|Year : 1982 | Volume
| Issue : 6 | Page : 621-626
Ultrasonography in eyes with vitreous haemorrhage
Mary N Abraham
Sankara Nethralaya, Madras, India
Mary N Abraham
Sankara Netharalaya, 18, College Road, Madras-6.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Abraham MN. Ultrasonography in eyes with vitreous haemorrhage. Indian J Ophthalmol 1982;30:621-6
This study webeedes an analysis of the ultrasonographic patterns of 76 eyes with vitreous haemorrhage seen at Sankara Nethralaya between February, and July 1980. Its usefulness in helping the vitreoretinal surgeon to decide on the operability, plan the procedure accordingly and proceed in a more knowledgeable manner anticipating certain difficulties is evaluated. The pitfalls encountered and the most common sources of error in ultrasonographic diagnosis are also analysed.
| Materials and methods|| |
The Ocuscan-400, Contact A & B Scan using a 10 MHz focussed transducer was the instrument used in all the cases. The procedure is done on an outpatient basis. The contact scanner filled with distilled water is placed over the closed upper lid of the patient who is in the supine position. A water soluble transmission get is used over the lid which serves as a viscous coupling agent that is necessary for the transmission of sound waves.
The transducer is motorised and moves back and forth in a fixed manner. Dynamic sector scanning is performed in all the meridonal planes. The optic nerve is first identified and horizontal and vertical sections are studied in order to determine the location of the abnormality in relation to the optic nerve head. The abnormalities seen on the oscilloscope with change in eye positions are studied and the in terpretation is made during the procedure based on the continuosly changing echo patterns and manipulations. Photographs of the oscilloscope screen showing the B-scan and the corresponding A-scan are taken to document the findings.
In our series, the most common cause of vitreous haemorrhage was diabetic retinopathy accounting for 44 eyes. Eales Disease was responsible in 15 eyes. Vitreous haemorrhage was due to a retinal tear in 2 eyes, hypertension in 3 eyes, trauma in 2 eyes and tumour in l eye. In 9 eyes, the cause of vitreous haemorrhage was unknown. [Table - 1].
| Observations|| |
The ultrasonographie picture of vitreous haemorrhage depends on the density, location, extent and membraneous changes associated with it. A recent haemorrhage that is diffuse and light may be accoustically clear although it completely obscures a view of the fundus.
The posterior vitreous was detached in 13 eyes with blood lining the posterior hyaloids face. This was seen as a membrane configuration at showed a characteristic `wafting' movement on kinetic B-scan with no attachment to the optic nervehead. [Figure - 1][Figure - 2]. The density and amplitude of these membranes were variable depicting their relative toughness They generally appeared as mid to low amplitude spikes on the A-scan which disappeared on lowering the sensitivity. The membranes were thought to have resulted from the formation of 'ochre' membrane which were formed by a compaction of intragel echoes against (the posterior hyaloid interface. On the other end of the spectrum were seen dense high ampli tude membranes which resulted from a fibrocellular or fibrovascular interface.
Posterior vitreous detachments can be either complete or incomplete and when incomplete can be associated with single or multiple vitreoretinal adhesions which show a stalk like adhesion to the retina on ultrasonography. One case showed an adhesion to the disc [Figure - 3], another to the macula and the third to a point in the lower temporal quadrant.
In 3 eyes, the posterior vitreous detachment was associated with scattered mid to low ampli tude dots posterior to it which was thought to arise from a retrovitreal haemorrhage [Figure - 4] produced probably as a result of vitreous strands pulling on the retinal blood vessele during the process of posterior vitreous detachment.
Proliferating membranes were seen to arise from the disc or elsewhere in the retina in 22 eyes, of which 1 had associated posterior vitreous detachment which acted as a scaffold on which the fibrovascular tissue proliferated.
In 15 eyes these membranes were so organised to form traction retinal detachments, as a result of contraction of fibrous tissue along the detached posterior hyaloid. Traction detachments characteristically appeared triangular on B-scan with the traction bands at its apex making the detachment immobile on dynamic testing. This type of detachment produced a tall amplitude echo on the corresponding A scan and appeared as a taut straight line or with a concavity forwards [Figure - 5] as against a typical rhegmatogenous detachment that is convex forwards.
Scattered dot like mobile echoes of varying amplitude were seen in 12 eyes where the haemorrhage was within the gel. The haemorrhage in the anterior vitreous is less mobile and clears less rapidly, whereas haemorrhage from the posterior shows greater movement and clears more rapidly. The number of dots varied from a few clumps to almost filling the entire vitreous cavity depending on the degree of organisation of the haemorrhage which act as echo reflecting surfaces. [Figure - 6] The location is best studied by its relation to other structures like the lens or optic nerve. In 5 eyes, a mid amplitude, sheet like membrane was seen in front of the optic nerve head which depicted a preretinal haemorrhage or membrane. A preretinal haemorrhage normally shows a `fluid shift' on dynamic testing whereas a preretinal membrane appears taut, immobile and sheet like. [Figure - 7].
In 2 eyes there was an associated rhegmatogenous retinal detachment seen as large amplitude membranes arising out of the optic nerve head and going forwards in a convex fashion towards the ora. These membranes differed from vitreous membranes in that they remained tall even on lowering sensitivies. [Figure - 8]. The retina was totally organised to form a 'morning glory' pattern in 3 cases [Figure - 9] which is typical of a massive vitreous retraction.
35 of the 76 eyes underwent vitrectomy and 14 more are awaiting surgery. In 4 eyes, a spontaneous clearing occured and sufficient follow up was lacking in 8 eyes. 15 eyes in this series were not subjected to surgery based on the ultrasonographic findings [Table - 3]. In 2 cases, of the 15 eyes vitreous haemorrhage did not clear but retained a visual acuity of more than 6'60 and in one case there was an underlying tumour of the optic nervehead. Extensive traction retinal detachments were seen in 7 cases and massive periretinal organisation in 2 cases. Surgery was also witheld in 1 case of trauma with dense vitreous haemorrhage without light perception and in another case where the eye showed massive choroidals and MVR, the globe itself showing distortion, suggesting a pthysis bulei.
The post oberative fundus appearance was compared with the pre-operative ultrasonographic findings and an overall accuracy of 80% was noted. This result as compared to Machemer's 85% was found very encouraging.
Traction detachments were grossly overdiagnosed, when in fact they turned out to be dense, proliferating, tall amplitude membranes which were attached to the retina at more than one point. However, it was not considered detrimental, as it only warned the surgeon to exert more caution and prepared him to expect vascular membranes or retina in these cases. According to Coleman, absolute differentiation is difficult on ultrasound since the retina is often very thin in these areas.
Of the 26 eyes diagnosed to have attached retina, 2 had retinal detachment, one was a localised retinal detachment of the lower nasal quadrant and the other was misdiagnosed as posterior vitreous detachment with retrovitreal haemorrhage [Table - 4]. This indicates that the surgeon should be ever alert and not be caught unawares with unexpected vitreoretinal pathology.
| Summary|| |
The ultrasonographic findings in these 76 eyes helped in determining whether the haemorhage was within the gel, lining the posterior hyaloid interface or had organised to form fibrovascular bands or traction retinal detachments. It aided in selecting cases for surgery and planning the surgical procedure. It also helped in avoiding surgery in those cases where the poor prognosis could be determined only from the ultrasonographic picture.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]