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 Table of Contents    
CLINICAL IMAGE
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 213-214  

High altitude subhyaloid hemorrhage


1 Department of Ophthalmology, Leighton Hospital, Crewe, Cheshire, England
2 Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
3 Monklands Hospital, North Lanarkshire, Scotland, United Kingdom

Date of Web Publication20-Nov-2015

Correspondence Address:
Elliott Yann Ah-Kee
Monklands Hospital, Monkscourt Ave, Airdrie, North Lanarkshire, Scotland
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.169885

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   Abstract 

Subhyaloid hemorrhages can occur as a result of exposure to high altitude. We hereby report a clinical picture of subhyaloid hemorrhage associated with high altitude. The case demonstrates optical coherence tomography findings that aid diagnosis of subhyaloid hemorrhage.

Keywords: High altitude, optical coherence tomography, subhyaloid hemorrhage


How to cite this article:
Hanifudin A, Lim LT, Ah-Kee EY, El-Khashab T. High altitude subhyaloid hemorrhage. Oman J Ophthalmol 2015;8:213-4

How to cite this URL:
Hanifudin A, Lim LT, Ah-Kee EY, El-Khashab T. High altitude subhyaloid hemorrhage. Oman J Ophthalmol [serial online] 2015 [cited 2020 Sep 21];8:213-4. Available from: http://www.ojoonline.org/text.asp?2015/8/3/213/169885


   Introduction Top


Altitude illness is a clinical syndrome caused by exposure to high altitude and includes acute mountain sickness (AMS), high-altitude pulmonary edema, high-altitude cerebral edema and high-altitude retinopathy (HAR).[1] HAR is characterized by dilated retinal vessels and superficial retinal or subhyaloid hemorrhages, mainly in the posterior pole. In more severe cases, vitreous hemorrhage, papillary hemorrhage, peripapillary hyperemia, and papilledema may occur.[2],[3] Subhyaloid hemorrhage is rare and usually contained in a self-created space between the posterior hyaloid and retina.[4] We hereby describe a case of high altitude subhyaloid hemorrhage and associated optical coherence tomography (OCT) findings.


   Case Report Top


A 46-year-old Caucasian lady with no previous medical or ocular history presented with a sudden onset of painless visual loss in her right eye and associated symptoms of photophobia. It happened while she was mountaineering in Tibet. Her visual acuity was 6/60 and fundoscopy revealed a dense subhyaloid hemorrhage and premacular elevation [Figure 1]. Retinal vessels and optic disc appeared normal. A B-scan ultrasound showed localized elevation of the blood in the subhyaloid space [Figure 2]. Subsequently, an OCT was performed and confirmed the finding, showing a highly reflective, sharply demarcated, dome-shaped hemorrhage in the subhyaloid space [Figure 3]. We report a clinical picture of subhyaloid hemorrhage associated with high altitude. In this case, the subhyaloid hemorrhage was resorbed spontaneously without any complications following observation of up to 3 months. Our case demonstrates OCT findings that aid diagnosis of subhyaloid hemorrhage.
Figure 1: Fundus photograph showing dense subhyaloid hemorrhage and premacular elevation

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Figure 2: B-scan ultrasound showing localized elevation of the blood in the subhyaloid space

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Figure 3: Optical coherence tomography confirming the finding showing a highly reflective, sharply demarcated, dome-shaped hemorrhage in the subhyaloid space

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   Discussion Top


Inadequate autoregulatory response of the retinal vascular system to hypoxia and hypobarism is thought to be the cause of AMS and high altitude subhyaloid hemorrhages.[5] The configuration of the hemorrhages is variable; they may be diffuse or punctuated, confluent or flamed-shaped. Several treatment modalities can be considered for the management of a subhyaloid hemorrhage.

