Persistent unsealed internal limiting membrane after Nd:YAG laser treatment for valsalva retinopathy

Abstract

Background: To report a long-term complication of unsealed and un-reattached internal limiting membrane in Valsalva retinopathy after neodymium-doped yttrium-aluminium-garnet (Nd:YAG) laser membranotomy.

Case presentation: A 41-year-old man presenting with a massive premacular hemorrhage due to Valsalva retinopathy underwent Nd:YAG laser membranotomy. During follow-up, best-corrected visual acuity, retinal alteration and optical coherence tomography (OCT) outcomes were documented. One month after membranotomy, his visual acuity improved to 20/20 and the hemorrhage resolved completely. At an 8-month follow-up visit, the fundus showed progressive wrinkling of the internal limiting membrane with the laser perforation located in the center. OCT showed a persistent unsealed and un-reattached internal limiting membrane.

Conclusions: Not all patients with Valslava retinopathy with premacular hemorrhage are appropriate candidates for laser membranotomy, especially patients with sub- internal limiting membrane hemorrhage. The key point for observation is the interface between internal limiting membrane and retinal surface. The long-term consequences of unsealed internal limiting membrane after Nd:YAG laser membranotomy require further understanding.

Figure 1

Fundus photograph (a) of the left eye in a 41-year-old man with Valsalva retinopathy showing a massive premacular hemorrhage. Corresponding SD-OCT reveals a dome-shaped hypo-reflective area consistent with blood (b). Above the level of settled blood there are two distinct membranes (c): the low reflective band of the posterior hyaloid surface (red arrow) and the hyper-reflective internal limiting membrane (ILM, white arrow). Fundus photography 1 month after laser (d) shows complete resolution of the hemorrhage. Corresponding SD-OCT shows the laser perforation in the ILM (e, blue arrow) and a sub-ILM hypo-reflective space (f). Fundus photography at 3 months (g) and 8 months (j) after the Nd:YAG laser membranotomy show progressive ILM wrinkling and striae radiating from the central perforation. Based on the OCT tracking system, the un-sealed ILM defect (blue arrow) is seen to persist at 3 months (h) and 8 months (k) after treatment; and the sub-ILM space also fails to show any substantial reduction in size at the 3-month (i) or 8-month (l) follow-up.