Intraoperative optical coherence tomography guided removal of premacular hemorrhage in Valsalva retinopathy

Manuscript received: 18.10.15; Revision accepted: 29.02.16 A 32‐year‐old male presented with 4 weeks history of sudden decrease of vision in his right eye following a bout of cough. The left eye was normal. The anterior segment in the right eye was normal. A dilated fundus of the right eye showed a 6 mm × 4 mm area of premacular hemorrhage [Fig. 1a]. Spectral domain optical coherence tomography (SD‐OCT) showed smooth convex dome‐shaped hyper‐reflectivity from blood with shadowing underneath [Fig. 1b]. After informed consent, the patient underwent 25‐gauge pars plana vitrectomy with removal of premacular blood. The premacular blood remained unchanged after triamcinolone‐assisted posterior vitreous detachment [Fig. 2]. The internal limiting membrane (ILM) was then stained with the help of brilliant blue G dye. After ILM peeling had been initiated, microscope‐integrated intraoperative OCT (Rescan 700, Carl Zeiss Meditec, Germany) confirmed the location of blood in the sub‐ILM space as the lifted torn edge of ILM was seen over the hemorrhage [Fig. 3a]. The ILM was seen as a separate undulating membrane now over the surface of hyper‐reflective hemorrhage where ILM was yet to be peeled [Fig. 3b]. Once ILM peeling was complete, the surface of hemorrhage became irregular [Fig. 3c]. The hemorrhage was then cleared with the help of passive suction. The underlying retina showed flattened foveal contour. The fluid‐air exchange was done and sclerotomies were messaged to prevent any leakage. The patient was advised topical steroids and antibiotics along with cycloplegic.