Viterous Hemorrage

8/20/2019 Viterous Hemorrage

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Journal o Ophthalmology

ollow-up examination and % remained undiagnosed afer year []. Little is known about the causes and visual prog-nosis o acute-onset VH o preoperatively unknown origin.Here, we analyzed the causes and overall visual prognosis o acute-onset VH o preoperatively unknown origin. We alsoanalyzed the characteristics o the ellow eye in all patients.

In addition, we generated a risk scoring system (RSS) to pre-dict visual prognosis o acute-onset preoperatively unknownorigin VH.

2. Materials and Methods

.. Study Design and Participants. Tis retrospective review was conducted on patients who underwent vitrectomy oracute-onset VH o preoperatively unknown origin at AsanMedical Center, Seoul, Republic o Korea, between January and June . Te ollowing inclusion criteria wereapplied:() a historyo -portpars plana vitrectomy oracute-onset VH, with or without cataract surgery, and () the cause

o acute-onset VH could not be preoperatively identiedbecause o dense VH which prevented retinal examination.Exclusion criteria included eyes with other ocular diseasesthat might affect vision, active intraocular inammationand/or inection, and VH caused by trauma. Patients withmore than mild nonprolierative diabetic retinopathy in theellow eye and those with grades III–IV AMD (AREDS (age-related eye disease study) classication) in the ellow eye werealso excluded. Tis study was approved by the institutionalreview board o Asan Medical Center and ollowed the tenetso the Declaration o Helsinki (-).

.. Primary and Secondary Objectives. Te primary objec-

tive o this study was to analyze the causes o acute-onset VHo preoperatively unknown origin. Te secondary objectiveso this study were to determine () the causes o acute-onsetVH o preoperatively unknown origin according to age, ()the visual prognosis o acute-onset VH o preoperatively unknown origin, () differencesin the baseline characteristicsaccording to postoperative diagnosis, and () characteristicso the ellow eye and () to devise an RSS or predictingthe visual prognosis o acute-onset VH o preoperatively unknown origin.

.. Ophthalmic Examinations. All included patients under-went a complete bilateral ophthalmic examination, including

determination o BCVA using the Snellen chart. BCVA resultswere converted to the logMAR scale. Patients who were only able to count ngers, were only able to detect hand motion,hadlight perception, or hadno light perception were assignedlogMAR values ., ., ., and ., respectively []. Allpatients also underwent biomicroscopic examination, dilatedundus examination, and undus photography o both eyes.Ultrasonography was perormed on all eyes with VH o preoperatively unknown origin.

.. Identication of Causes of Acute-Onset VH of Preopera-tively UnknownOrigin. Te postoperative diagnosis o acute-onset VH o preoperatively unknown origin was identied

by thorough review o each patient’s medical records. Wedivided all included patients according to age (≤, –,and > years), andthe causes o VH were analyzed accordingto age.

.. Surgical Procedures. Vitrectomy was perormed by well-

experienced retinal surgeons (Joo Yong Lee, June-GoneKim, and Young Hee Yoon). A -gauge, -gauge, and -gauge vitrectomy system was used to perorm -port vit-rectomy. Cataracts were extracted by phacoemulsication i the crystalline lens had signicant opacity. Afer resolvingthe VH, which obscured retinal inspection, we attempted todeterminethe causeo VH andrecordedthe underlying causeo VH as an operative note. Afer completing vitrectomy,eyes with retinal break received peruoropropane (C3F8) gastamponade. For complicated cases, such as those with severetractional retinal detachment or multiple retinal breaks,silicone oil tamponade was perormed. Te silicone oil wasremoved months later.

.. Statistical Analysis. One-way ANOVA and the Boner-roni post test were used to analyze the visual prognosis o VH according to the postoperative diagnosis. According tothe postoperative diagnosis, the clinical characteristics wereanalyzed using one-way ANOVA with the Bonerroni posttest and Pearson Chi-square test. Finally, to develop an RSSor predicting visual prognosis o acute-onset VH o pre-operatively unknown origin, multivariate logistic regressionmodeling was perormed. Risk actors were selected usingbackward elimination rom the ull logistic model. Modeldiscrimination was estimated using C -tatistic (or AUC),and calibration was assessed by determining agreement

between the predicted and recorded prognosis o acute-onset VH o preoperatively unknown origin. We ran aninternal validation o discrimination (C -statistic) to pro-duce optimism-corrected values o the C -statistic by usingbootstrapping with replications o individuals that weresampled with replacement []. Afer considering the inter-nally validated variables, we developed a scoring systemusing the model parameter estimates described by Sullivanet al. []. ROC curves rom the original model and scoringsystem are presented. SPSS (version .; SPSS, Inc., Chicago,IL) and R .. (ree sofware that can be downloaded athttp://www.r-project.org/) with package “boot” and “pROC”were used to perorm the statistical analyses.

3. Results

In total, eyes in patients underwent vitrectomy orVH at Asan Medical Center between January and June. Among these patients, the underlying cause o VH was not identied in eyes in patients (.%),and these patients thereore satised the inclusion criteria orenrollment.

