|Year : 2023 | Volume
| Issue : 1 | Page : 120-122
Ocular decompression retinopathy following bleb needling in a young child
Karthikeyan Mahalingam, Abhidnya Surve, Vatsala Nidhi, Viney Gupta, Shorya Vardhan Azad
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||17-Oct-2021|
|Date of Decision||09-Jan-2022|
|Date of Acceptance||28-Dec-2022|
|Date of Web Publication||21-Feb-2023|
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Ocular decompression retinopathy (ODR) is caused by a sudden lowering of high intraocular pressure. Trabeculectomy is the most common procedure preceding ODR. Various mechanical and vascular etiologies have been proposed to cause ODR, with autoregulation and hemodynamics playing a contributing role. Herein, we report a rare case of ODR occurring after bleb needling in a young child using ultrawide-field fundus photography, fluorescein angiography, and optical coherence tomography.
Keywords: Needling, ocular decompression retinopathy, pediatric
|How to cite this article:|
Mahalingam K, Surve A, Nidhi V, Gupta V, Azad SV. Ocular decompression retinopathy following bleb needling in a young child. Oman J Ophthalmol 2023;16:120-2
|How to cite this URL:|
Mahalingam K, Surve A, Nidhi V, Gupta V, Azad SV. Ocular decompression retinopathy following bleb needling in a young child. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 26];16:120-2. Available from: https://www.ojoonline.org/text.asp?2023/16/1/120/370045
| Introduction|| |
Ocular decompression retinopathy (ODR), first described by Fechtner et al., is caused by a sudden lowering of high intraocular pressure (IOP) presenting as retinal hemorrhages. The core factor involved in the pathogenesis of ODR is a sudden decrease in IOP and hence is seen as associated with different types of glaucoma including congenital glaucoma, angle-closure glaucoma, posttraumatic, or steroid-induced glaucoma with the most common procedure being posttrabeculectomy., Herein, we describe a rare case of ODR occurring immediately after the needling of bleb in a young child.
| Case Report|| |
A 12-year-old male child presented with complaints of decreased vision in the right eye (RE) for 1 month following blunt trauma with a cricket ball. RE vision was a perception of light with accurate projection of rays in all quadrants. On examination, corneal edema, 1 mm anterior chamber hyphema, and the cataractous lens were noted with IOP of 64 mmHg. On fundus examination, the media was hazy with near-total optic disc cupping and no other posterior segment involvement. The left eye was within normal limits. Topical steroids, cycloplegics, and antiglaucoma medications along with oral acetazolamide and glycerol were started. Intravitreal mannitol was also given but IOP still persisted at 40 mmHg. Hence, trabeculectomy with mitomycin C and two releasable sutures was performed under general anesthesia after obtaining written informed consent. On the 1st postoperative day (POD), RE IOP was 36 mmHg and hence bleb massage, early removal of releasable suture was performed over the next 2–3 days. Fundus examination at this stage was similar to before. However, the IOP varied from 22 mmHg on POD-2 and 34 mmHg on POD-6, hence, bleb needling was performed.
On the next day examination, vision was hand movements close to face, and IOP had dropped to 6 mmHg with an elevated bleb. The fundus examination revealed multiple hemorrhages prominently in the peripapillary area extending to periphery along with mild tortuosity and dilatation of the veins. The hemorrhages were preretinal, intraretinal, as well as in the vitreous cavity. Few white-centered hemorrhages were also seen [Figure 1]a. Fundus fluorescein angiography (FFA) showed blocked fluorescence corresponding to retinal hemorrhages. However, no delay in retinal circulation or capillary nonperfusion (CNP) was noted [Figure 1]b. Optical coherence tomography through the optic disc revealed mild disc edema with intraretinal and preretinal bleed [Figure 1]c. A diagnosis of ODR was made and topical and oral steroids were started to build up the IOP. After 2 weeks, the vision was 1/60, and IOP was 10 mmHg. Hemorrhages, disc edema, and dilatation of veins had completely resolved [Figure 2].
