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 Table of Contents    
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 172-174  

Subinternal limiting membrane hemorrhage post-Ahmed glaucoma valve in vitrectomized eye

Vitreo-Retina Services, Bharti Eye Foundation and Hospital, New Delhi, India

Date of Web Publication28-May-2018

Correspondence Address:
Bhuvan Chanana
91, Pocket-B, Sukhdev Vihar, New Delhi - 110 025
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.OJO_72_2017

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Glaucoma drainage devices are mostly used for refractory glaucoma. Early postoperative complications include flat anterior chamber, choroidal effusion, and suprachoroidal hemorrhage. An 8-year-old male patient with a prior history of vitreous surgery for traumatic vitreous hemorrhage, presented to us with angle recession glaucoma in his right eye. His intraocular pressure (IOP) was 44 mmHg despite maximum antiglaucoma medication. Ahmed glaucoma valve (AGV) surgery was performed to control his IOP. In the early postoperative period, the patient developed premacular subinternal limiting membrane (ILM) hemorrhage, which did not resolve even after 4 weeks. Vitreoretinal intervention involving removal of the thickened ILM and sub-ILM bleed had to be performed. To the best of our knowledge, no case has been reported with sub-ILM bleed post aqueous humor shunts. Here, we report a case of premacular sub-ILM bleed following AGV in vitrectomized eye.

Keywords: Ahmed glaucoma valve, sub-internal limiting membrane hemorrhage, vitrectomized eye

How to cite this article:
Chanana B, Kajla G, Bharti S. Subinternal limiting membrane hemorrhage post-Ahmed glaucoma valve in vitrectomized eye. Oman J Ophthalmol 2018;11:172-4

How to cite this URL:
Chanana B, Kajla G, Bharti S. Subinternal limiting membrane hemorrhage post-Ahmed glaucoma valve in vitrectomized eye. Oman J Ophthalmol [serial online] 2018 [cited 2022 May 16];11:172-4. Available from: https://www.ojoonline.org/text.asp?2018/11/2/172/233320

   Introduction Top

Aqueous humor shunts have been utilized successfully in the management of complicated and refractory glaucoma, both as primary surgical modality and as a secondary procedure where trabeculectomy with or without antimetabolite treatment has either failed or is reported to have very low chances of success.[1],[2] Glaucoma drainage devices (GDD) work by creating an alternate pathway for aqueous outflow by channeling aqueous from anterior chamber through a tube of implant toward subconjunctival space.[2] Ahmed glaucoma valve (AGV) has been used in vitrectomized eyes for the management of neovascular glaucoma and considered safe and effective procedure for control of intraocular pressure (IOP) with comparable complication rates in vitrectomized and non-vitrectomized eyes.[3],[4] They are associated with postoperative complications of hypotony, flat anterior chamber, choroidal effusion, suprachoroidal hemorrhage, endophthalmitis, and tube occlusion.[2] However, subinternal limiting membrane (ILM) bleed following aqueous humor shunts has not been described in the world literature. We report a case of premacular sub-ILM bleed following AGV surgery in vitrectomized eye.

   Case Report Top

An 8-year-old boy presented to us with complaints of severe pain in his right eye with headache and vomiting for 1 day. He had a prior history of pars plana vitrectomy in his right eye for traumatic vitreous hemorrhage 3 weeks back. The best corrected visual acuity (BCVA) was finger counting at 2 meters OD and 6/6 OS. Slit lamp examination revealed mild corneal epithelial edema with traumatic mydriasis and a subluxated clear lens nasally (90°) in his right eye. His IOP was 56 mmHg OD and gonioscopy revealed angle recession in his right eye. Fundus examination was normal in both eyes. Despite maximal topical and systemic antiglaucoma medication, the IOP was still 44 mmHg after 3 days.

The patient underwent AGV surgery in his right eye. On the 1st postoperative day, the BCVA was finger counting close to face, and IOP was 4 mmHg OD. Fundus examination showed premacular hemorrhage and choroidal detachment superiorly. The patient was started on topical and oral steroids. After 3 days, the choroidal detachment resolved, however, premacular hemorrhage persisted [Figure 1]a. Optical coherence tomography revealed the hemorrhage to be present beneath the ILM [Figure 1]b. After 4 weeks, the resolution of hemorrhage was insignificant, and the blood became organized with thickening and wrinkling of overlying ILM [Figure 2].
Figure 1: (a) Fundus photograph of right eye showing pre-macular hemorrhage involving the macula following Ahmed glaucoma valve surgery. (b) Vertical optical coherence tomography scan through the macula shows the presence of hemorrhage below the internal limiting membrane. The internal limiting membrane can be seen in the superior part with a clear cavity beneath it, and inferiorly there is hyper reflectivity due to blood and shadowing of retinal layers underneath the blood

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Figure 2: Fundus photograph post-Ahmed glaucoma valve at 1 week (left) and 4 weeks (right) shows the sub-internal limiting membrane hemorrhage has become organized. The overlying internal limiting membrane appears thickened and wrinkled