.. Primary Objective. Te postoperative diagnoses o acute-onset VH o preoperatively unknown origin are listed inable . RVO ( eyes, .%) was the most common cause.


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: Causes o acute-onset vitreous hemorrhage (VH) o preop-eratively unknown origin.

Underlying causes o VH Eyes, (%)

Retinal vein occlusion (.%)

Central retinal vein occlusion (CRVO) / (.%)

Branch retinal vein occlusion (BRVO) / (.%)

BRVO with oveal involvement / (.%)

Vitreous hemorrhage with retinal break (.%)

Age-related macular degeneration (.%)

Macroaneurysm (.%)

Eales disease (.%)

Coats’ disease (.%)

Idiopathic (.%)

otal (%)

All RVO eyes had branch retinal vein occlusion (BRVO).Tere were no cases o central or hemiretinal vein occlusion.

Among the eyes with BRVO, oveal involvement wasonly ound in eyes (.%). Fify (.%), (.%), and (.%) eyes were diagnosed with retinal break, wet age-related macular degeneration (wAMD), or retinal arterialmacroaneurysm, respectively, as the cause o preoperatively unknown VH. In eyes (.%), we could not identiy any retinal pathology even afer vitrectomy.

.. Secondary Objectives. Te causes o acute-onset VH o preoperatively unknown origin according to age are shownin Figure . We divided all included patients according toage (≤, –, and > years). In patients aged ≤years, retinal break was the most common cause o acute-onset VH o preoperatively unknown origin; however, theproportion o patients with retinal break declined with age.By contrast, the proportion o patients with wAMD increasedwith age. Among patients aged > years, RVO was the mostcommon cause o acute-onset VH o preoperativelyunknownorigin. Visual prognoses according to postoperative diagnosisare shown in Figure . Afer vitrectomy, logMAR BCVAimproved rom . ± . to 0.47 ± 0.71. PreoperativelogMAR BCVA signicantly differed according to the post-operative diagnosis. Te preoperative logMAR BCVA valueso the wAMD patients were signicantly poorer than those o other patients (wAMD, 2.37 ± 0.36; RVO, 1.87 ± 0.58; retinalbreak, 1.97 ± 0.57; = 0.001). Te postoperative logMAR

BCVA values o the wAMD patients were also signicantly worse than those o other patients (wAMD, 1.65± 0.88; RVO,0.30±0.43; retinal break, 0.21±0.40; < 0.001). Visual acuity changes afervitrectomy accordingto postoperative diagnosisare shown in Figure . BCVA signicantly improved afer

vitrectomy among the RVO, retinal break, and idiopathicpatients. However, vision did not improve afer vitrectomy inwAMD patients.

Te clinical characteristics o VH according to postopera-tive diagnoses are listed in able . Mean age signicantly di-ered according to the postoperative diagnosis. Te mean ageo the wAMD patients was signicantly higher than that o the patients with RVO or retinal break (wAMD, . ± .

60

50

40

30

20

10

0

( %

)

Retinal break

RVO

wAMD

Age ≤ 60 60 70

F : Causes o acute-onset vitreous hemorrhage o unknown

origin according to age. Among patients aged ≤ years, retinalbreak was the main cause o acute-onset VH o preoperatively unknown origin. Moreover, the proportion o cases o acute-onsetVH o preoperatively unknown origin that was due to retinal break declined with age. In contrast to retinal break, the proportion o vitreous hemorrhage due to wAMD increased with age. Amongpatients aged > years, RVO was the most common cause o acute-onset VH o preoperatively unknown origin. RVO, retinal veinocclusion; wAMD, wet age-related macular degeneration.

years; RVO, 65.36 ± 9.82 years; retinal break, 58.50 ± 11.78

years; = 0.001). Systemic hypertension was morerequently associated with RVO and wAMD patients.Te characteristicso the ellow eyes among patients with acute-onset VH o preoperatively unknown origin are shown in able .Telog-MAR BCVA values o the ellow eyes in wAMD patients werealso signicantly lower than in other patients (wAMD, . ±.; RVO, 0.17 ± 0.38; retinal break, 0.05 ± 0.09; < 0.001).Drusen was more signicant in the ellow eyes o wAMDpatients than in those o patients with RVO or retinal break (RVO, .%; wAMD, .%; retinal break, .%; < 0.001).

Te RSSs used to predict poor visual outcomes afer vitrectomy among patients with acute-onset preoperatively unknown origin VH are shown in able , and the risk scores

o the included acute-onset VH o preoperatively unknownorigin patients are shown in able . Te multivariate logisticregression model shows that old age, poor preoperative visualacuity in both the affected and ellow eyes, and drusen inthe ellow eye were signicantly associated with a poor visualprognosis afer vitrectomy. Te AUC o the scoring systemwas . (% condence interval [CI] = .–.).Internal validation was investigated using the bootstrap val-idation algorithm. Te optimism-corrected AUC was .,which indicates the reliability o the RSS (Figure ). In thisRSS model, the maximal summation o risk score was −.Tereore, to prevent obtaining a negative integer or the risk score, we added to each estimated risk score.


