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Editor,—In patients with no light perception (NLP) vision following extensive subretinal haemorrhage, visual recovery rarely occurs. In this patient, however, visual recovery occurred after total retinal detachment with massive subretinal haemorrhage of 3 months’ duration. The eye, which had NLP vision, developed obstructed angle closure glaucoma that necessitated a subretinal tap and an anterior chamber deepening procedure. Further removal of blood from the vitreous resulted in counting fingers (CF) vision, suggesting that surgery may restore some vision despite relatively long lasting massive subretinal haemorrhage.
A 60-year-old woman with total retinal detachment, severe ocular pain, and NLP vision was referred to us. The eye had a dark pupillary reflex, and the fundus was obscured upon ophthalmoscopy. On slit-lamp examination, a retinal detachment was observed behind the lens and blood cells were seen percolating slowly behind the detached retina. The detached retina pushed the lens-iris diaphragm forward, making the anterior chamber extremely shallow. The filtration angle was not visible. The intraocular pressure (IOP) was 43 mm Hg. The electroretinogram (ERG) and the visual evoked (VER) and electrically evoked responses (EER) were non-recordable. Medical evaluation revealed atrial fibrillation, chronic myelocytic leukaemia, and hypertension. The IOP responded only temporarily to topical medications and oral acetazolamide. The patient experienced nausea and severe ocular pain. Two days after the examination, a subretinal tap was performed. No fluid escaped after full thickness sclerotomy, indicating that there was no significant suprachoroidal fluid or a choroidal detachment. When the choroidal knuckle was pierced in the scleral wound, copious tar-coloured fluid drained from the wound, and the eye softened. The anterior chamber deepened, the IOP normalised by injection of the balanced salt solution, and the ocular pain resolved postoperatively. The patient regained dim light perception in the inferior nasal projection 10 days postoperatively. The fundus was invisible because of blood in the vitreous. The ERG remained non-recordable until 7 months postoperatively when very small ERG responses were obtained by the computer summation technique. The VER and EER were recordable 5 months postoperatively. Encouraged by the recovery of light perception and the electrophysiological responses, and because the vitreous blood did not resolve after 7 months’ observation, closed vitrectomy was performed. The retina was found reattached. Three months after the second surgery, the vision was CF at 4–5 feet. The visual field was constricted to the central 15 degrees, and the dark adaptation curve was monophasic with loss of the rod component and an elevated cone threshold. The retina stayed reattached but was blotchy with pigment clumping (Fig 1(A)). A dense, white subretinal sheet was seen nasally and inferiorly near the equator (Fig 1(B)). The retinal blood vessels and the optic nerve head appeared normal.
Angle closure glaucoma secondary to extensive choroidal detachment occurs frequently. In the present case, there was no choroidal detachment but total retinal detachment with massive subretinal haemorrhage. The subretinal tap and anterior chamber deepening procedure lowered the IOP and relieved pain. Chronic leukaemia with a bleeding tendency1-3 would have predisposed the patient to massive subretinal haemorrhage upon eye rubbing. No disciform macular scarring was observed, but presence of a peripheral subretinal neovascular membrane could not be excluded because subretinal organisation in the peripheral fundus was found postoperatively.
In animals, irreversible retinal damage from experimental subretinal haemorrhage occurs rapidly.4 Even in cases operated on within 7 days of visual loss, the clots removed are more densely fibrous and more rigidly adherent to the surrounding tissues,56 making visual recovery difficult. The possible mechanism of the loss of light perception in this patient is unclear: the IOP was not sufficiently high to stop intraocular circulation. The detached retina was visible behind the clear lens. In this respect, it is noteworthy that the initial EER was non-recordable, which indicated that the neural retinal network was impaired.
Visual recovery was reported after subretinal haemorrhage involving the macula,57 but the haemorrhage was localised and brief in duration. When the retina was totally detached with massive subretinal haemorrhage of more than 3 months’ duration, functional recovery was not reported when similar ocular conditions prevailed.1289
Although the retina had deteriorated with diffuse pigmentation, the patient regained some vision, possibly because the blood in the subretinal space was not clotted, and the subretinal space was not packed with blood cells. Therefore, some retinal receptors escaped rapid deterioration from contact with dense blood. There might have been exudative or transudative components in her retinal detachment. The patient later died from an acute leukaemic crisis; no necropsy was performed.
Ryo Suzuki, MD, was supported in part by Japanese Overseas Research Fund from the Ministry of Education, Science and Culture, Japan.
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