|Figure 1: (a) Ultrawide-field fundus picture showing optic disc hemorrhages and multiple preretinal, intraretinal, and intravitreal hemorrhages. Mild tortuosity and dilatation of veins along with a few white-centered hemorrhages were also seen. The black arrow indicates the direction of the OCT scan. (b) Ultrawide-field fundus fluorescein angiography arteriovenous phase showing blocked fluorescence (white arrow) corresponding to retinal hemorrhages without any CNP areas. (c) OCT through the optic disc revealed mild disc edema with intraretinal and preretinal bleed (white arrow). OCT: Optical coherence tomography, CNP: Capillary nonperfusion|
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|Figure 2: Ultrawide-field fundus picture showing resolution of hemorrhages, disc edema, and dilatation of veins after conservative management|
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| Discussion|| |
ODR is mostly seen after a sudden iatrogenic decrease in IOP, presenting as multiple hemorrhages at various levels including subhyaloid, intravitreal, intraretinal, and subretinal. White-centered hemorrhages and optic disc involvement can also be seen in approximately 20%–25% of cases, respectively., In our case, the presence of all these features along with the absence of delay in arm–retinal circulation time or any CNP areas on FFA differentiated it from central retinal vein occlusion (CRVO) and suggested the diagnosis of ODR. CRVO presents as multiple flame-shaped hemorrhages with dilatation and tortuosity of veins and commonly occurs in cases with advanced glaucoma and has a lesser visual prognosis. Hence, the need for differentiation.
ODR has been documented most often the following trabeculectomy but can also be seen after glaucoma drainage devices, phacoemulsification, vitrectomy, silicone oil removal, iridotomy, anterior chamber paracentesis, and orbital decompression as well as following medical management of glaucoma.,, Only one case is documented by Kawai et al. in a 55-year-old adult after bleb needling in a case with neovascular glaucoma. The mean reduction in IOP seen in ODR cases is approximately 33 ± 16 mmHg and almost around 82% are diagnosed within the 1st POD. In our case, IOP had initially dropped gradually from 60 mmHg to 34 mmHg following medical management, trabeculectomy, bleb massage, and suture removal, but it was following bleb needling that the IOP dropped from 32 mmHg to 6 mmHg causing ODR. This sudden IOP drop to a very low level was responsible for the development of ODR.
Various mechanisms involving mechanical and vascular factors have been proposed to cause ODR. Along with disturbed autoregulation of blood vessels seen in long-standing and advanced glaucoma cases, the sudden decrease in IOP leads to increased blood flow in the choroidal and vascular area which results in intravascular pressure exceeding the retinal capillary bed capacitance and causes multifocal multilayered hemorrhages., Mechanical factors include the shearing forces due to scleral deformity and posterior vitreous attachments. Anterior shift and expansion of lamina cribrosa due to sudden lowering of IOP might cause a decrease in axoplasmic flow, resulting in optic disc edema and compression of the central retinal vein causing diffuse retinal hemorrhages.,, Further, long-standing inflammation affects the blood–retinal barrier causing leakage of retinal capillaries during increased blood flow has also been suggested.,
Most of the ODR cases are unilateral and seen in the age group of 44.2 ± 23 years (21.2–67.2 years). However, Fadel et al. found a slightly higher incidence of 5.24% in the pediatric age group as compared to 3.03% documented by Jung et al. in the adult age group., In children additionally, lesser scleral rigidity further allows mechanical changes predisposing to a higher risk of ODR occurrence. Therefore, one needs to be careful and avoid a sudden large decrease in IOP even at lower IOPs.
| Conclusion|| |
ODR is usually benign and resolves completely with good prognosis even with conservative management. However, in pediatric cases with dense vitreous hemorrhage, one may need to intervene surgically to prevent amblyopia. Although bleb needling is a safe and effective procedure, adequate precaution may be needed at each step to prevent a sudden fall in IOP.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given their consent for images and other clinical information to be reported in the journal. The guardian understands 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.
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[Figure 1], [Figure 2]