.25 cyl ax 60, and in the left 20/20 with piano +0.75 cyl ax 170. The intraocular pressure From the Department of Ophthalmology, State University of New York Upstate Medical Center, Syracuse, New York. Reprint requests to 614 State Tower Building (13202). 300
Fig. 1 (Delaney). Fundus of Patient No. 1, preoperatively.
V O L . 66, N O . 2
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301
was 140/75; a chest X-ray was negative. Laboratory values were normal for the following: fasting blood sugar (83 mg/100 cc) ; bleeding time (30 sec) ; clotting time (7 min) ; BUN (10 mg/100 cc) ; platelet count (249,000) ; differential (70 neutrophiles, 30 lymphocytes) ; sedimentation rate (27 at 1 hour) ; urinalysis and hematocrit (40 v o l . % ) . A nerve deafness was present and the patient was mildly emphysematous. The absence of pedal pulses indicated arterioscleratic peripheral vascular disease. CLINICAL COURSE
During the period of medical evaluation (12 days), the nasal subretinal blood absorbed considerably. At surgery, two meridional staphylomas were observed coinciding with the retinal breaks, and dissection was impossible. Transscleral diathermy was placed under visualization. Donor slcera was positioned over the diathermy and reinforced by an encircling band of silicone. No bleeding occurred on release of subretinal fluid. A good buckle was achieved and prompt reattachment occurred. One and one-half years postoperatively, the retina remained attached but the patient had only 10/400 vision, and a macular pucker could be seen (fig. 2 ) . No
Fig. 3 (Delaney). Fundus of Patient No. 2, preoperatively.
macular hole was present and careful slit lamp observation failed to demonstrate a preretinal membrane. In the area of the nasal collection of blood the retina was perfectly flat. Testing confirmed a central scotoma with a full peripheral field. The left eye had 20/20 vision and the macula was normal. CASE 2 OCULAR FINDINGS
Fig. 2 (Delaney). Fundus of Patient No. 1, postoperatively.
C R., a 65-year-old white man who four years previously had had vision in the right eye of 20/40 due to cataract, and in the left eye 20/100 due to a cataract and amblyopia, was seen in February 1966 complaining of a "cobweb" in the right eye; vision was decreased to 20/100. The examining physician noted a vitreous floater and also a macular hemorrhage. One month later, the findings were unchanged but two months later, a superior temporal detachment was seen. On admission, vision in the right eye was counting fingers at two feet with —1.75 sph + 3.00 cyl ax 175, and in the left, 20/80 with - 2 . 2 5 sph +2.75 cyl ax 15. The right retina was detached (fig. 3 ) , with intravitreal blood below and venous subretinal macular blood. A
302
AMERICAN JOURNAL OF OPHTHALMOLOGY
A U G U S T , 1968
DISCUSSION
Although it is generally accepted that the return of macular function after retinal detachment is inversely proportional to the duration and height of the detachment, ' factors such as subretinal blood may be more important. Gass* bas demonstrated the extension of capillaries through Bruch's membrane beneath the pigment epithelium. These areas of neovascularization may bleed subretinally in disciform macular degeneration. Similar subpigment epithelial neovascularization occurs in the peripheral retina. This has been known since 1867, but recently was documented with digestion studies by Friedman and associates. Neovascularization from the choriocapillaris has not been described in areas of lattice or paving-stone degeneration and, in fact, the choriocapillaris itself may be deficient in these areas. 2 3
5
Fig. 4 (Delany). Fundus of Patient No. 2, postoperatively.
horseshoe-shaped tear and round hole were present temporally. A star fold was already present in the macula. The macula of the left eye was normal and no peripheral retinal degeneration was present. The intraocular pressure was 18.5 mm Hg in both eyes (Schätz). MEDICAL FINDINGS
No history of a bleeding tendency or easy bruising was elicited. Blood pressure was 120/60 and no physical abnormalities could be found. Laboratory values for hematocrit, differential, platelets, urinalysis and bleeding time were normal. CLINICAL COURSE
Surgery to seal the retinal tear was successfully accomplished by a local buckle and diathermy. The blood clotted normally and no subretinal bleeding occurred. One and one-half years after surgery the retina remained attached with a macular star fold still present (fig. 4 ) . No macular hole was present, and by slitlamp, no preretinal membrane was observable. A central scotoma was present and vision was 20/400. Vision in the left eye remained at 20/100 and the macula was normal.
The observed accumulation of subretinal blood in two patients poses the question of its source. If it were not for blood caught in a fold of nasal retina (fig. 1 ) , and a normal-appearing macula in the fellow eye of each patient, senile macular neovascularization coexistent with detachment could easily dismiss these findings. The blood in the retinal fold (Patient No. 1) would seem to have settled there from a distant source. Since bleeding with detachment seems to occur coincidentally with a retinal tear, and this precedes a subsequent detachment, it is difficult to understand blood from the retina reaching a still-nonexistent subretinal space. A possible explanation, not present in either patient described here, would be a secondary hole at the site of a chorioretinal scar with bleeding produced from its resistance to a remotely caused detachment. Neovascularization in the macula or peripheral retina, or both, would seem to be the logical explanation for the subretinal bleeding in these two unusual cases. The rapid absorption of the nasal subretinal blood in Patient 1 within 12 days, noted before surgery, suggests that small amounts of subretinal bleeding may occur, be ab-
SUBRETINAL BLOOD
V O L . 66, N O . 2
303
sorbed, and go undetected. The rare observation of subretinal blood may be a factor of timing and amount. The rapid absorption of the peripheral blood (Patient No. 1) contrasted sharply with the slow hemolysis and elimination of the macular blood. The total absence of any fixed retinal folds nasally, as compared to the star fold residue in the macula, may be due to difference in the removal rate from these two areas, or to macular susceptibility to hemosiderosis. In these patients, subretinal gliosis could cause the macular pucker and thereby explain the absence of a preretinal tissue. Cibis has described the degenerative effect of subretinal blood without distinction between the macula and peripheral retina. Hemosiderosis of the pigment epithelium is followed by replacement of rods and cones by glial tissue. I have personally observed clinical evidence of this fibroplasia when a small amount of subretinal blood on a buckle enhances the operative diathermy or cryopexy scar.
inal bleeding. Blood collected in the maculas of both patients, peripherally in one, prior to surgical intervention. No evidence of prior macular disease, bleeding tendency, related systemic disease, or other ocular disease existed to explain this occurrence. Reattachment surgery was not complicated by the subretinal bleeding, but surgical cure improved vision only slightly. The presumed source of the subretinal blood is macular or peripheral neovascularization from the choriocapillaris or both. The possibility that spontaneous undetected subretinal bleeding may be a cause for poor visual recovery after retinal reattachment is suggested.
Aside from the source or elimination rate of their subretinal blood, these patients had a final visual result akin to that achieved when accidental hemorrhage at surgery allows blood to reach the macula. The spontaneous subretinal bleeding reported here in two patients may be rare, or possibly a frequently overlooked reason for failure to achieve a better functional cure of retinal detachment.
1. Schepens, C. L. and Regan, C D . J. : Controversial Aspects of the Management of Retinal Detachment Boston, Little, Brown, 1965, p. 127. 2. Jay, B. : Functional cure of retinal detachment Tr. Ophth. Soc U.K. 85:101, 1965. 3. Hughes, W . F., Jr.: Evaluation of results of retinal detachment surgery. Tr. Am. Acad Ophth. Otolaryng. 56:439, 1952. 4. Gass, J. D. : Pathogenesis of disciform detachment of the neuroepithelium. Am. J. Ophth. 63:628, 1967. 5. Friedman, E., Smith, T . and Kuwabara, T . : Senile choroidal vascular patterns and drusen. Arch. Ophth. 69:220,1963. 6. Cibis, P. A . : Vitroretinal Pathology and Surgery in Retinal Detachment. St. Louis, Mosby, 1965, p. 71.
6
SUMMARY
Two patients are presented in whom retinal detachments were accompanied by subret-
ACKNOWLEDGMENTS
I wish to thank Drs. J. Franklin McVeigh and Theodore N . Smith for the referral of these two patients, Mrs. Julia Hammack for the painstaking art work, and my colleagues Drs. Charles J. Campbell, Anthony Dark and James L. McGraw for their constructive criticism. REFERENCES
The ominous prognosis of blood between the neural and pigmented layers of the retina in the macular region is well known to retinal surgeons. For this reason, great care is taken to avoid bleeding from choroidal perforation, excessive diathermy, or sudden ocular decompression. Schepens and associates described a technique of careful selection and inspection of the choroidal puncture site when releasing subretinal fluid, with positioning of the patient to avoid drainage of blood to the macula if hemorrhage occurs. In cryopexy, which, unlike diathermy, does not thrombose choroidal vessels, a cutdown for fluid through thawed tissue is avoided when possible. 1
In this report two patients are described, each of whom, on initial examination prior to any surgery, had subretinal blood accompanying his detachment. Neither had any unusual medical problems and neither regained better than 20/400 vision, despite successful reattachment of the retina. T o my knowledge, spontaneous subretinal bleeding as a complication of retinal detachment has never been reported. CASE
York
was 9.0 mm Hg in the right eye and 10.9 mm Hg in the left (Schip'tz). Advanced arcus senilis and cortical spoke cataracts were present bilaterally. The retina was threequarters detached. Two small round holes were present at the 11:30-o'clock meridian; no operculae were seen. An area of lattice degeneration was present at the 8-o'clock position. Venous blood was observed beneath the nasal and macular retina (fig. 1 ) . In addition, grayish-yellow material was present at the margin of the macular blood, thought to be absorbing blood. No preretinal membrane was discernible by slitlamp. No gross intravitreal blood could be seen but cells were present. The left eye had a small area of temporal lattice degeneration. The left macula was normal. MEDICAL FINDINGS
The patient's medical history was unremarkable. His neck skin was loose, but there was insufficient evidence for a diagnosis of pseudoxanthoma elasticum. Blood pressure
1
OCULAR FINDINGS
Mr. P. O., an 81-year-old white man. noted poor vision in the right eye V/z weeks prior to admission. His vision had been normal when checked by his family physician one month previously. He denied floaters or lightning streaks. On admission, the patient's vision in the right eye was counting fingers at one foot with a +0.75 sph +0.25 cyl ax 60, and in the left 20/20 with piano +0.75 cyl ax 170. The intraocular pressure From the Department of Ophthalmology, State University of New York Upstate Medical Center, Syracuse, New York. Reprint requests to 614 State Tower Building (13202). 300
Fig. 1 (Delaney). Fundus of Patient No. 1, preoperatively.
V O L . 66, N O . 2
SUBRETINAL BLOOD
301
was 140/75; a chest X-ray was negative. Laboratory values were normal for the following: fasting blood sugar (83 mg/100 cc) ; bleeding time (30 sec) ; clotting time (7 min) ; BUN (10 mg/100 cc) ; platelet count (249,000) ; differential (70 neutrophiles, 30 lymphocytes) ; sedimentation rate (27 at 1 hour) ; urinalysis and hematocrit (40 v o l . % ) . A nerve deafness was present and the patient was mildly emphysematous. The absence of pedal pulses indicated arterioscleratic peripheral vascular disease. CLINICAL COURSE
During the period of medical evaluation (12 days), the nasal subretinal blood absorbed considerably. At surgery, two meridional staphylomas were observed coinciding with the retinal breaks, and dissection was impossible. Transscleral diathermy was placed under visualization. Donor slcera was positioned over the diathermy and reinforced by an encircling band of silicone. No bleeding occurred on release of subretinal fluid. A good buckle was achieved and prompt reattachment occurred. One and one-half years postoperatively, the retina remained attached but the patient had only 10/400 vision, and a macular pucker could be seen (fig. 2 ) . No
Fig. 3 (Delaney). Fundus of Patient No. 2, preoperatively.
macular hole was present and careful slit lamp observation failed to demonstrate a preretinal membrane. In the area of the nasal collection of blood the retina was perfectly flat. Testing confirmed a central scotoma with a full peripheral field. The left eye had 20/20 vision and the macula was normal. CASE 2 OCULAR FINDINGS
Fig. 2 (Delaney). Fundus of Patient No. 1, postoperatively.
C R., a 65-year-old white man who four years previously had had vision in the right eye of 20/40 due to cataract, and in the left eye 20/100 due to a cataract and amblyopia, was seen in February 1966 complaining of a "cobweb" in the right eye; vision was decreased to 20/100. The examining physician noted a vitreous floater and also a macular hemorrhage. One month later, the findings were unchanged but two months later, a superior temporal detachment was seen. On admission, vision in the right eye was counting fingers at two feet with —1.75 sph + 3.00 cyl ax 175, and in the left, 20/80 with - 2 . 2 5 sph +2.75 cyl ax 15. The right retina was detached (fig. 3 ) , with intravitreal blood below and venous subretinal macular blood. A
302
AMERICAN JOURNAL OF OPHTHALMOLOGY
A U G U S T , 1968
DISCUSSION
Although it is generally accepted that the return of macular function after retinal detachment is inversely proportional to the duration and height of the detachment, ' factors such as subretinal blood may be more important. Gass* bas demonstrated the extension of capillaries through Bruch's membrane beneath the pigment epithelium. These areas of neovascularization may bleed subretinally in disciform macular degeneration. Similar subpigment epithelial neovascularization occurs in the peripheral retina. This has been known since 1867, but recently was documented with digestion studies by Friedman and associates. Neovascularization from the choriocapillaris has not been described in areas of lattice or paving-stone degeneration and, in fact, the choriocapillaris itself may be deficient in these areas. 2 3
5
Fig. 4 (Delany). Fundus of Patient No. 2, postoperatively.
horseshoe-shaped tear and round hole were present temporally. A star fold was already present in the macula. The macula of the left eye was normal and no peripheral retinal degeneration was present. The intraocular pressure was 18.5 mm Hg in both eyes (Schätz). MEDICAL FINDINGS
No history of a bleeding tendency or easy bruising was elicited. Blood pressure was 120/60 and no physical abnormalities could be found. Laboratory values for hematocrit, differential, platelets, urinalysis and bleeding time were normal. CLINICAL COURSE
Surgery to seal the retinal tear was successfully accomplished by a local buckle and diathermy. The blood clotted normally and no subretinal bleeding occurred. One and one-half years after surgery the retina remained attached with a macular star fold still present (fig. 4 ) . No macular hole was present, and by slitlamp, no preretinal membrane was observable. A central scotoma was present and vision was 20/400. Vision in the left eye remained at 20/100 and the macula was normal.
The observed accumulation of subretinal blood in two patients poses the question of its source. If it were not for blood caught in a fold of nasal retina (fig. 1 ) , and a normal-appearing macula in the fellow eye of each patient, senile macular neovascularization coexistent with detachment could easily dismiss these findings. The blood in the retinal fold (Patient No. 1) would seem to have settled there from a distant source. Since bleeding with detachment seems to occur coincidentally with a retinal tear, and this precedes a subsequent detachment, it is difficult to understand blood from the retina reaching a still-nonexistent subretinal space. A possible explanation, not present in either patient described here, would be a secondary hole at the site of a chorioretinal scar with bleeding produced from its resistance to a remotely caused detachment. Neovascularization in the macula or peripheral retina, or both, would seem to be the logical explanation for the subretinal bleeding in these two unusual cases. The rapid absorption of the nasal subretinal blood in Patient 1 within 12 days, noted before surgery, suggests that small amounts of subretinal bleeding may occur, be ab-
SUBRETINAL BLOOD
V O L . 66, N O . 2
303
sorbed, and go undetected. The rare observation of subretinal blood may be a factor of timing and amount. The rapid absorption of the peripheral blood (Patient No. 1) contrasted sharply with the slow hemolysis and elimination of the macular blood. The total absence of any fixed retinal folds nasally, as compared to the star fold residue in the macula, may be due to difference in the removal rate from these two areas, or to macular susceptibility to hemosiderosis. In these patients, subretinal gliosis could cause the macular pucker and thereby explain the absence of a preretinal tissue. Cibis has described the degenerative effect of subretinal blood without distinction between the macula and peripheral retina. Hemosiderosis of the pigment epithelium is followed by replacement of rods and cones by glial tissue. I have personally observed clinical evidence of this fibroplasia when a small amount of subretinal blood on a buckle enhances the operative diathermy or cryopexy scar.
inal bleeding. Blood collected in the maculas of both patients, peripherally in one, prior to surgical intervention. No evidence of prior macular disease, bleeding tendency, related systemic disease, or other ocular disease existed to explain this occurrence. Reattachment surgery was not complicated by the subretinal bleeding, but surgical cure improved vision only slightly. The presumed source of the subretinal blood is macular or peripheral neovascularization from the choriocapillaris or both. The possibility that spontaneous undetected subretinal bleeding may be a cause for poor visual recovery after retinal reattachment is suggested.
Aside from the source or elimination rate of their subretinal blood, these patients had a final visual result akin to that achieved when accidental hemorrhage at surgery allows blood to reach the macula. The spontaneous subretinal bleeding reported here in two patients may be rare, or possibly a frequently overlooked reason for failure to achieve a better functional cure of retinal detachment.
1. Schepens, C. L. and Regan, C D . J. : Controversial Aspects of the Management of Retinal Detachment Boston, Little, Brown, 1965, p. 127. 2. Jay, B. : Functional cure of retinal detachment Tr. Ophth. Soc U.K. 85:101, 1965. 3. Hughes, W . F., Jr.: Evaluation of results of retinal detachment surgery. Tr. Am. Acad Ophth. Otolaryng. 56:439, 1952. 4. Gass, J. D. : Pathogenesis of disciform detachment of the neuroepithelium. Am. J. Ophth. 63:628, 1967. 5. Friedman, E., Smith, T . and Kuwabara, T . : Senile choroidal vascular patterns and drusen. Arch. Ophth. 69:220,1963. 6. Cibis, P. A . : Vitroretinal Pathology and Surgery in Retinal Detachment. St. Louis, Mosby, 1965, p. 71.
6
SUMMARY
Two patients are presented in whom retinal detachments were accompanied by subret-
ACKNOWLEDGMENTS
I wish to thank Drs. J. Franklin McVeigh and Theodore N . Smith for the referral of these two patients, Mrs. Julia Hammack for the painstaking art work, and my colleagues Drs. Charles J. Campbell, Anthony Dark and James L. McGraw for their constructive criticism. REFERENCES