Multifaceted approach to evacuating multi-level premacular hemorrhage in a case of suspected Valsalva retinopathy - a case report

Accurate localization of premacular hemorrhages (PMHs) is crucial as treatment strategies vary significantly based on whether the hemorrhage resides within the vitreous gel, subhyaloid space, or beneath the internal limiting membrane (ILM). This report outlines the clinical features, diagnostic findings, and treatment outcomes in a patient diagnosed with a PMH secondary to suspected Valsalva retinopathy.

This is a retrospective interventional case report.

A 43-year-old healthy male presented with sudden vision loss in his left eye, reporting a visual acuity of 6/120 since the previous evening. Fundus examination revealed a PMH characterized by a "double-ring sign" accompanied by diffuse retinal hemorrhages. Optical coherence tomography confirmed that the hemorrhage was located in the sub-ILM space. The patient underwent two sessions of YAG laser membranotomy, utilizing energies of 2.5 mJ and 5 mJ, which successfully facilitated drainage of fresh hemorrhage from the sub-ILM space to the subhyaloid space and vitreous cavity. However, the presence of residual coagulated blood over the fovea resulted in persistent visual impairment, necessitating a subsequent pars plana vitrectomy (PPV). The PPV, in conjunction with internal limiting membrane peeling, effectively removed the remaining blood in front of the fovea and restored the visual acuity. By postoperative day 3, the patient experienced a significant improvement in visual acuity, measuring 6/8.

This case underscores the importance of thorough clinical examination and precise diagnostic techniques in the individualized management of PMHs, which is essential for achieving optimal visual outcomes.