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Indocyanine green (ICG) dye has been used to stain the retinal internal limiting membrane (ILM) and facilitate its removal in macular hole and epiretinal membrane (ERM) surgeries.1,2 In our previous study, removal of ICG stained ILM around idiopathic macular hole was confirmed with histology.1 Here we report two (3.6%) cases of vision threatening vitreous haemorrhage out of 55 prospective consecutive cases operated by one of the authors (AKHK) with ICG assisted ILM removal in macular hole and ERM surgeries.
A 73 year old woman with essential hypertension presented with moderate cataract and a chronic stage 4 macular hole of 500 μm in the right eye; and cataract and stage 2 macular hole of 250 μm in the left eye. Best corrected Snellen visual acuity (BCVA) was hand movements and 6/36 in the right and left eye, respectively. Standard pars plana vitrectomy (PPV), induction of posterior hyaloid detachment, and removal of ICG stained ILM around the macular hole up to the temporal arcade vessels and optic disc margin was performed in the left eye. This was followed by a two stage fluid-air exchange and finally 12% perfluoropropane as internal tamponade. The perioperative course was uneventful. On the sixth postoperative day, the patient returned after she had bumped her head gently against a table. Significant vitreous haemorrhage was found in the left eye. The intraocular pressure was normal and ultrasonography revealed no retinal detachment. Two months postoperatively, the vitreous haemorrhage persisted and an uneventful external fluid-air exchange was then performed. Three months postoperatively, her BCVA was 6/36 with a closed macular hole and significant decrease of central scotoma in the left eye.
A 65 year old man with essential hypertension presented with mild cataract and ERM with disturbing metamorphopsia in the left eye. BCVA was 6/12 and 6/18 in the right and left eye, respectively. PPV and removal of ERM with ICG stained ILM was performed. The perioperative course was uneventful. On the sixth postoperative day, the patient returned with a sudden drop in vision in the left eye. Significant vitreous haemorrhage was found. Ultrasonography revealed no retinal detachment. On the 12th postoperative day, a haemolytic glaucoma occurred with an intraocular pressure of 55 mm Hg, which was successfully controlled by a combination of systemic and topical antiglaucomatous drugs. Three weeks postoperatively, the vitreous haemorrhage resolved almost completely. The intraocular pressure was normal without drugs. Three months postoperatively, BCVA was 6/12 with no recurrence of ERM and significant improvement of metamorphopsia in the left eye.
Recently, suspected complications associated with ILM peeling, with or without ICG, have been reported.3,4 These included small asymptomatic scotomas and retinal tissue detected with ILM under electron microscopy. Although minimal superficial retinal haemorrhages are commonly encountered as ILM is peeled, they are usually self limiting and harmless. However, Brooks reported that three (2.5%) eyes developed postoperative hyphaema that required repeat vitrectomy or anterior chamber washout.5 We report two (3.6%) cases of vision threatening vitreous haemorrhage out of a prospective consecutive series of 55 cases operated by one surgeon with ICG assisted ILM removal. We suspect that ILM peeling may expose the already compromised superficial retinal vessels in hypertensive patients, and trauma may precipitate a significant vitreous haemorrhage. Limiting the areas of ILM peeling, avoidance of trauma, and adequate control of essential hypertension may decrease the chance of such complication.
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