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Am J Ophthalmol Case Rep
Am J Ophthalmol Case Rep
American Journal of Ophthalmology Case Reports
2451-9936
Elsevier

S2451-9936(24)00165-8
10.1016/j.ajoc.2024.102155
102155
Case Report
Two cases of avulsed retinal vessel syndrome with different course
Washio Noriaki wassie197405@gmail.com
⁎
Tsuchida Nobuo
Tsuchida Eye Clinic, Kodaira City, Tokyo, Japan
⁎ Corresponding author. 2-9-6 Hanakoganei, Kodaira City, Tokyo, 187-0002 , Japan. wassie197405@gmail.com
23 8 2024
12 2024
23 8 2024
36 1021551 4 2024
23 7 2024
21 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Purpose

To report two cases of vitreous hemorrhage caused by avulsed retinal vessel syndrome (ARVS), one of which was successfully treated without vascular occlusion.

Observations

A 62-year-old female presented with vitreous hemorrhage of unknown origin. We performed vitrectomy and found a detached and ruptured retinal vein below the optic nerve head. After coagulating the peripheral side of the blood vessel, we were able to prevent the recurrence of vitreous hemorrhage. However, she developed branch retinal vein occlusion and subsequently macular edema. In the other case, a 71-year-old woman also had vitreous hemorrhage, but the fundus was partially visible. The retinal vein in the superior nasal quadrant was detached from the retinal surface and bled into the vitreous cavity. We performed vitrectomy to relieve the vitreous traction. Although we did not coagulate the vein, there was no recurrence of vitreous hemorrhage after surgery.

Conclusions and Importance

By releasing the vitreous traction with vitrectomy, we were able to treat the patient with ARVS without vascular occlusion.

Keywords

Avulsed retinal vessel syndrome
Vitreous hemorrhage
Vitrectomy
Vascular occlusion
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pmc1 Introduction

Avulsed retinal vessel syndrome (ARVS) is a condition characterized by the detachment of retinal vessels from the retinal surface due to vitreous traction.1 While it is often associated with retinal detachment and proliferative diabetic retinopathy,1,2 it is rarely seen in isolation.2, 3, 4, 5, 6, 7, 8 Due to its potential to cause vitreous hemorrhage, interventions such as coagulation of the detached vessels, scleral buckling, or other therapies have been performed to prevent bleeding.1,3, 4, 5, 6, 7, 8, 9 Previously, vascular occlusion was considered essential for its resolution.1,7,10 However, it has since been reported that this condition can be treated simply by releasing the vitreous traction using YAG laser.3

In this study, we report two cases of vitreous hemorrhage due to ARVS, for which we performed vitrectomy. Notably, we successfully treated one case without vascular coagulation by releasing the vitreous traction.

2 Case report

Case 1: A 62-year-old woman presented to us with difficulty seeing in her right eye for approximately one month. She had a history of hypertension and dyslipidemia, but was not diabetic and was not taking anticoagulants. At the initial examination, her best corrected visual acuity (BCVA) was hand motion in the right eye and 20/16 in the left eye, and mild cataracts were observed in both eyes. The fundus of the right eye was obscured due to vitreous hemorrhage. Ultrasonography revealed incomplete posterior vitreous detachment. We proceeded with vitrectomy and cataract surgery. During the surgery, we identified a detached and ruptured retinal vein below the optic disc that was bleeding. There were no other retinal tears, retinal neovascularization, or other lesions that could have caused vitreous hemorrhage. We coagulated the peripheral end of the vein to halt the bleeding. Postoperatively, there was no rebleeding in the vitreous and her BCVA improved to 20/16. However, retinal hemorrhage on the inferior area gradually developed and worsened, resulting in macular edema (Fig. 1A–E) and a decrease in her BCVA to 20/25. After an intravitreal injection of aflibercept, the edema subsided (Fig. 1 F) and her BCVA was restored to 20/16.Fig. 1 Fundus photos and optical coherent tomography images of case 1.

A: On the day after the surgery, a minor hemorrhage was observed on the inferior retina. B, C: The retinal hemorrhage gradually worsened (as shown in the photos taken one week and three months after surgery, respectively). D: The ends of the avulsed vessel (arrow); most of the vessel in the avulsed area have been removed. E: Macular edema was observed one month after surgery. F: The edema had subsided two weeks after vitreous injection.