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: Clinical characteristics o acute-onset vitreous hemorrhage (VH) o preoperatively unknown origin.

All RVO wAMD Retinal break Other

Number o eyes .

Age (y) . ± . . ± . . ± . . ± . . ± .


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: Findings in the ellow eye o acute-onset vitreous hemorrhage (VH) o preoperatively unknown origin.

All RVO wAMD Retinal break

LogMAR BCVA . ± . . ± . . ± . . ± .


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: Risk scores o study patients with acute-onset vitreous hemorrhage (VH) o preoperatively unknown origin.

Score∗ Estimated chance having good visionAll included patients

Snellen visual acuity


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1.0

1.0

0.8

0.8

0.6

0.6

0.4

0.4

0.2

0.0

0.2 0.0

S e n s i t i v i t y

1 − specicity

F : ROC curves o the scoring system used to predict the visual prognosis o acute-onset VH o preoperatively unknownorigin. Te solid line shows the ROC curves o our variables (age,baseline BCVA o the affected eye, baseline BCVA o the unaffectedeye, andage-relatedmacular changes in the ellow eyes), which weresignicantly associated with poor visual acuity ollowing vitrectomy.Te dashed line shows the ROC curve o the scoring system. TeAUC o the scoring system was . (% CI = .–.).

o oveal involvement, the visual prognosis o RVO as causeo acute-onset VH o preoperatively unknown origin was rel-atively good. By contrast, among wAMD patients with acute-onset VH o preoperatively unknown origin, the visual prog-nosis was poor due to subretinal disciorm scar ormation.

We also developed an RSS to predict the visual prognosiso unknown origin VH. Our multivariate logistic regressionmodel showed that () old age, () poor preoperative visualacuity in the affected eye, () poor preoperative visual acuity in the ellow eye, and () drusen in the ellow eye are sig-nicantly associated with poor visual prognosis afer vitrec-tomy. Te sensitivity and specicity values o this scoringsystem were . and ., respectively. With this simple RSS,we could predict the visual prognosis o acute-onset preoper-atively unknown origin VH ollowing vitrectomy. Because o the retrospective nature o this study, we could not validate

the accuracy o this RSS. We thereore plan to conduct auture prospective study to validate this system.

o the best o our knowledge, this is the rst study toanalyze the causes and visual prognosis o acute-onset VH o preoperatively unknown origin. However, our analyses hadlimitations that are inherent to its retrospective design. Inaddition, this study was conducted at a single tertiary reer-ring center, which might have caused some selection bias. Tesample size o this study was also relatively small, which may have limited the statistical strength o the analysis. Tereore,uture studies that examine a larger number o patients areneeded to conrm the causes and visual prognosis o acute-onset VH.

In conclusion, the rst, second, and third most commoncauses o acute-onset VH o preoperatively unknown originwere RVO, retinal break, and wAMD, respectively. In addi-tion, the most common cause o acute-onset VH o preop-eratively unknown origin changed according to patient age.Te visual prognosis o unknown origin VH was relatively

good, except among AMD patients. Afer considering age,preoperative BCVA, and the characteristics o the ellow eye,we predicted visual prognosis o unknown VH. Furthermore,the characteristics o patients with poor visual outcomesollowing vitrectomy include () old age, () low preoperative

visual acuity in the affected and ellow eyes, and () age-related macular changes in the ellow eye. Tereore, in thesepatients, we expect visual prognosis o acute-onset VH o preoperatively unknown origin to be poor.

Financial Disclosures

All authors certiy that they have no affiliations with or

involvement in any organization or entity with any nancialinterest (such as honoraria; educational grants; participationin speakers’ bureaus; membership, employment, consultan-cies, stock ownership, or other equity interest; and experttestimony or patent-licensing arrangements), or nonnancialinterest(such as personal or proessional relationships,affilia-tions, knowledge or belies) in the subject matter or materialsdiscussed in this paper.

Conflict of Interests

Te authors declare that there is no conict o interestsregarding the publication o this paper.

Authors’ Contribution

Dong Yoon Kim, Joo Yong Lee, and June-Gone Kim designedthe study. Dong Yoon Kim, Seunghee Baek, and Joo Yong Leemanaged the data. Dong Yoon Kim, Joo Yong Lee, Soo GeunJoe, June-Gone Kim, and Joo Yong Lee analyzed, collected,and interpreted the data. Dong Yoon Kim, Seunghee Baek,Joo Yong Lee, Soo Geun Joe, June-Gone Kim, and Joo YongLee prepared the paper, perormed the statistical analysis,and interpreted the data. Dong Yoon Kim, Joo Yong Lee, SooGeun Joe, Seunghee Baek, June-Gone Kim, and Joo Yong Leereviewed and approved the paper.

Acknowledgment

Tis study was supported by a grant (-) rom theAsan Institute or Lie Sciences, Seoul, Republic o Korea.

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Viterous Hemorrage