Clinical observation for spontaneous clearing of the hemorrhage is acceptable and can take 1–2 months. However, the risk of irreversible damage to the retina due to proliferative vitreoretinopathy and preretinal tractional membrane caused by the persistence of blood, has to be taken into account.[6]

Laser membranotomy creates an opening into the vitreous cavity, allowing rapid drainage of the hemorrhage. It has yielded favorable visual outcomes, with rare reported cases of serious complications such as macular hole formation and retinal detachment.[7],[8],[9] However, this procedure is associated with an increased risk of epimacular membrane formation, likely due to stimulation of entrapped cells by growth factors, along the retinal surface.[10],[11]

Intravitreal tissue plasminogen activator (tPA) and gas have previously been successfully used to displace subhyaloid hemorrhages. Indications for their use include media opacity or issues with contact lens application for laser.[12],[13] However, these are more routinely used in the treatment of submacular hemorrhage secondary to age-related macular degeneration.[14]

In this case, the subhyaloid hemorrhage was resorbed spontaneously without any complications following observation of up to 3 months. Therefore, no surgical intervention was required to clear the hemorrhage. Several factors including underlying condition, age of the patient, size of hemorrhage and duration since onset of hemorrhage should be considered when deciding on watchful waiting versus administering treatment, as well as the treatment modality.[15] In summary, OCT can be helpful to diagnose subhyaloid hemorrhage. In addition, we also would like to highlight that the importance of asking about travel history in a patient presenting with sudden painless visual loss.

 
   References Top

1.
Houston CS. High altitude illness. Disease with protean manifestations. JAMA 1976;236:2193-5.  Back to cited text no. 1
    
2.
McFadden DM, Houston CS, Sutton JR, Powles AC, Gray GW, Roberts RS. High-altitude retinopathy. JAMA 1981;245:581-6.  Back to cited text no. 2
    
3.
Wiedman M, Tabin GC. High-altitude retinopathy and altitude illness. Ophthalmology 1999;106:1924-6.  Back to cited text no. 3
    
4.
Bisland T, Topilow A. Subhyaloid hemorrhage and exophthalmos due to ruptured intraventricular aneurysm; A case occurring in toxemia of pregnancy. AMA Arch Ophthalmol 1952;47:470-6.  Back to cited text no. 4
    
5.
Wiedman M. High altitude retinal hemorrhage. Arch Ophthalmol 1975;93:401-3.  Back to cited text no. 5
    
6.
Kroll P, Busse H. Therapy of preretinal macular hemorrhages. Klin Monbl Augenheilkd 1986;188:610-2.  Back to cited text no. 6
    
7.
Kroll P, Le Mer Y. Treatment of preretinal retrohyaloidal hemorrhage: Value of early argon laser photocoagulation. J Fr Ophtalmol 1989;12:61-6.  Back to cited text no. 7
    
8.
Heydenreich A. Treatment of preretinal haemorrhages by means of photocoagulation (author's transl). Klin Monbl Augenheilkd 1973;163:671-6.  Back to cited text no. 8
    
9.
Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd: YAG laser. Arch Ophthalmol 1998;116:1465-9.  Back to cited text no. 9
    
10.
Kwok AK, Lai TY, Chan NR. Epiretinal membrane formation with internal limiting membrane wrinkling after Nd: YAG laser membranotomy in valsalva retinopathy. Am J Ophthalmol 2003;136:763-6.  Back to cited text no. 10
    
11.
Meyer CH, Mennel S, Rodrigues EB, Schmidt JC. Persistent premacular cavity after membranotomy in valsalva retinopathy evident by optical coherence tomography. Retina 2006;26:116-8.  Back to cited text no. 11
    
12.
Schmitz K, Kreutzer B, Hitzer S, Behrens-Bauman W. Therapy of subhyaloidal hemorrhage by intravitreal application of rtPA and SF (6) gas. Br J Ophthalmol 2000;84:1324-5.  Back to cited text no. 12
    
13.
Koh HJ, Kim SH, Lee SC, Kwon OW. Treatment of subhyaloid haemorrhage with intravitreal tissue plasminogen activator and C3F8 gas injection. Br J Ophthalmol 2000;84:1329-30.  Back to cited text no. 13
    
14.
Mennel S. Subhyaloidal and macular haemorrhage: Localisation and treatment strategies. Br J Ophthalmol 2007;91:850-2.  Back to cited text no. 14
    
15.
Hesse L, Schmidt J, Kroll P. Management of acute submacular hemorrhage using recombinant tissue plasminogen activator and gas. Graefes Arch Clin Exp Ophthalmol 1999;237:273-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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