Speaker 1 (00:00):
Support for this podcast comes from Bryn Mawr Communications. BMC produces a number of informative podcast series spanning a variety of topics in ophthalmology. Discover a new show at eyetube.net/podcasts.
Ogul Uner (00:38):
Welcome to Pupil Pod, where we use clinical cases to guide discussions on board review topics. I'm your host, Ogul Uner, and my guest today is Dr. Aris Thanos. Dr. Thanos is a board-certified ophthalmologist and vitreoretinal surgeon at Devers Eye Institute at Legacy Health in Portland, Oregon. And I'm so excited to have him on the podcast today. Dr. Thanos, thank you again for joining me.
Aris Thanos (00:58):
Thank you for the kind invitation.
Ogul Uner (01:00):
Let's delve directly into our case. We have a 62-year-old man who presents urgently to your clinic with sudden painless vision loss in the right eye that started this morning. He describes it as a dark cloud with some floaters. He denies a history of trauma. Past medical history is significant for Type II diabetes and hypertension. He's also on apixaban for atrial fibrillation. Visual acuity is counting fingers in the affected right eye, 20/25 in the left eye. There's no relevant relative afferent pupillary defect. Anterior segment is unremarkable and the view posteriorly is obscured by vitreous hemorrhage in the right eye. There's moderate non-proliferative diabetic retinopathy in the left eye. The B scan shows the retina is attached. Dr. Thanos, what are your initial thoughts about this case?
Aris Thanos (01:46):
Yes. So certainly, this is a patient that everybody has seen and will be seeing, especially as the prevalence of diabetes is increasing. And this is I think the history of diabetes, hypertension, that we're dealing with a vascular path here. This is pointing more that we are dealing with a vitreous hemorrhage secondary to proliferative diabetic retinopathy. So certainly, this is here, especially examination of the other eye, seeing that there are signs of NPDR, all of that points towards this direction of PDR as a source of vitreous hemorrhage.
Ogul Uner (02:31):
And what are some common causes of vitreous hemorrhage in adults and children? So, you mentioned proliferative diabetic retinopathy as a very common cause. What are some other things that you think about?
Aris Thanos (02:42):
By far, especially in this age group of our patient, we should also consider posterior vitreous detachment, which is one of the most common causes. Certainly, we'll see not only vitreous hemorrhage, but also vitreoretinal complications that may be vision threatening like retinal tears or retinal detachment. But going down towards the list of the differential diagnosis, we can have in elderly patients ruptured micro aneurysm, some young females with hypertension, then we can have in elderly in the 70th or 80th decades macular degeneration that can break through or peripheral exudative hemorrhagic or retinopathy. So, these are all certainly age, certainly systemic vascular path. In the past medical history in general helps us kind of differentiate in terms of where we are in the... Certainly now, because you asked about kids as well, kids by far we have trauma as the number one cause and certainly other usually proliferative retinopathies.
(03:56):
Sometimes this would be in genetic conditions that can cause it. So, a lot of times examination of the other eye will give a lot of information.
Ogul Uner (04:05):
You summarized it very well. I kind of think about it as either rupture of normal vessels through a mechanical force as you mentioned from traction or it could be hemorrhage from a pathological structure. So, trauma could do either. And I think the BCSC really likes harping on the order. As we said, PDR, proliferative diabetic retinopathy is by far the most common, followed by a retinal tear, a hemorrhagic PVD, a rhegmatogenous retinal detachment and a vein occlusion in that order. And then without trauma in children, as you said, hereditary conditions like X-linked retinoschisis or pars planitis are common sources. And I think you also illustrated really well that the bleeding can be exacerbated by other systemic factors such as hypertension or use of systemic anticoagulants as in this patient. What do you think about the prevalence of vitreous hemorrhage? When a patient comes in with an acute PVD, what is the prevalence of vitreous hemorrhage in that population?
(05:06):
And of those patients, how many of them have retinal tears?
