Combine intravitreal bevacizumab with Nd: YAG laser hyaloidotomy for valsalva pre-macular haemorrhage and observe the internal limiting membrane changes: a spectralis study

Abstract

Valsalva retinopathy was described as a particular form of retinopathy, pre-retinal and subinternal limiting membrane haemorrhages in nature that rarely may break through and become subhyloid or intravitreal, secondary to a sudden increase in intrathoracic pressure. We reported a new way that Nd:YAG laser for ILM hyaloidotomy in order to drain the sub-ILM blood into vitreous cavity combined with intravitreal bevacizumab to improve the absorption of blood. Therapeutic alliance make significant outcome, protecting vision in time. We used spectralis OCT to observe sub-ILM mix cells and special ILM structure in this lesion for the first time, as the spectralis OCT can reach histology level imagination.

Keywords: bevacizumab; internal limiting membrane; spectralis OCT; valsalva retinopathy.

Figure 1. Fundus photograph demonstrates the nature history of valsalva retinopathy before and after therapy which is correspondence to table 2

A: Before therapy; B: 1 day after Nd:YAG hyaloidotomy; C: 10 days after Nd:YAG hyaloidotomy and 1 day after intravitreal bevacizumab; D: 2 months after Nd:YAG hyaloidotomy and 1 month and 19 days after intravitreal bevacizumab; E: 3 months and 5 days after Nd:YAG hyaloidotomy and 2 months and 24 days after intravitreal bevacizumab; F: 4 months after Nd:YAG hyaloidotomy and 3 months and 8 days after intravitreal bevacizumab.

Figure 2. follow up by spectralis OCT in accord with Table 2

A: Before therapy; B: 2 months after Nd:YAG hyaloidotomy and 1 month and 19 days after intravitreal bevacizumab. The elevation of ILM decreased by 825 nm and the 1/4PD preretinal hemorrhage scattered into vitreous cavity.; C: 3 months and 5 days after Nd:YAG hyaloidotomy and 2 months and 24 days after intravitreal bevacizumab. The elevation of ILM continued to decrease and the 1/4PD preretinal hemorrhage continued to scatter into vitreous cavity; D: 4 months after Nd:YAG hyaloidotomy and 3 months and 8 days after intravitreal bevacizumab.

Figure 3. ILM changes

A: the same as image B in Figure 2; B: SD-OCT showed a special reflective layer on RNFL tightly (blue arrow) derived from the intact ILM (red arrow); the rough side of elevated ILM (yellow arrowheads); the posterior hyaloids (Green arrow); C: High-power view of section in staining with periodic acid schiff reagent and haematoxylin to show that the cells are on the undulated (retinal) surface of the ILM (arrows) whereas no cells are seen on the smooth (vitreous) surface (arrowheads); D: Stained with the immunoperoxidase technique for cytokeratin 7 (red-brown chromogen) and counterstained with haematoxylin: layers of transdifferentiated retinal pigment epithelial (RPE) cells are observed (arrows). Inset: higher magnification demonstrates that the RPE cells are adjacent to the undulated (retinal) surface of the ILM (arrow). (C,D were cited from Gibran SK study: Changes in the retinal inner limiting membrane associated with Valsalva retinopathy).