Neodymium:YAG laser treatment for a premacular haemorrhage in a T cell lymphoblastic lymphoma patient

T cell lymphoblastic lymphoma is a high grade non‐Hodgkin's lymphoma commonly found in children and characterised by haematological abnormalities such as anaemia, leucopenia, and thrombocytopenia.¹ Although rare, ocular manifestations may result in intraretinal, preretinal, and premacular haemorrhages. Similar to other conditions such as proliferative diabetic retinopathy, Valsalva retinopathy, and retinal macroaneurysms, a premacular haemorrhage may develop, acutely decreasing vision and take several months to spontaneously reabsorb. We report a patient with T cell lymphoblastic lymphoma and a large premacular haemorrhage treated effectively with a neodymium:YAG laser.

Case report

A 21 year old man with a history of stage IV T cell lymphoblastic lymphoma previously treated with chemotherapy consisting of ifosfamide, etoposide, and cytarabine presented with a 1 week history of decreased vision in both eyes. Visual acuity was initially counting fingers at 3 feet in the right eye and 20/200 in the left eye. His pupils were equal and reactive, with no afferent pupillary defect. Anterior examination was normal while dilated funduscopic examination revealed diffuse intraretinal haemorrhages in both eyes with a large premacular haemorrhage in the right eye (fig 1A) and a smaller one in the left eye. Laboratory values measured his white blood count at 8100 ×10⁶/l with 89% blast cells, a haematocrit level of 22.8%, and platelet level of 24 ×10⁹/l.

Figure 1 (A) Before treatment with the neodymium:YAG laser, the right eye shows diffuse intraretinal haemorrhages and a large premacular haemorrhage. (B) Immediately after treatment, a hole has been made in the posterior hyaloid with subsequent draining into the inferior vitreous. (C) Two minutes after treatment, the level of the premacular haemorrhage has further declined. (D) The day following treatment the premacular haemorrhage has nearly cleared.

The patient was currently under hospice care and no drastic measurements were desired. However, he was concerned about the acute decrease in vision, therefore a neodymium:YAG laser (one shot at 2.7 mJ) was used to create a hole in the posterior hyaloid. Immediately following treatment, the haemorrhage drained inferiorly into the vitreous space (fig 1B, C). He returned the following day and his vision improved to 20/200 in the right eye with nearly complete resolution of the premacular haemorrhage with no signs of a macular hole (fig 1D).

Comment

Observation is usually the first line of treatment of premacular haemorrhages in a variety of conditions including proliferative diabetic retinopathy, central retinal vein occlusion, Valsalva retinopathy, and retinal macroaneurysms. However, these haemorrhages may take several months to spontaneously reabsorb and may be associated with macular traction with profound implications for visual prognosis.² Alternatively, attempts at a pars plana vitrectomy have been described to successfully treat the premacular haemorrhages to improve visual acuity.³ In addition, there are limited reports showing the beneficial use of applying neodymium:YAG laser or krypton laser to disrupt the posterior hyaloid allowing drainage of the premacular haemorrhage.⁴,⁵,⁶ The procedure is not without risk as macular hole formation and retinal detachment have been described.⁶

The use of the neodymium:YAG laser to clear the premacular haemorrhage in our patient with metastatic T cell lymphoblastic lymphoma resulted in immediate drainage into the inferior vitreous with improved visual acuity and no complications. This approach may be considered as an alternative therapy to clear a premacular haemorrhage in similar patients who are unable to undergo surgery or wait for the haemorrhage to spontaneously reabsorb.