Aris Thanos (05:09):
Yes. So certainly, the prevalence can be up to, again, according to studies, up to 20% here. And certainly, depending on the severity of the PVD, all of our patients, they get an OCT before they even see us. So, a lot of times they may have microscopic vitreous hemorrhage. We'll see these vitreal hyperreflective foci on the OCT. And a lot of times by just seeing how many of those are on the OCT, sometimes we can tell in terms of how suspicious we should be about checking and doing a very thorough scleral depressed examination for presence of retinal tears, because that can be even up to 15 to 20% having a retinal tear. And this is certainly what needs to be promptly managed.
Ogul Uner (06:06):
The classic notion is that if you do see a hemorrhagic PVD, you really need to look carefully with a scleral depressed exam because the prevalence of a retinal tear is quite high, as you said. And I think that segues well into our next question. What are some clinical features you look for on an exam with a patient with vitreous hemorrhage, starting from the anterior segment going posteriorly, what are some things that you find most helpful?
Aris Thanos (06:32):
Certainly, we need to check the iris for signs of neovascularization. Has the eye had prior surgeries, cataract surgery? Was there a sulcus IOL placed or is there a sclero-fixated lens? Sometimes sclero-fixated lens cases can cause syndrome with vitreous hemorrhage. So certainly, here we need, but somebody in a typical patient, phakic, no prior ocular history who presents with an acute fundus obscuring vitreous hemorrhage, then certainly this is, and who doesn't have diabetes, then immediately we should be thinking certainly that this is probably hemorrhagic posterior vitreous detachment plus or minus a vitreoretinal pathology, NRD or a retinal tear or multiple retinal tears. And this is when certainly we need to be very, very careful how to manage this patient.
Ogul Uner (07:33):
You talked about other ancillary imaging, like what OCT is helpful or we talked about ultrasonography. What's your imaging of choice in these patients? When they have vision obscuring hemorrhage or maybe minimal vitreous hemorrhage, does that kind of change your approach?
Aris Thanos (07:50):
So sometimes if the vitreous hemorrhage is obscuring mostly the posterior pole but allows some peripheral scleral depression to assess the vitreous base, yes, certainly a good clinical examination is important, but certainly B-scan ultrasonography is the gold standard over there. Whitefield CSLO imaging, sometimes you can have some hints for some areas that may look suspicious that can aid as well. So, obtaining that can help as well. But certainly, here I want to emphasize that also the B scan is not that sensitive in order to pick up vitreoretinal pathology, sometimes small retinal tears or tears in the posterior pole or very anteriorly. So, we have to be here, have a very, very high level of suspicion in terms of when and how quickly we will take a patient to the OR or keep observing. And this is kind of part of the art here. Sometimes this can be a very, although something like a condition as common vitreous hemorrhage, this can be a very challenging decision as to how quickly you take a patient to the operating room or not, or you decide to wait.
Ogul Uner (09:09):
I think those are all great thoughts. Do you think about any ancillary testing for these patients in a patient who doesn't have trauma and doesn't have known diabetes? Do you test for an A1C or get a CBC? What's your thought process behind that?
Aris Thanos (09:25):
Yes. So certainly, in a patient who presents in the age range for having a posterior vitreous detachment, I wouldn't typically refer the patient to a primary care physician. I feel that the patient may get lost or certainly this is something where we need to emphasize on the eye pathology and clearing out, making sure in terms of what is causing the vitreous hemorrhage. Because if this is a hemorrhagic PVD with a retinal tear and that patient needs prompt OR, that means about a week, one to two weeks maximum. I think we know that it's not that easy to get into a primary care physician within a week, weeks of time. So, I think here, additional workup certainly may delay the care here. And certainly, I think it's not if we see on the other eye, on the contralateral eye, signs of NPDR and without any known diagnosis of diabetes, most certainly yes.
(10:34):
So, it just certainly depends on all the examination also of the other eye as well.
Ogul Uner (10:39):
I think you focused on a great point that the fellow eye is really important in our diagnostic considerations. I've definitely seen leukemic retinopathy cause vitreous hemorrhage. You can have a variety of different conditions and looking at the other eye for signs of retinopathy or performing a gonioscopic exam to look for neovascularization of the angle can be really helpful, as you said, to see if this is potentially a systemic process that needs to be elucidated further or whether this is an eye only process that we need to deal with urgently. Before we talk about additional treatment, let's take a quick break to hear more from our sponsors. We'll be back shortly.
