Atypical Retinal Hemorrhages after Vitrectomy for Idiopathic Macular Hole: Possible Toxicity of Brilliant Blue G

Abstract

Purpose: To describe the development of multiple retinal hemorrhages after uncomplicated macular hole (MH) surgery, and to determine the associated factors.

Methods: The medical records of 163 patients (167 eyes) diagnosed with idiopathic MHs and who underwent surgery at Pusan National University Hospital between March 2016 and July 2018 were retrospectively reviewed. The development of retinal hemorrhages was evaluated using ultra-widefield fundus photographs. Multiple retinal hemorrhages were defined as three or more dot or blot hemorrhages that had not been observed before and during the surgery. The patients were divided into two groups according to the presence of multiple retinal hemorrhages. The variable parameters were compared between the two groups to find the risk factors. The associated factors were evaluated further for the independent factor using multiple logistic regression analysis.

Results: Multiple retinal hemorrhages were observed in 31 eyes (18.6%) after MH surgery. The associated factors were the surgical induction of posterior vitreous detachment (PVD) (p = 0.003), use of the internal limiting membrane flap technique (p = 0.028), and staining with Brilliant Blue G (BBG) (p = 0.003). Retinal hemorrhages were exclusively observed in eyes in which BBG was used. Surgical PVD induction was the only independent risk factor (odds ratio, 13.099; p = 0.013). No statistically significant differences were observed between the two groups in the postoperative visual outcomes and MH closure rate. Additionally, patients who underwent surgery for idiopathic epiretinal membrane during the study period were reviewed to validate the above findings. Multiple retinal hemorrhages were noted in only one case (0.4%) in which BBG was used after surgical induction of PVD.

Conclusions: Multiple retinal hemorrhages after MH surgery appear to be related to the intravitreal use of BBG in eyes that sustained mechanical damage because of surgical induction of PVD; however, they did not affect surgical outcomes.

Keywords: Brilliant blue G; Retinal hemorrhage; Retinal perforation; Vitrectomy; Vitreous detachment.

Fig. 1

Representative case from the retinal hemorrhage group. (A) Ultra-widefield fundus photograph of a patient with an idiopathic macular hole before surgery with no other specific finding. (B) A few clusters of retinal hemorrhages in the midperiphery are noted on the widefield fundus photograph acquired the day after uncomplicated macular hole surgery, using Brilliant Blue G stain and a room-air tamponade. (C) After 4 days, the gas bubble remains in less than half of the vitreous cavity, and multiple retinal hemorrhages are clearly observed. (D) The retinal hemorrhages have all resolved at 1 month after the surgery.

Fig. 2

Various findings of multiple retinal hemorrhages after macular hole surgery. (A,B) Whitening of the retinal vessels (arrows) and (C,D) a central white core, which resembles Roth’s spot (arrows), are noted in conjunction with multiple retinal hemorrhages.

Fig. 3

Changes in visual acuity after macular hole surgery. Visual acuity significantly improved after macular hole surgery (p < 0.001) in both groups. At 1 and 3 months after the surgery, no statistically significant differences in visual acuity were observed between the hemorrhage and no hemorrhage groups. logMAR = logarithm of the minimum angle of resolution.

Fig. 4

Fluorescein angiography findings of multiple retinal hemorrhages after macular hole surgery. (A) Multiple retinal hemorrhages are noted in a 65-year-old male 6 days after macular hole surgery. (B) Fluorescein angiography reveals blocked fluorescence at the sites of hemorrhage, without leakage or non-perfusion. (C) Multiple blot hemorrhages are observed in the area temporal to the macula (arrows). (D) Blocked fluorescence is noted at the sites of hemorrhage (arrows). (E) The hemorrhages are almost completely resolved at six weeks after surgery (arrows).