Alex Kolesar Diabetes Information

What if there is a vitreous hemorrhage but no obvious neo

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Although knowing when to intervene earlier is important, it is also good to know when to hold off. Such a situation may occur when you are faced with a patient who has a vitreous hemorrhage but no evidence of neovascularization. The DRS showed that a vitreous hemorrhage alone is generally not an indication for PRP, but this is true only if you are certain there is no neovascularization. If there is a localized preretinal hemorrhage that blocks the view of a section of the retina, or a dense vitreous hemorrhage that allows only a limited view, it is usually best to assume there are new blood vessels somewhere and treat the patient.

Remember that if the hemorrhage is so dense that there is no view, you have to get an ultrasound to be sure the retina is not being pulled off. You are taking a big risk for both yourself and your patient if you can't see the retina and you don't get an ultrasound; if something is going wrong back there, it is usually bad to do nothing.

The nature of the retinopathy in the fellow eye can help in such a situation, too. If the fellow eye has already had proliferative disease that required laser, it is worthwhile considering laser in the second eye even if you do not see any obvious neovascularization. On the other hand, if there is only minimal diabetic disease in the fellow eye, observation may be the best course.

If the hemorrhage is mild, though, you need to study the retinal periphery carefully, or even consider fluorescein angiography to help you decide whether there are new vessels. If there are no vessels, then it is definitely better to watch such patients; recall that the diabetic vitreous is sticky and is more likely to break a few capillaries if it separates. You will end up needlessly burning retina if you automatically treat every diabetic with a mild vitreous hemorrhage.

Finally, for the second time in the same chapter, never forget that diabetics can get non-diabetic problems such as retinal tears, so remember to inspect the far periphery closely—don't just look in the mid-periphery and quit if you don't see anything.