Speaker 1 (11:28):
Support for this podcast comes from Bryn Mawr Communications. BMC produces a number of informative podcast series spanning a variety of topics in ophthalmology. Discover a new show at eyetube.net/podcasts.
Ogul Uner (11:45):
Welcome back. Let's talk now about the treatment for patients with vitreous hemorrhage. Dr. Thanos, what is your treatment in the acute setting and in long term? Does all vitreous hemorrhage go away and what is your treatment approach in terms of stepwise considerations of invasive and non-invasive therapies?
Aris Thanos (12:06):
Yeah, so certainly I think establishing the right diagnosis here in terms of what is causing the vitreous hemorrhage of course will guide the treatment here, right? Because in the case scenario that we had initially, it's a patient with proliferative diabetic retinopathy. So certainly, this patient needs anti-VEGF injection. Whereas in somebody with no systemic illnesses, not perfectly healthy who comes in with fundus obscuring vitreous hemorrhage, this patient may certainly need either close observation or sometimes if the ultrasound is suggestive of a possible retinal tear, let alone a localized RD, this patient may need a prompt vitrectomy surgery.
Ogul Uner (13:03):
For proliferative cases such as NPDR or retinal vein occlusions, how many anti-VEGF injections would you consider before proceeding with a vitrectomy?
Aris Thanos (13:15):
Certainly, this is something that, especially in diabetes, for example, in proliferative diabetic retinopathy, we have good data from DRCR where they studied this exact question in terms of what is better to do? Do we need to do prompt vitrectomy versus injections? And certainly, we know that both groups are doing very, very well. It's just then we have to dig into the prior ocular history. Is this the first hemorrhage or is it the number 10 hemorrhage? Does this patient have a history of years of injections? So, this is all guides in terms of at least my personal decision making in terms of what we should be offering. But certainly, I think initially, especially in the context of a vitreous hemorrhage from RVO or diabetes, I think especially in the acute setting, starting with an anti-VEGF, at least one to two, this is certainly a good choice.
(14:24):
I don't think that there is a timing, there's pressure on time to make a decision promptly. This is not the case though with fundus obscuring, perfectly healthy 55-year-old who comes in with a vitreous hemorrhage and has potentially a retinal tear.
Ogul Uner (14:42):
I think you harped on a very important point that if we really can't see, there are only certain things that we can do. I think eye patching, making sure that these patients ensure good bed rest for several days I think is really important. We always tell the patient to elevate the head of the bed. That may permit that infrahyoid and retrohyaloid blood to settle down. That may allow a better view of the posterior segment. And you mentioned frequent re-examinations with repeat ultrasonography if we don't really know the cause, or we can go in with a vitrectomy as you said, if we're not sure or maybe there is a retinal tear, but we can't see to laser or perform cryotherapy, I think are important points. And I think also important to talk about that the blood may not all go away. Even after a pars plana vitrectomy, we can still have a lot of residual blood that will be left.
(15:42):
So, if we see some pigmented anterior vitreous cells consistent with those degenerated blood products that it's not something completely unexpected. So, I think this segues well into the next question on considering a pars plana vitrectomy. You mentioned retinal tears or detachments to clear the hemorrhage, maybe dense vitreous hemorrhage with poor response to anti-VEGF. And what is your timeline in terms of somebody who might be completely healthy, their fundus is completely obscured, they don't have diabetes, would you take those patients promptly or would you observe?
Aris Thanos (16:21):
Certainly, this is if my level of suspicion is very, very high here, yes, definitely. I may see the patient fairly soon within two to three days if the hemorrhage doesn't clear up. And again, I don't have a good view to the back. Again, I think we are very fortunate to have 25-, 27-gauge instrumentation and it's a very different ball game to have to operate on a retinal detachment next if the patient detaches in the future from delayed intervention. So, catching the disease of the stage of a vitreous hemorrhage with a single retinal tear, this is an eye that can go back to 20/20 within a week. Whereas if that same eye, we wait for a week or two for retinal detachment to occur, so certainly all of a sudden, the visual prognosis is not the same. And certainly, there have been lots of several retrospective series that have seen that the ultrasound is not that accurate in diagnosing retinal tears in this setting.
