Diferentes abordajes en el manejo de las hemorragias maculares: reporte de casos y revisión de literatura / Different approaches in the management of macular hemorrhage: case reports and a literature review

INTRODUCCIÓN: Las hemorragias maculares producen una pérdida de la visión súbita y profunda. Las principales modalidades de tratamiento incluyen observación, inyección intravítrea de fármacos antiangiogénicos, hialoidotomía con láser neodymium-doped yttrium aluminium garnet, inyección intravítrea de gas y/o activador de plasminógeno tisular, en monoterapia o combinadas con cirugía. En el presente trabajo reportamos cuatro casos de hemorragias maculares de distintas causas, tratadas con diferentes abordajes, y realizamos una revisión de la literatura al respecto. PRESENTACIÓN DE CASOS: Los cuatro pacientes mostrados presentaron diferentes causas de hemorragias maculares. El primer caso tuvo una hemorragia prerretiniana debido a retinopatía de Valsalva y fue tratado con cirugía, el Caso 2 tuvo una hemorragia macular multinivel debido a una rotura de un macroaneurisma arteriolar retiniano y fue manejado con desplazamiento neumático, láser y ranibizumab intravítreo, el Caso 3 presentó una hemorragia subretiniana extensa debido a rotura coroidea posterior a un trauma ocular cerrado de alta energía y fue tratado exitosamente con cirugía. El último caso presentó una hemorragia prerretiniana debido a retinopatía diabética, manejada con láser neodymium-doped yttrium aluminium garnet. Los diferentes tratamientos fueron realizados exitosamente con buenos resultados. CONCLUSIÓN: Existen amplias opciones disponibles para el manejo de las hemorragias maculares y la mejor opción depende de las características de cada caso en particular. El manejo apropiado y oportuno de éstas puede lograr un resultado visual bueno, especialmente si la localización de la hemorragia es prerretiniana.

INTRODUCTION: Macular hemorrhages result in a sudden and profound loss of vision. The primary treatment modalities include observation, intravitreal injection of antiangiogenic drugs, neodymium-doped yttrium aluminum garnet hialoidotomy, intravitreal injection of gas with or without tissue plasminogen activator, as monotherapy or combined with surgery. In this paper, we report four cases of macular hemorrhages of different causes treated with different approaches, and we review the literature in this regard. CASE PRESENTATION: All four patients presented different causes of macular hemorrhage. The first case had a preretinal hemorrhage due to a Valsalva retinopathy and was treated with surgery. Case 2 had a multilevel macular hemorrhage due to a rupture of a retinal arteriolar macroaneurysm and was treated with pneumatic displacement, laser, and intravitreal ranibizumab. Case 3 presented an extensive subretinal hemorrhage due to a choroidal rupture after high-energy ocular trauma that was also successfully treated with surgery. The last case was a preretinal hemorrhage due to diabetic retinopathy managed with neodymium-doped yttrium aluminum garnet laser. Different treatment approaches were successfully performed in all cases with good outcomes. CONCLUSION: There is an extensive range of options available for the management of macular hemorrhages, and the best option depends on the characteristics of each particular case. Proper and timely management of these diseases can achieve an excellent visual outcome, especially if the location of the hemorrhage is preretinal.

Macular hemorrhage after roller coaster riding in a single-eyed patient with congenital glaucoma / Hemorragia macular após passeio em montanha russa em paciente monocular com glaucoma congênito

ABSTRACT A 21-year-old female presented with a 4-day history of decreased vision in her only functional eye (right eye, OD). She had a history of multiple ocular surgeries in both eyes because of congenital glaucoma and had lost light perception in her left eye several years prior. Ophthalmological examination revealed 0.15 Snellen visual acuity, and fundoscopy revealed nearly total cupping and pallor of the optic disc and multiple retinal hemorrhagic foci in the macula in OD. Lesions spontaneously resolved over a few months. Gravitational forces during a roller coaster ride may have caused this macular hemorrhage.

RESUMO Uma paciente de 21 anos de idade se apresentou com perda de visão há quatro dias em seu único olho com visão útil. Ela tinha uma história de cirurgias oculares múltiplas nos dois olhos devido a um glaucoma congênito e perda de percepção luminosa em olho esquerdo há muitos anos. O exame oftalmológico revelou acuidade visual de Snellen de 0,15 e na fundoscopia foi observada escavação do nervo óptico quase total e palidez de papila, assim como focos hemorrágicos múltiplos na região macular. As lesões se resolveram espontaneamente em alguns meses. Acreditamos que essas hemorragias maculares tenham sido causadas pelas forças gravitacionais geradas durante o passeio na montanha russa.

Intraretinal hemorrhage associated with visceral leishmaniasis / Hemorragia intrarretiniana associada à leishmaniose visceral

ABSTRACT Visceral Leishmaniasis, also know as Kala-azar, is a parasitic tropical disease caused by protozoa of the genus Leishmania donovani. It is an endemic disease in many countries. It affects approximately 1,5 million people every year, and when associated with mal-nutrition and co-infection it may be fatal. Fever, hepatosplenomegaly, and pancytopenia is its typical clinical picture. Ocular manifestations of Kalaazar are relatively rare and can affect either anterior or posterior segment of the eye. We report a patient with kala-azar presenting intraretinal hemorrhages that regress completely after the successful treatment for visceral leishmaniasis.

