Robert W. Knighton, PhD. Giovanni ... nopathy with subhyaloid hemorrhage. A raster ... From the Department of Ophthalmology, Bascom Palmer Eye Institute,.
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Spectral Domain Optical Coherence Tomography for Proliferative Diabetic Retinopathy With Subhyaloid Hemorrhage Omar S. Punjabi, MD Harry W. Flynn, Jr., MD Robert W. Knighton, PhD Giovanni Gregori, PhD Stephen S. Couvillion, MD Geeta L. Lalwani, MD Carmen A. Puliafito, MD, MBA ABSTRACT
A prototype 6-μm axial resolution spectral domain optical coherence tomography (SD-OCT) device was used to image the retina of a patient with uncontrolled diabetes mellitus who had proliferative diabetic retinopathy with subhyaloid hemorrhage. A raster scan pattern with 128 B-scans covering a 6 6 2-mm volume of the retina was obtained. SD-OCT showed the presence of blood localized between the internal limiting membrane and the posterior hyaloid face and allowed visualization of the cross sectional retinal architecture and the vitreoretinal interface at different horizontal levels that could be registered with the color fundus photograph. SD-OCT provided useful information about the relationship of the hemorrhage to the posterior hyaloid and the retina. [Ophthalmic Surg Lasers Imaging 2008;39:494-496.] From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Accepted for publication September 20, 2007. Research funding provided in part by a grant from Carl Zeiss Meditec, Dublin, California (Drs. Punjabi, Gregori, Knighton, and Puliafito). Dr. Puliafito is a Research and Clinical Consultant for Carl Zeiss Meditec. Supported in part by Research to Prevent Blindness, Inc., New York, New York, and an unrestricted grant from Carl Zeiss Meditec. Dr. Puliafito did not participate in the editorial review of this manuscript. Address correspondence to Omar S. Punjabi, MD, 1638 NW 10th Ave., Miami, FL 33136.
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INTRODUCTION
Subhyaloid hemorrhage may occur between the inner surface of the retina and the posterior hyaloid. In proliferative diabetic retinopathy, subhyaloid hemorrhage may result from fragile neovascularization following partial or total posterior vitreous detachment. Optical coherence tomography (OCT) is a method of in vivo visualization of the retinal cross section and is useful in studying retinal architecture and the vitreoretinal interface. Spectral domain OCT (SD-OCT) allows for a much faster acquisition time than time domain OCT, provides a greater number of images per unit area, and covers larger regions of the retina, which enables quantification of retinal structure.1,2 SD-OCT has the potential to improve image quality, retinal coverage, and registration compared to other imaging systems.2 Our prototype 6-μm axial resolution SD-OCT was used to study the vitreoretinal relationships in a patient with diabetes mellitus who developed subhyaloid hemorrhage. CASE REPORT
A 31-year-old woman with poorly controlled diabetes mellitus had been diagnosed as having mild proliferative diabetic retinopathy in her right eye 2 years earlier and was treated with panretinal photocoagulation in that eye. The patient missed her follow-up appointments and returned with a history of rapid onset of central visual loss 1½ years later. On examination at that time, her visual acuity was restricted to counting fingers in the right eye. There was evidence of neovascularization of the iris, the disc, and elsewhere. In addition, there was evidence of dense subhyaloid hemorrhage covering the macula. Anterior segment photography documented neovascularization of the iris and color fundus photographs confirmed the findings on posterior segment examination. SD-OCT showed the presence of a meniscus-shaped, bright, back-scattering lesion consistent with blood that was localized in the subhyaloid space. It was well demarcated and the hyaloid face was
OPHTHALMIC SURGERY, LASERS & IMAGING · NOVEMBER/DECEMBER 2008 · VOL 39, NO 6
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Figure. Spectral domain optical coherence tomography of the right eye (scans 1 to 8, which are exactly registered to the lines shown in the color fundus photograph, bottom right) showing evidence of dense subhyaloid hemorrhage that could be accurately registered with the color fundus photograph. The color photograph of the right eye (top right) shows evidence of a dense subhyaloid hemorrhage, neovascularization of the disc, and neovascularization elsewhere.
clearly visible anterior to it. Accurate image registration was possible with the fundus photograph. SD-OCT showed not only the extent of the lesion relative to the fundus photograph, but also the change in appearance of the hemorrhage in different parts of the retina (Figure). The retina was attached in the area underlying the hemorrhage. The patient underwent pars plana vitrectomy with removal of the blood (following preoperative panretinal photocoagulation and intravitreal injection of bevacizumab). Postoperative visual acuity improved to 20/60 in the right eye at 3 months of follow-up. DISCUSSION
Diabetic retinopathy is a common cause of visual loss and its frequency depends on the duration and control of the systemic disease.3 Subhyaloid hemorrhage may occur in proliferative diabetic retinopathy after a partial posterior vitreous detachment.4 Diffuse
CASE REPORT
vitreous hemorrhage is characterized by dispersion and more rapid clearance. In the current patient, blood in the subhyaloid space blocked macular function and showed no sign of dispersion. SD-OCT was useful in assessing the location of blood relative to the internal limiting membrane and the hyaloid face. The figure shows the extent of the hemorrhage and the B-scans at different horizontal locations relative to the color fundus photograph. The meniscus-shaped blood is present between the internal limiting membrane and the posterior hyaloid face. Scans 7 and 8 in the figure demonstrate a thin bright line above the internal limiting membrane that approximates the organized blood. This could possibly be fibrous tissue that forms a capsule around the blood, but the exact nature of this bright band is unknown. The retinal architecture seems to be relatively normal posterior to the hemorrhage, which accounts for the dramatic vision improvement following surgery.
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SD-OCT may provide useful clinical information on vitreoretinal relationships. SD-OCT shows the exact position and appearance of diabetic subhyaloid hemorrhage and appears to be a valuable technique in studying the vitreomacular interface. REFERENCES
1. Srinivasan VJ, Ko TH, Wojtkowski M, et al. Noninvasive volumetric imaging and morphometry of the rodent retina with high-speed, ultrahigh-resolution optical coherence tomography. Invest Ophthalmol Vis Sci. 2006;47:5522-5528.
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2. Srinivasan VJ, Wojtkowski M, Witkin AJ, et al. Highdefinition and 3-dimensional imaging of macular pathologies with high-speed ultrahigh-resolution optical coherence tomography. Ophthalmology. 2006;113:2054. e14. 3. Wong TY, Klein R, Islam FM, et al. Diabetic retinopathy in a multi-ethnic cohort in the United States. Am J Ophthalmol. 2006;141:446-455. 4. Goff MJ, McDonald HR, Johnson RN, Ai E, Jumper JM, Fu AD. Causes and treatment of vitreous hemorrhage. Compr Ophthalmol Update. 2006;7:97-111.
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