Fig. 1

Case 2: A 71-year-old woman presented to us with black streaks in her right eye that had appeared a few hours earlier. She had undergone interferon treatment for hepatitis C, but she was not diabetic and was not taking anticoagulants. At the initial examination, her BCVA was 20/63 in the right eye and 20/20 in the left eye. She exhibited pseudoexfoliation in the right eye and mild cataracts in both eyes. The fundus of the right eye showed vitreous hemorrhage, though the upper part of the fundus remained visible. She had a detached retinal vessel on the superior nasal surface, which did not involve a retinal tear, but from which hemorrhage was observed into the vitreous cavity. As she was about to go on a trip, we decided to adopt a wait-and-see approach. Upon her return to our clinic five days later, the vitreous hemorrhage had worsened to the point that intraocular observation was almost impossible, and her visual acuity had deteriorated to mere light perception. She wanted her vision restored early, so we proceeded with vitrectomy and cataract surgery. During the surgery, we found that the vitreous body was attached to the detached vessels and was exerting traction (Fig. 2 A). We carefully removed the vitreous and released the traction, taking utmost care to avoid any damage to the vessels. As there was no new bleeding from the detached vessel, we completed the surgery without coagulation. Postoperatively, the detached blood vessel remained detached from the retinal surface (Fig. 2 B), but there was no recurrence of vitreous hemorrhage, and her BCVA improved to 20/20.Fig. 2 Fundus photos of case 2.

A: At the initial visit. Hemorrhage into the vitreous cavity from the avulsed vessels (circle) was observed. B: After surgery. No hemorrhage was visible, but the avulsed vessel remained detached (circle).

Fig. 2

3 Discussion

The primary objective of ARVS treatment is to prevent vitreous hemorrhage, and several methods have been attempted.1,3, 4, 5, 6, 7, 8, 9 Laser coagulation has been utilized to occlude avulsed vessels.1,3,10,11 However, achieving complete occlusion can often be challenging. Moreover, this method frequently requires multiple treatments, which raises concerns about the potential adverse effects of prolonged laser exposure.4

The fundamental treatment is considered to be the removal of vitreous traction. In this respect, vitreous amputation using the YAG laser appears to be a logical approach.3 However, it still presents several challenges: it may require multiple treatments, it cannot be applied when detached vessels are close to the retinal surface due to the risk of retinal damage,3 and the laser procedure itself cannot be performed if there is significant vitreous hemorrhage. Scleral buckling has also been utilized. However, it may lead to post operative vitreous hemorrhage,5,6 and it is not indicated for cases located at the posterior pole, which limits its applicability. Furthermore, if the hemorrhage is still substantial, this treatment is not indicated because the location of the hemorrhage cannot be determined. Although vitrectomy has been reported, it was a method that involves coagulation and occlusion of the vessels, and did not preserve the blood flow.6,7

In this study, we performed vitrectomy in two patients with thick vitreous hemorrhage caused by ARVS. In the first case, the blood vessel was already ruptured, so coagulation occlusion was the only option. This resulted in postoperative branch retinal vein occlusion and necessitated additional treatment due to the development of macular edema.

Vitreous hemorrhage can cause severe visual dysfunction, necessitating treatment to prevent hemorrhage. However, occlusion of the blood vessels for this purpose may lead to impaired blood flow and postoperative complications, as seen in the first case. Therefore, it is desirable to preserve the blood vessels if possible. In the second case, there was no complete rupture of the vessel, and no new bleeding from the vessel wall was observed at the time of surgery. Consequently, we were able to treat the patient without resorting coagulation and occlusion of the vessels by simply removing the vitreous traction.

Although the YAG laser and scleral buckling techniques preserve blood flow similarly to our method, ours may offer advantages in the following aspects: it can treat cases where the operative field is obscured by vitreous hemorrhage, it is not dependent on the location of the site (whether peripheral or posterior pole), and it has the ability to remove the hemorrhage simultaneously. Despite the challenge posed by the surgical technique's difficulty, which requires careful manipulation due to the risk of avulsed vessels being easily sucked into the vitreous cutter, this treatment method is considered to provide significant benefits for the patient. Although patients in these cases chose surgery, it may not always be the optimal treatment, as the bleeding could potentially resolve spontaneously without surgical intervention. The limitations of this study, due to its small sample size, suggest that a larger series or a randomized controlled trial would be required to definitively determine the optimal management for these patients.

4 Conclusions

We performed vitrectomy in two cases of vitreous hemorrhage due to ARVS, one of which could be treated without vascular occlusion.

Patient consent

The patients consented to publication of the case in writing.

Funding

No funding or grant support.

Authorship

All authors attest that they meet the current ICMJE criteria for Authorship.

CRediT authorship contribution statement

Noriaki Washio: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Nobuo Tsuchida: Writing – review & editing, Funding acquisition, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

None.
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