(17:48):
So, this is where clinical judgment and very good communication with a patient is critical, telling the patient, "Well, it's not ideal that we cannot see what's causing your hemorrhage. We have to clear it out so that we can do that." And patients I think are very, very appreciative and understanding because they're coming to us with sudden painless vision loss. And I think vitrectomy in this type of setting is critical, I think, and prompt vitrectomy.
Ogul Uner (18:22):
I think those were great points. So going back to our patient who as a reminder has a vitreous hemorrhage and we can't see any details of the retina, the B scan was normal, and the fellow eye has moderate NPDR. How would you treat and counsel him?
Aris Thanos (18:41):
Yeah. So certainly, this is a patient where I would recommend an anti-VEGF injection. Pursuing here, fluorescein angiography certainly has both advantages and disadvantages. Certainly, if the vitreous hemorrhage is very dense, you don't get any information about the affected eye. Certainly, that may help your diagnosis and solidify your diagnosis, especially if you see severe NPDR with maybe some small nubbings of neovascularization in the other eye or even non-perfusion, then you're absolutely certain here that you're dealing with, for example, PDR. But for example, if you see very mild NPDR, then you maybe also steer towards, for example, ocular ischemic syndrome. And this is what we were discussing before about basically using the other eye as an information to guide you towards that. So certainly here, I think anti-VEGF here, it's the first step.
Ogul Uner (19:53):
And if a patient doesn't wish to perform anti-VEGF, which they could for a variety of different reasons, how often would you follow this patient?
Aris Thanos (20:02):
Certainly, to begin with, especially with a reliable ultrasound here, and of course with all the limitations that we've mentioned before, certainly first I would ask him to return back again in another two weeks or so then with increasing intervals basically when I'm also getting confident that yes, nothing is changing inside the eye. But at the same time also I need to also understand the patient's concerns in terms of why he is refusing the standard of care and how could I change some sort of false perception or fear or how can I help him basically pass that step here just to receive treatment because most likely he may need treatment in the other eye at some point.
Ogul Uner (20:57):
Definitely. And let's say you performed anti-VEGF injections; you cleared the vitreous hemorrhage. What would be your longer-term management of this patient if they have PDR?
Aris Thanos (21:09):
So yes, so certainly this is something that has been evaluated in several clinical trials as to whether do we go with PRP versus continuation of anti-VEGF monotherapy. And this is where a lot of the discussions and consults are coming with the patient in terms of risks and benefits of its procedure, maintaining the patient on Q12, Q16, anti-VEGF injections versus filling in some PRP. What is the likelihood that this patient may not follow up? So certainly, this is all of these things that we need to put into the equation before we come to a solid treatment plan.
Ogul Uner (22:00):
And we know that longstanding vitreous hemorrhage can also have some complications if we don't do anything about it, or even if we do, we can see some degenerated red blood cells. So, talk more perhaps about how often we see these and what types of other complications we can see, not just from a retina standpoint, but for the rest of the eye.
Aris Thanos (22:26):
Yes, exactly. So sometimes we see patients that have great gaps in care in diabetes, especially that come with just fundus obscuring, completely de-hemoglobinized vitreous hemorrhages. Sometimes they may have increased in the eye pressure from cell glaucoma. Certainly, these patients will tell you, "Well, yes, I haven't been able to see well for two years." And I think these are the patients that are the most appreciative after the vitrectomy. And I think if I recall correctly, I think the first vitrectomy that was done by Robert Machemer was on a vitreous hemorrhage, I believe from either one of the first two vitreous hemorrhage on a pregnant patient. So, something I'm hoping I'm not wrong on, but certainly this is where vitrectomy again is amazing in restoring the vision.
Ogul Uner (23:38):
I think it's important to keep in mind that this is a problem for the whole eye. So, it's important to make sure that the pressure is well controlled because as you said, those de-hemoglobinized cells can clog the trabecular meshwork. You can even get hemolytic glaucoma as well. So, in acute settings, especially if there's UGH syndrome, like you mentioned, you can get concomitant hyphemas. It's always important to do a complete exam and monitor and counsel our patients. And in patients with hemorrhagic PVDs, segueing to the non-diabetic patients, what is your follow-up protocol? So, let's say you have a hemorrhagic PVD, you don't see a tear, when would you see the patient back?
