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When Blood Suddenly Appears…

Vitreoretinal surgeon Dr. Kenneth Fong from Kuala Lumpur, Malaysia, shared a case of submacular hemorrhage after an attempted subretinal proliferative vitreoretinopathy (PVR) band removal during the LV Prasad Eye Institute (LVPEI) Vitreoretinal Surgery Masterclass 2022.

Subretinal PVR band removal can be a tricky business, especially when the band is located near blood vessels, thereby increasing the risk of submacular bleeding. 

Dr. Fong told of a 28-year-old patient who presented at his clinic with chronic retinal detachment for about six months. The delayed presentation occurred due to the pandemic. By the time the patient came to the clinic, his macula was already detached, his vision was counting fingers, and he had a large inferior tear. The patient had cataract surgery 10 years prior. 

Initially during the surgery, things went smoothly as Dr. Fong performed diathermy on some edges of the tear and was able to remove part of the subretinal band.  

However, as he attempted to remove another band, which is located more posteriorly, by moving it away from the macula, it did not come out through the retinotomy hole as expected, even though he spent much time trying to grab it with the forceps. Changing to a soft tip cannula, he tried to find the edge of the band again in order to aspirate it but the attempt was not successful.

Hence, Dr. Fong decided to change the position of the retinotomy. He made another retinotomy inferior to the macula, a move that was a bit risky. Using the forceps, he tried to find the plane of the band through that retinotomy. He was able to grasp the band and as he tried to pull it out through the retinotomy, blood suddenly started oozing out in the submacular area at the site of his attempted band removal. 

“This is quite bad news, as such a large bleed would clot fast and that would be a big problem,” he said. He tried to remove the blood quickly. Using the soft tip backflush, he tried to aspirate the blood through different retinotomy holes but unfortunately, the blood has solidified and would not come out easily. 

As the patient, who was under local anesthesia, was becoming restless, Dr. Fong decided to wrap up the operation. He filled the eye with air, lasered the three retinotomy holes and inserted silicone oil into the eye. He also postured the patient on his side in an attempt to push the submacular blood away temporally. 

On the first day post-op, the optical coherence tomography (OCT) scan showed that the submacular clot was directly over the fovea. The patient’s vision remained poor at counting fingers. 

So, three weeks later, Dr. Fong attempted to redo the surgery with the advice of his colleague Dr. Manoharan Shunmugam. They injected heavy liquid into the eye and used the 41-gauge subretinal needle for the surgery. They also injected balanced salt solution (BSS) into the clot in order to mobilize it. “The plan was to lay the patient onto the side and try to push the clot away from the fovea. My aim was just to get the clot away from the fovea so that the patient can have some vision,” he said. 

After injecting the BSS, some of the clotted blood came out from the retinotomy holes, and Dr. Fong was able to move some of the blood away from the fovea. They proceeded to do the fluid air exchange while at the same time positioning the patient temporally. 

Unfortunately, the attempted subretinal BSS injection to disperse the clot temporally was not sufficient to remove the clot. The patient subsequently developed severe re-detachment with clot lysis and giant retinal tear which was inoperable. 

Summing up, Dr. Fong noted that one of the things he learned from this case is to avoid doing retinotomy near major blood vessels. “And perhaps, I could have done a 180-degree inferior retinotomy at the first surgery, fold over the macular to remove the whole blood clot, put in heavy liquid and do the laser at one sitting. But again, the first surgery took more than an hour and the patient was getting restless under local anesthesia,” he said. 

During discussion, some of the points suggested by the doctors in the panel in regards to this case included: raising the pressure in the eye to stop the bleeding; putting in heavy liquid immediately to the posterior pole to keep the blood away from the fovea; and doing a peripheral retinotomy away from the macula, and putting the forceps underneath the macula to get to the band.  

One doctor from the panel also commented that he would never use diathermy during punch-through retinotomy, and that he thought that in this case, the bleed was from the forceps tip reaching the choroid instead of a major blood vessel. 

Editor’s Note: The LV Prasad Eye Institute’s  Vitreoretinal Surgery Master Class, aptly titled “Tough case or a surgical surprise, let’s learn the enterprise” was held from February 26 to 27, 2022.

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