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Theodor Stappler, Rumana Hussain, George Pappas, Paul Hiscott, David Wong; Sub-Internal Limiting Membrane Haemorrhage: A clinico-pathological study to guide the timing of surgical intervention.. Invest. Ophthalmol. Vis. Sci. 2018;59(9):5258.
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© ARVO (1962-2015); The Authors (2016-present)
Sub-internal limiting membrane (ILM) haemorrhage is a rare occurrence in a number of diseases such as Valsalva's retinopathy, Terson's Syndrome and ruptured macroaneurysms. It often leads to a sudden and profound central vision loss. Earlier reports from our group analysing intraoperative specimen identified the pathology and location of such haemorrhages to be a "haemo-dissection" between the ILM and the macular neuroretina rather than just pre-retinal or retrohyaloidal blood. No evidence base exists yet to guide surgical indication for such pathology.
Retrospective case series of patients who underwent vitrectomy at a single centre (St Paul’s Eye Unit, Liverpool) with subsequent histological analysis of the removed internal limiting membrane. Due to varying referral patterns, two groups of patients emerged: emergency walk-ins to our centre and delayed referrals following observation by other units.
Of the 15 patients in our study, 5 had Valsalva retinopathy, 5 had underlying Terson’s syndrome and 5 had ruptured macroaneurysms. Quick surgical intervention was offered on presentation to the vitreoretinal unit to all patients whether they presented as emergency walk-ins or when referred after a period of observation.Overall, 14/15 patients (1 lost to follow up) showed visual improvement with acuity of 0.43 logMAR after 3 months. However, post-operative vision improved to 0.11 logMAR (range -0.1-0.4) in the "Walk-in group" with quick intervention (<2 weeks) while it only improved to 0.88 logMAR (0.0-HM) in the "referral group" with delayed surgery.Histological analysis using GFAP, cytokeratin 7, CD68pg and Prussian blue showed seven patients to have developed cellular proliferation on the retinal surface of the ILM and all came from patients undergoing delayed surgery >4 weeks following initial symptoms.In some patients, OCT showed long-term inner retinal layer hyper-reflectance, suggesting a permanent alteration of the whole retina.
Early surgical intervention for sub-ILM haemorrhage resulted in good final vision. Delayed surgery led to proliferative vitreoretinopathy-like pathology and persistent inner retinal changes that might limit full recovery of central vision.
This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.
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