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The patient had to further undergo vitreoretinal surgery for removal of the thickened ILM and organized blood beneath it. The BCVA improved to 6/18 OD at 1 week and 6/9 OD at 4 weeks and was stable at 3 months. The IOP was 14 mmHg at the end of 3 months. Fundus examination showed the absence of premacular hemorrhage and a healthy macula [Figure 3].
Figure 3: Fundus photograph following vitreoretinal intervention at 1 week (left) and 3 months (right)

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   Discussion Top

GDD has been successfully utilized in controlling IOP in eyes with previously failed trabeculectomy and complicated glaucoma that are known to have poor success rates with trabeculectomy such as uveitic glaucoma, neovascular glaucoma, pediatric and developmental glaucoma, postvitreoretinal surgery, aphakic, and pseudophakic glaucoma.[1],[3],[4],[5],[6],[7],[8] In the present case, AGV was the preferred choice as there were high chances of failure with trabeculectomy due to the presence of traumatic mydriasis.

The early postoperative complications associated with GDD such as flat anterior chambers, choroidal effusion, and suprachoroidal hemorrhage, are similar to other filtration procedures.[1] Other complications include tube occlusion, endophthalmitis, vitreous hemorrhage, cystoid macular edema, and hypotony maculopathy.[2] Early postoperative hypotony usually results from wound leak, inflammation, incomplete occlusion of the tube or larger venting slits with nonvalved implants. The AGV is widely used because of the internal resistance that prevents postoperative hypotony as compared to nonvalved implants.[1],[2] According to a various studies, AGV implantation significantly lowers intraocular pressure, and concurrent vitrectomy does not affect either the degree of IOP reduction or the rate of postoperative complications.[3],[4],[5]

However, in our case, the patient developed severe hypotony and choroidal detachment on the 1st postoperative day. Our hypothesis is sudden and more reduction of intraocular volume, due to loss of aqueous in a vitrectomized eye could have led to severe hypotony resulting in premacular sub-ILM hemorrhage.

Sub-ILM bleeds are usually associated with Terson syndrome and Valsalva retinopathy.[9] Other causes include severe anemia, thrombocytopenia, leukemia, ruptured retinal microaneurysms, blunt or penetrating ocular trauma. There is almost no study in literature reporting sub-ILM bleed following AGV implantation in a vitrectomized eye.

The contact of the retina with hemoglobin and its catabolites may cause irreversible toxic retinal damage.[10] Hence, surgical management is indicated in prolonged sub-ILM bleeds involving the fovea. Our case was successfully managed with removal of overlying thickened ILM and premacular hemorrhage.

   Conclusion Top

AGV is a safe and effective procedure for the management of refractory glaucoma. However, in vitrectomized eyes, severe hypotony and its associated complications may develop, and hence, it is advisable to be cautious while performing AGV surgery in such eyes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Wilson MR, Mendis U, Smith SD, Paliwal A. Ahmed glaucoma valve implant vs. trabeculectomy in the surgical treatment of glaucoma: A randomized clinical trial. Am J Ophthalmol 2000;130:267-73.  Back to cited text no. 1
Budenz DL, Barton K, Feuer WJ, Schiffman J, Costa VP, Godfrey DG, et al. Treatment outcomes in the Ahmed Baerveldt Comparison Study after 1 year of follow-up. Ophthalmology 2011;118:443-52.  Back to cited text no. 2
Cheng Y, Liu XH, Shen X, Zhong YS. Ahmed valve implantation for neovascular glaucoma after 23-gauge vitrectomy in eyes with proliferative diabetic retinopathy. Int J Ophthalmol 2013;6:316-20.  Back to cited text no. 3
Park UC, Park KH, Kim DM, Yu HG. Ahmed glaucoma valve implantation for neovascular glaucoma after vitrectomy for proliferative diabetic retinopathy. J Glaucoma 2011;20:433-8.  Back to cited text no. 4
Gandham SB, Costa VP, Katz LJ, Wilson RP, Sivalingam A, Belmont J, et al. Aqueous tube-shunt implantation and pars plana vitrectomy in eyes with refractory glaucoma. Am J Ophthalmol 1993;116:189-95.  Back to cited text no. 5
Da Mata A, Burk SE, Netland PA, Baltatzis S, Christen W, Foster CS. Management of uveitic glaucoma with Ahmed glaucoma valve implantation. Ophthalmology 1999;106:2168-72.  Back to cited text no. 6
Netland PA, Walton DS. Glaucoma drainage implants in pediatric patients. Ophthalmic Surg 1993;24:723-9.  Back to cited text no. 7
Varma R, Heuer DK, Lundy DC, Baerveldt G, Lee PP, Minckler DS. Pars plana Baerveldt tube insertion with vitrectomy in glaucomas associated with pseudophakia and aphakia. Am J Ophthalmol 1995;119:401-7.  Back to cited text no. 8
De Maeyer K, Van Ginderdeuren R, Postelmans L, Stalmans P, Van Calster J. Sub-inner limiting membrane haemorrhage: Causes and treatment with vitrectomy. Br J Ophthalmol 2007;91:869-72.  Back to cited text no. 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. 10


  [Figure 1], [Figure 2], [Figure 3]


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