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PHOTO ESSAY
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 297-298

Documentation of active bleed from retinal neovascularization during fluorescein angiography


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission13-Aug-2017
Date of Acceptance16-Nov-2017
Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Ruchir Tewari
699, Sector 5, Vaishali, Ghaziabad - 201 010, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_700_17

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  Abstract 


Keywords: Diabetic retinopathy, fundus fluorescein angiography, vomiting


How to cite this article:
Tewari R, Kumar V, Chandra P, Kumar A. Documentation of active bleed from retinal neovascularization during fluorescein angiography. Indian J Ophthalmol 2018;66:297-8

How to cite this URL:
Tewari R, Kumar V, Chandra P, Kumar A. Documentation of active bleed from retinal neovascularization during fluorescein angiography. Indian J Ophthalmol [serial online] 2018 [cited 2019 Dec 6];66:297-8. Available from: http://www.ijo.in/text.asp?2018/66/2/297/224097



A 54-year-old gentleman with type 2 diabetes mellitus for the past 15 years was diagnosed with bilateral proliferative diabetic retinopathy (PDR) and diabetic macular edema. Best-corrected visual acuity was noted to be 6/18 (Snellen acuity) in both eyes. He was posted for a baseline fundus fluorescein angiography (FFA). Color fundus photographs of both eyes showed multiple microaneurysms as well as hard and soft exudates at the macula. The right eye also had few regions of retinal hemorrhages and a lacy branching network of fine blood vessels in the superotemporal region suggestive of a neovascularization elsewhere (NVE). The left eye also showed a similar NVE in the superotemporal region [Figure 1]. FFA revealed leakage from the NVE in the left eye [Figure 2].
Figure 1: The color fundus image of the left eye of the patient shows a fine branching network of blood vessels suggestive of an neovascularization elsewhere (arrow) near the edge of the superotemporal vascular arcade

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Figure 2: Angiographic image of the arteriovenous phase shows leakage from the neovascularization elsewhere (arrow)

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Minutes after the dye was injected, the patient had an episode of retching and vomiting. Image acquisition was initiated after stabilizing the patient. Leakage from NVE had developed into a round configuration which had central punctate hyperfluorescence surrounded by a ring of intense hyperfluorescence [Figure 3]. Color fundus picture from the same region revealed this to be a subhyaloid bleed [Figure 4]. After about half an hour, the patient complained of sudden onset decrease in vision. Color fundus picture showed a breakthrough bleed in vitreous cavity covering the macular region [Figure 5].
Figure 3: Angiographic image of the late phase shows a round structure with mottled hyperfluorescence surrounded by intense hyperfluorescence at the location of the neovascularization elsewhere (arrow)

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Figure 4: Color fundus image from the same region shows a subhyaloid bleed (arrow). Note the increase in size from the previous image

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Figure 5: Color fundus picture taken after half an hour shows breakthrough vitreous bleed covering the macular region

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  Comment Top


FFA is an important and widely performed investigation in cases of diabetic retinopathy. Nausea and vomiting after fluorescein dye injection are not uncommon though active bleeding from neovascularization during the procedure is extremely rare and only reported twice.[1],[2] Possible causes for this event could be vitreous traction over the neovascularization due to sudden head movements [3] or a “Valsalva retinopathy”[4] like phenomenon, where sudden rise in intrathoracic pressure leads to rupture of superficial retinal vessels. The fragile vessels of neovascularization may especially be susceptible to venous pressure changes. Active bleeding in such a scenario may cause a delay in performing scatter laser photocoagulation which is the standard of care for PDR. The sudden decrease in vision may come as a surprise for the unsuspecting patient due to a very rare complication of a routine investigation.


  Conclusion Top


Active bleeding from preexisting retinal neovascularization during FFA may be a rare occurrence but the ophthalmologist should be aware of this complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kassoff A, Catalano RA, Mehu M. Vitreous hemorrhage and the Valsalva maneuver in proliferative diabetic retinopathy. Retina 1988;8:174-6.  Back to cited text no. 1
[PUBMED]    
2.
Levy J, Rosenthal G, Klemperer I, Schneck M, Lifshitz T. Active spontaneous bleeding from optic disc neovascularization during fluorescein angiography. Arch Ophthalmol 2002;120:1766.  Back to cited text no. 2
[PUBMED]    
3.
Clarke MP. Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head injury? – No. Eye (Lond) 2009;23:1761-3.  Back to cited text no. 3
[PUBMED]    
4.
Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc 1972;70:298-313.  Back to cited text no. 4
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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