Two different options in the treatment of premacular hemorrhage secondary to macroaneurysm: about 2 clinical cases

Coutinho, I; Ramalho, M; Pedrosa, C; Silva, F; Bernardo, M; Vendrell, C

http://hdl.handle.net/10400.10/1317

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PURPOSE Premacular hemorrhage is one of the etiologies of sudden visual loss and may occur in a variety of disorders, including retinal artery macroaneurysm. Possible therapeutic options include observation, LASER posterior hyaloidotomy, vitrectomy or T-PA intravitreal injection,however the best treatment is still a controversial subject. We describe 2 cases of premacular haemorrhage. The first case was successfully treated with LASER posterior hyaloidotomy and on the second no treatment was applied. METHODS Description and discussion of 2 clinical cases. RESULTS Case 1: A 57 year old male, with hypertension, was observed after a sudden and painless loss of vision of the right eye (OD). Visual acuity was light perception in the OD and 20/20 in the left eye (OS). Slit lamp biomicroscopy revealed a normal anterior segment in each eye. Fundoscopy of the OD revealed a premacular haemorrhage and was completely normal in the OS. Three days after the initial symptoms a posterior hyaloidotomy with photodisruptive Nd: YAG LASER was performed. After reabsorption of much of the hemovitreous, the retinography was compatible with an arterial macroaneurysm of a branch of the superotemporal arteriole, which was confirmed by angiographic image. We carried out a photocoagulation LASER on the macroaneurysm. At the fourth month of posterior hyaloidotomy the visual acuity of patient improved to 20/20 and blood in vitreous had cleared completely. Case 2: A 56 year old woman presented sudden and painless decrease of vision in the OS. Her previous medical history was unremarkable. Her best corrected visual acuity was finger counting in OS and 20/20 in OD. Left eye fundus examination showed premacular hemorrhage. No treatment was applied by patient’s decision. Premacular hemorrhage was spontaneously reabsorbed and after four months, the visual acuity of patient improved to 20/20. CONCLUSION The premacular hemorrahge may cause a severe decrease in visual acuity, affecting the day-to-day routine of the patient and may also cause macular damage. In case 1, to speed visual acuity recovery and minimize complications, we have performed a posterior hyaloidotomy of the pre-retinal haemorrhage and no complications was reported. In case 2 no treatment was applied. In both cases visual acuity recovers to 20/20 after more or less 4 months. In conclusion, there is not a ideal treatment for premacular hemorrhage. The choice must always be balanced against the benefit/risk and patient’s decision. Patients who developed premacular hemorrhage secondary to retinal artery macroaneurysms may require other therapeutic modalities like photocoagulation and these can be undertaken only once the premacular hemorrhage is drained.