RESUMO Leishmaniose visceral, também conhecida como calazar é uma doença tropical parasitária, causada pelo protozoário do gênero Leishmania donovan uma doença endêmica em muitos países. Afeta aproximadamente 1,5 milhões de pessoas durante todo ano e quando associada à desnutrição e coinfecção pode ser fatal. Febre, hepatoesplenomegalia e pancitopenia e o quadro típico. Manifestações oculares são raras e podem afetar tanto o segmento anterior como o posterior do olho. Relatamos o caso de um paciente com calazar e hemorragia intrarretiniana que regrediu após tratamento para leishmaniose visceral.

Síndrome del niño sacudido o Shaken Baby Syndrome: Lesiones oculares / Shaken Baby Syndrome: Eye lesions

Introducción: el síndrome del niño sacudido se incluye en la clasificación del maltrato físico. Las lesiones oculares se deben a la tracción producida sobre la retina a partir del vítreo del niño, fuertemente unido a ella, con desgarro de las capas retinales y colección de sangre en la cavidad resultante (retinosquisis hemorrágica). Objetivo: describir las manifestaciones oftalmológicas iniciales y la evolución del síndrome del bebé sacudido. Materiales y métodos: se realiza un estudio descriptivo y retrospectivo de cuatro pacientes con el síndrome del niño sacudido. Las variables analizadas son: sexo, edad, fondo de ojos, ecografía ocular, tratamiento y evolución visual. Resultados: los casos 1 y 2 eran gemelos, uno de ellos presentó manifestaciones a nivel del fondo de ojos y el segundo no, ambos requirieron intervención neuroquirúrgica. El tercero presentaba lesiones a nivel ocular con opacidad de medios por lo cual se le realizó en ambos ojos vitrectomía exploradora. El cuarto caso se trataba de una paciente de 6 meses con hemovítreo en ojo derecho y retinosquisis hemorrágica en ojo izquierdo, y requirió vitrectomía para la resolución del hemovítreo, aunque el resultado visual fue desfavorable. Conclusión: el examen oftalmológico contribuye al diagnóstico del síndrome del bebé sacudido por lo que es necesario en la evaluación de los niños pequeños que presenten lesiones sospechosas de abuso (AU)

Introduction: Shaken baby syndrome is included in the classification of physical abuse. Ocular lesions in the infant are due to traction to the retina from the adjacent vitreous causing with tears of the retinal layers and blood collection in the resulting cavity (hemorrhagic retinoschisis). Objective: To describe early ocular manifestations and outcome of shaken baby syndrome. Material and methods: A retrospective, descriptive study was conducted in four patients with shaken baby syndrome. Sex, age, ocular fundus, ultrasonography, treatment, and visual outcome were analyzed. Results: Cases 1 and 2 were twins, one of them presented with fundus manifestations, the other did not; both required neurosurgical intervention. The third infant had eye lesions with media opacities and therefore exploratory vitrectomy was performed in both eyes. The fourth was a 6-month-old baby girl with hemovitreous in the right and hemorrhagic retinoschisis in the left eye. She required vitrectomy to resolve the hemovitreous, but the result was poor. Conclusion: Ophthalmological examination was useful in the diagnosis of shaken baby syndrome and should therefore be performed in little children in whom child abuse is suspected (AU)

Hemorrhagic retinopathy in an infant with hemolytic-uremic syndrome / Retinopatia hemorrágica em lactente com síndrome hemolítico-urêmica

We describe the case of a 23-month-old female infant with a diagnosis of hemolytic uremic syndrome (HUS) and hemorrhagic retinopathy. The patient had a past history of abdominal pain, bloody diarrhea, and acute renal failure. On ophthalmologic examination, indirect ophthalmoscopy revealed extensive areas of flame-shaped hemorrhage, cotton wool spots, macular edema and optic nerve head neovascularization in both eyes. Fluorescein angiography showed severe bilateral retinal ischemia and neovascularization leakage in disk. The patient, who had the visual acuity of 20/1000 in the right eye (OD) and 20/540 in the left eye (OS) at the first examination, was treated with panretinal photocoagulation (PRP) and presented at the end of the 6th month of follow-up improvement to 20/540 in OD and 20/270 in OS. There was also a regression of disc neovascularization, hemorrhages and macular edema. Despite intense retinal ischemia, there were no complications related to angiogenesis such as vitreous hemorrhage and/or neovascular glaucoma. We describe, in this report, the association between hemorrhagic retinopathy with features of Purtscher-like disease and HUS.

Descrevemos o caso de um lactente do sexo feminino de 23 meses com diagnóstico de síndrome hemolítico-urêmica (SHU) e retinopatia hemorrágica. A paciente apresentou história clínica prévia de dor abdominal, diarréia sanguinolenta e insuficiência renal aguda. Ao exame oftalmológico, a oftalmoscopia indireta evidenciou, em ambos os olhos, extensas áreas de hemorragia em chama de vela, exsudatos algodonosos, edema macular e neovasos na cabeça do nervo óptico. A angiofluoresceinografia mostrou intensa isquemia retiniana bilateral e vazamento na neovascularização de disco. A paciente, a qual apresentava acuidade visual de 20/1000 no olho direito (OD) e 20/540 no olho esquerdo (OE) no primeiro exame, foi tratada com panfotocoagulação retiniana e apresentou no final do 6º mês de acompanhamento a acuidade visual de 20/540 no OD e 20/270 no OE. