A 67-year-old female presented with vitreous hemorrhage and sub-internal limited membrane (ILM) hemorrhage in her right eye associated with ruptured retinal arterial macroaneurysm. During pars plana vitrectomy, intraoperative optical coherence tomography aided in the diagnosis of a small macular hole previously obscured by the sub-ILM hemorrhage. Nonexpansile gas was placed followed by postoperative prone positioning, and the hole closed successfully.
[Ophthalmic Surg Lasers Imaging Retina. 2019;50:e125–e127.]
In recent years, advancements in intraoperative optical coherence tomography (OCT) have enabled surgeons to visualize retinal structures in real-time during surgery. Several studies have found that use of intraoperative OCT alters surgical management in a significant percentage of cases and provides information to the surgeon that may aid in successful completion of surgery.1–5 This case illustrates how intraoperative OCT has potential to diagnose vitreomacular interface disease intraoperatively with the potential to impact surgical decision-making.
A 67-year-old female with history of treated hypertension presented with sudden painless vision loss in her right eye. On examination, she had counting fingers visual acuity (VA), and was noted to have a ruptured retinal arterial macroaneurysm (RAM) associated with diffuse vitreous hemorrhage and sub-internal limiting membrane (ILM) hemorrhage obscuring the central macula (Figure 1A).
(A) Fundus photograph of the right eye at presentation, demonstrating diffuse vitreous hemorrhage and sub-internal limiting membrane (ILM) hemorrhage, with retinal arterial macroaneurysm (RAM) in superotemporal macula. (B) Spectral-domain optical coherence tomography of the right eye at presentation, with hazy media secondary to vitreous hemorrhage, and dome-shaped sub-ILM hemorrhage obscuring the underlying retina. (C) Fundus photograph of the right eye showing improvement in vitreous hemorrhage but persistent sub-ILM blood as well as RAM in superotemporal macula.
After a period of 4 weeks of observation, the vitreous hemorrhage was somewhat improved, but the sub-ILM hemorrhage was persistent and vision remained counting fingers (Figure 1B); therefore, the patient underwent pars plana vitrectomy. Once the ILM was removed and sub-ILM blood had been aspirated, the foveal appearance was suspicious for a large full-thickness macular hole (MH). RESCAN 700 intraoperative OCT (Carl Zeiss Meditec, Jena, Germany) was performed and confirmed that the large central hyperpigmented area was in fact not a MH but showed the presence of a small full-thickness MH (Figure 2). Air-fluid exchange and 20% SF6 gas injection were then performed, and the patient was instructed to maintain face-down positioning for 3 days after surgery.
Intraoperative optical coherence tomography from surgeon's view demonstrating full-thickness macular hole.
The MH was closed successfully, and best-corrected VA was 20/25 3 months after surgery in the operative eye (Figure 3).
Spectral-domain optical coherence tomography from 2 weeks after surgery demonstrating closure of macular hole.
MH following ruptured RAM has previously been described.6–8 The mechanism of MH development in these cases is likely related to location of hemorrhage from RAM. If subretinal hemorrhage is present, MH formation may be related to sudden increase in pressure in the subretinal space resulting in expulsion of blood through the foveal center, which is relatively thin compared to the surrounding retina. If hemorrhage is in the sub-ILM space, as in our case, sudden elevation of the ILM away from the retinal surface at the time of hemorrhage may exert traction on the fovea resulting in MH development. Proximity to the fovea is suggested as a risk factor for MH development associated with ruptured RAM.7
In this case, intraoperative OCT enabled confirmation of the presence of MH, and helped with the decision to perform air-fluid exchange, gas injection, and have the patient perform face-down positioning. To our knowledge, this is the first case in which MH associated with ruptured RAM was identified on intraoperative OCT.
In conclusion, MH may be associated with ruptured retinal arterial macroaneurysm. Intraoperative OCT has the potential to provide vital information to surgeons in real-time to assist in decision-making during surgery, with potential to improve surgical outcomes.
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- Colucciello M, Nachbar JG. Macular hole following ruptured retinal arterial macroaneurysm. Retina. 2000;20(1):94–96. doi:10.1097/00006982-200001000-00018 [CrossRef]