Year : 1992 | Volume
: 40 | Issue : 2 | Page : 35--37
Pars plana vitrectomy in vitreous haemorrhage due to Eales' disease
SS Gadkari, PA Kamdar, RP Jehangir, NA Shah, SD Adrianwala
Dept of Ophthalmology, Seth G.S. Medical College, KEM Hospital, Parel, Mumbai, India
S S Gadkari
Dept of Ophthalmology, Seth G.S. Medical College, KEM Hospital, Parel, Mumbai
Repeated vitreous haemorrhage is a common occurrence in Eales disease. 25 eyes of unresolving vitreous haemorrhage were subjected to pars plana vitrectomy. 18 eyes improved to 1/60 or better. Vitreous rebleed was the commonest problem encountered. We discuss our experience, complications and limitations.
|How to cite this article:|
Gadkari S S, Kamdar P A, Jehangir R P, Shah N A, Adrianwala S D. Pars plana vitrectomy in vitreous haemorrhage due to Eales' disease.Indian J Ophthalmol 1992;40:35-37
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Gadkari S S, Kamdar P A, Jehangir R P, Shah N A, Adrianwala S D. Pars plana vitrectomy in vitreous haemorrhage due to Eales' disease. Indian J Ophthalmol [serial online] 1992 [cited 2020 Sep 25 ];40:35-37
Available from: http://www.ijo.in/text.asp?1992/40/2/35/24408
In 1880, Henry Eales described a condition causing primary recurrent retinal haemorrhage in young men associated with epistaxis and constipation . The condition was subsequently found to be associated with repeated vitreous haemorrhage. The primary changes include inflammation of retinal vessels, especially periphlebitis, Repeated such episodes cause vascular occlusions, retinal ischaemia and neovascularization which results into unresolving vitreous haemorrhage, retinitis proliferans and tractional retinal detachment. Vitreous haemorrhage in cases with Eales' disease may occur due to necrosis of vessel wall due to severe vasculitis; peripheral vascular embarrassment resulting in ischaemia and leakage from capillaries; and due to neovascularization .
We have analyzed the results of 25 eyes of 22 patients who underwent pars plana vitrectomy for unresolving vitreous haemorrhage in Eales' disease at our centre in the past 42 months.
This disease is more common in the tropics. It affects one of every 200-250 ophthalmic patients in India, as compared to one in 4800 in Great Britain .
MATERIAL AND METHODS
25 eyes of 22 patients of Eales' disease, who underwent pars plana vitrectomy at the K.E.M. Hospital in Bombay, over a period of three and a half years, were evaluated. The study was prospective and retrospective in nature. The follow-up period varied from one week to three years. The majority of patients .(76%) were between 11 and 30 years of age [Table 1]. Males were predominantly affected, constituting 21 of the 22 cases. The duration of visual loss was greater than 3 months in 8 cases [Table 2]. Only 3 patients were found to be suffering from pulmonary tuberculosis.
24 eyes (96`0) had a preoperative visual acuity of less than finger counting at a quarter metre.
18 eyes (72%) had a previous history of similar disease in the same eye.
18 fellow eyes (72%) were also affected by Eales' disease. 18 (72%) patients presented to us with an unresolving vitreous haemorrhage. while 7 (28%) developed vitreous haemorrhage while they were being followed up. 16%% of the latter had been subjected to photocoagulation, while 20% had been treated medically with antituberculosis drugs.
Visual acuity, intraocular tension, and slit lamp examination for evidence of iris new vessels was carried out as a routine for all these patients. None of out patients had rubeosis. The visual acuity of the patients pre-operatively is given in [Table 3].
In 21 cases (84%), vitreous haemorrhage prevented visualization of fundus details. The preoperative fundus findings are given in [Table 4]. None of the patients had an elevated intraocular tension.
In the present series two types of vitrectomy systems were utilized - one with a multifunction, gas driven, single port probe with a guillotine type cutter (the Peyman vitreophage) and automated controlled vacuum suction. The other was a multiple port system with an infusion cannula, and oscillating rotatory cutter with manual suction and fibreoptic illuminator. The observation system used was either a binocular indirect ophthalmoscope (Schepens type) or an operating microscope with X-Y coupling and a fundus contact lens. The infusion fluid used was Ringer's lactate with gentamicin (4mcg/ml).