Aris Thanos (24:22):
So certainly, these are patients that I would bring back a little bit sooner within one to two weeks just to recheck good thorough depressed examination and make sure that they don't develop a tear. Certainly, these are, especially on the scleral depressed examination, you can get a lot of cues about abnormal vitreous base insertion. So, these are the things that you should be looking for in order to see, well, this looks like an abnormal vitreoretinal interface. This patient may benefit from closer follow-up, but certainly uncomplicated posterior vitreous detachment without vitreous hemorrhage, yes, we know four weeks. This is the American Academy of Ophthalmology Preferred Practice Pattern. But certainly, somebody comes with, depending also on the degree of the vitreous hemorrhage, certainly may need to be seen within a week and then with increasing intervals afterwards based on the exam.
Ogul Uner (25:26):
I think you hit it spot on that we talked about the higher incidence of retinal tears and detachments in this population. So generally, a week follow up and then if it's good, maybe you can see him back another three to four weeks, then you can start extending to a few months and very important to perform a thorough scleral depressed exam and give good return precautions to the patient. So, I think you focused on that really well. Let's summarize what we learned from Dr. Thanos. Vitreous hemorrhage occurs due to either a rupture of normal vessels through a mechanical force like a PVD or due to pathological structures leading to bleeding like neovascularization. In adults, it presents as a sudden painless vision loss with floaters. The most common etiologies in adults in the absence of trauma are PDR, retinal tear, hemorrhagic PVD, a rhegmatogenous retinal detachment and vein occlusions in that order.
(26:20):
However, don't assume diabetic retinopathy even in diabetics. Rule out globe injury if there's trauma, look for neovascularization of the iris or angle, assess for the lens position, and perform a thorough scleral depressed exam and a B scan, especially if the hemorrhage is too dense. The fellow eye can contain important clues like we focused on throughout the episode to the etiology of bleeding. About 50 to 70% of hemorrhagic PVDs are associated with retinal tears, so this warrants careful examination and follow up in one to two weeks if no tears or detachments are found on the initial exam. Eye patching and elevating the head of the bed can help clear the hemorrhage sooner but remember that not all of it can go away and it can de-hemoglobinize over time. Vitrectomy is essential for cases with retinal tears unable to be adequately lasered or cryoed or for detachments or in cases where we don't know why it's being caused.
(27:13):
Early vitrectomy can be considered in hemorrhage of unclear cause or NPDR that does not clear with anti-VEGF or ghost cell glaucoma where degenerated blood cells accumulate and block the trabecular meshwork. As a visual prognosis significantly differs based on the underlying etiology, as you said, Dr. Thanos, patients can have 20/20 vision or they may have really poor vision depending on the structures involved. It's important to provide individualized patient education and strict return precautions to make sure that our patients are thoroughly advised and that they can reduce the rate of complications from this condition. And Dr. Thanos, before we end the episode, I ask all of my guests a question. My question for you is if you could go back in time and give your younger self one piece of advice, what would it be?
Aris Thanos (28:03):
Well, I started my journey in becoming a vitreoretinal surgeon in the United States from my country in Greece where I graduated medical school. And certainly, along the way of obtaining a green card, I had to pass through different visas. And this is a big anxiety and sometimes could be also very, very restricting in terms of where you can train, where you can practice. So certainly, had I known, I would have consulted with probably an immigration lawyer a little bit earlier in this journey. But that being said, I don't regret a single step looking back. And after all, as we said, it's a journey and the journey sometimes matters. Sometimes there might be a little bit of stress with it, but I guess if we can avoid some of that stress, yes, an immigration lawyer could help with that.
Ogul Uner (29:10):
That's awesome. I fully sympathize with that and empathize with that answer as well as a fellow immigrant who is going through similar challenges. And I'm sure that a lot of our listeners can relate to a lot of the challenges that we go through in our journey. And so, I really liked how you emphasized that it's the journey that really counts and enjoying it along the way. 100%. Thank you so much.
Aris Thanos (29:35):
Thank you for having me.
Ogul Uner (29:36):
And thank you to our listeners. See you next time on the Pupil Pod.
