Subhyaloid Hemorrhage after Bungee Jumping Experience. A Case Report

INTRODUCTION

Subhyaloid hemorrhage is defined as the presence of blood between the internal limiting membrane (ILM) and the posterior hyaloid membrane. In the case that the hemorrhage is localized in the macular region, this condition may be the cause of a sudden deterioration of central visual acuity (CVA). The main causes of subhyaloid hemorrhage include the Valsalva maneuver, subarachnoid hemorrhage, age-related macular degeneration (AMD), ocular trauma, hypercoagulable and hyperviscosity states, arterial hypertension, diabetes mellitus and leukemia [1–3].

A number of methods are used in the treatment of subhyaloid hemorrhage. One of the options is observation of the patient with gradual spontaneous resorption of the blood, which may take several weeks to months, depending on the extent of the hemorrhage. This procedure entails the risk of macular complications. The long-term presence of blood in the macular region may lead to the development of an epiretinal membrane and toxic damage to the retinal pigment epithelium (RPE) and photoreceptors caused by iron ions from erythrocytes [3,4].

Other options for treatment include Nd-YAG hyaloidotomy, displacement of hemorrhage with the aid of intravitreal application of gas and the tissue activator plasminogen, or pars plana vitrectomy [1,5]. Nd-YAG hyaloidotomy is a minimally invasive method in which an opening is made in the hyaloid membrane with subsequent evacuation of hemorrhage into the vitreous space. Successful performance should lead to an improvement of CVA within a few days [3,4]. Nd-YAG hyaloidotomy was first used for drainage of subhyaloid hemorrhage into the vitreous cavity in 1988 [6].

CASE REPORT

A man aged 32 years was acutely treated at the ophthalmology outpatient clinic of the Regional Hospital in Mladá Boleslav for sudden deterioration of vision in the right eye. The patient’s general condition was healthy, and he was not using any medication. The subjective complaints included a pronounced deterioration of vision and a feeling of blind spots in the center of the visual field in the right eye. It was determined from the patient’s personal medical history that one day before the examination he had taken part in bungee jumping, after which the above-mentioned complaints appeared.

Initial CVA in the right eye was on the level of light perception, central scotoma was recorded on the perimeter (Figure 1). Objectively the anterior segment of both eyes was within the norm. Subhyaloid hemorrhage was evident on the posterior segment of the right eye of a size of 3.5 papillary diameter (PD), blood vessels were within the norm, the retina was without notable changes. Optical coherence tomography (OCT) together with photo documentation (Figure 2) confirmed a diagnosis of subhyaloid hemorrhage in the right eye.

The effectiveness of Nd-YAG laser in the treatment of subhyaloid hemorrhage has been described in the international literature [6]. In most cases an improvement of CVA was achieved within one month of the procedure. Complications within the time frame of six months are minimal, one case of retinal detachment is described in a myopic patient, and the development of macular hole in another case [6]. Failure of treatment may occur if coagulum forms beneath the posterior hyaloid membrane without drainage into the hyaloid space through the created opening. Final visual acuity is also influenced by the underlying triggering pathology, which may include leukemic retinopathy, Eales disease, Valsalva retinopathy, Terson’s syndrome, macroaneurysms or retinopathy at high altitudes [6,7].