Intraoperative optical coherence tomography (I-OCT)-guided identification of resolved sub-internal limiting membrane hemorrhage in leukemic retinopathy

Field: Medicine (Health Sciences)

A 17-year-old male with acute myeloid leukemia (AML), presented with diminution of vision OS for 6 months. The best-corrected visual acuity was 6/9 OD and 4/60 OS. Anterior segment OU was normal. Fundus revealed pale disc OD with multiple areas of well-circumscribed pigmentary changes [Figure 1a] and vitreous hemorrhage OS. The patient underwent OS 25-G vitrectomy after informed consent. After clearing hemorrhage and induction of posterior vitreous detachment (PVD), multiple pigmented areas similar to OD including one at macula were noted [Figure 1b]. Intraoperative optical coherence tomography (I-OCT) revealed them to be areas of regressed sub-internal limiting membrane (ILM) hemorrhage with premacular cavity [Figure 2a and b] Besides, the underlying macula was found to be thinned out. Brilliant blue G-assisted ILM peeling was done at the macula and routine postoperative treatment was given. At 1-month postoperatively, visual acuity improved to 6/60. Fundus revealed multiple such patches in the periphery and OCT revealed macular atrophy [Figure 3a and b].Figure 1: (a) Ultrawide field image OD showing pale disc, peripapillary atrophy, and multiple well-circumscribed areas of pigmentary changes; (b) intraoperative image after clearing of media in OS showing multiple areas of pigmentary disturbance (white arrows)Figure 2: After completing vitrectomy, intraoperative optical coherence tomography through the peripheral (a) and macular lesion (b) showing premacular cavity and thinning of the underlying retina. Altered blood is visible along the inferior margin of elevated ILM in both the lesions (white arrows)Figure 3: (a) Postoperative ultrawide field image OS showing pale disc, peripapillary atrophy, and multiple well-circumscribed areas of pigmentary changes (white arrows); (b) OCT through showing foveal atrophy and remnant of the internal limiting membrane (white arrow)Discussion PIONEER and DISCOVER studies have demonstrated the usefulness of I-OCT in intraoperative surgical decision making in a significant number of posterior and anterior segment surgeries.[1,2] Though altered blood visible along inferior margins [Figure 2] pointed towards the possibility of sub-ILM hemorrhage, the shape as well as the color of the lesions was not characteristic of premacular cavity and resembled retinal pigment epithelium alterations. I-OCT helped us to confirm the presence of premacular cavity, which led us to the diagnosis of resolved sub-ILM hemorrhage.[3,4] Since the vitreous had already been removed, the possibility of subhyaloid hemorrhage was not considered. Intraoperative diagnosis of atrophic macula helped us to explain prognosis to the patient.[5] I-OCT may, therefore, act as a useful tool for documentation, an integral part of modern medicine. Intraoperative feedback from I-OCT helped us in the characterization of resolved sub-ILM hemorrhage, guiding surgical decision to peel ILM and in explaining the expected prognosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflict of interest There are no conflicts of interest.