The cases were subjected to a core and posterior vitrectomy to achieve a clear visual axis. Membrane peeling was done wherever indicated.
Active fresh bleeding was controlled by increasing the intraocular pressure by raising the bottle containing infusion fluid. In one case, bipolar endodiathermy was used to coagulate the bleeder. The fellow eye was evaluated with fundus fluorescein angiography. Early treatment with photocoagulation (Xenon arc) was undertaken in patients with neovascularization. Antituberculous drugs and systemic steroids were used in the presence of active periphlebitis (characterised by retinal haemorrhage, oedema, fresh sheathing).
The vision of 18 patients (72%) improved beyond 1/60 [Table 5]. An anatomically successful result in the form of a. clear vitreous and release of traction bands was achieved in 19 cases (76%). The postoperative fundus condition is given in [Table 6]. The commonest problem encountered during surgery was vitreous rebleed. The fibrovascular stalks which were cut during vitrectomy bled in 14 (56%) cases. The complications encountered are given in [Table 8].
Eales' disease occurs in young healthy males especially in tropical countries. It is a bilateral disease. Given the natural course of this disease, its. socioeconomic implications especially in third world countries, are grave. We are of the opinion that it is best to treat the phase of active phlebitis with steroids. The incidence of vitreous haemorrhage can be reduced by performing fundus fluorescein angiography followed by photocoagulation of neovascular fronds, and follow up at regular intervals.
Once a vitreous haemorrhage occurs, a certain period of 6-8 weeks may be allowed to elapse, for spontaneous clearance. Vitrectomy serves many purposes - it ensures a clear optical axis; permits visualization of the retina for photocoagulation: relieves forces of vitreous traction; and in some cases, it even promotes the regression of new vessels. We prefer to operate in cases where active phlebitis has subsided. A multiple port system with an operating microscope is preferred. However, almost equally good results may be obtained with a single port and multipurpose probe, in certain cases. These include cases which do not require surgical manipulation very close to the retina or on the surface. A pre-operative B scan gives a fair idea about the presence of traction retinal detachment or vitreous bands. In our series the vision of 18 patients (72%) improved to better than finger counting 1 metre and 36% were better than 6/G0. Namperumalsamy'  reported 77°-% improvement in a series of 126 cases . Ronald G. Michaels reported 70-90% success in Eales' disease. In eyes with a vitreous haemorrhage alone. 8 out of 10 cases improved in vision. Four out of six improved, if vitreous haemorrhage is associated with tractional retinal detachment. Triester and Machemer reported improvement in 6 out of 7 cases and Kloti in 16 out of 18 eyes.
The most commonly encountered problem, on the table was rebleeding from neovascular fronds.
Various modalities were tried to control this, such as raising the bottle, maintaining pressure on the manual suction syringe, and endodiathermy or xenon arc photocoagulation.
Pre-operative application of cryopexy to the peripheral retina may decrease the incidence of preoperative rebleed. Photocoagulation may be performed postoperatively to prevent recurrent haemorrhage. This is however, associated with the danger of scarring and tractional retinal detachment, in the long run.
If vitreous haemorrhage recurs in a vitrectomised eye, the reabsorption is faster, failing which. a vitreous lavage may be undertaken.
|1||Eales H: Primary retinal haemorrhages in young men in Ophthalmol Rev. 1:41, 1882.|
|2||Kalsi R. Patnaik B. The Developing features of phlebitis retinae (A vertical study) Indian Journal of Ophthalmology Vol. 27, No. 3. October 1979. Pg 87|
|3||Chandra NN 1962 Acta. XIX Concilium Ophthalmologicum. 2:880.|
|4||Namperumalsamy P. Eales disease - Aetiology and management in proceedings of the 44th Annual Conference of All India Ophthalmological Society: 1986: Pg: 281-285|
|5||Machemar R. et al: Vitrectomy Second edition, 1979: Grune & Stratton, New York. 1979: Pg: 82|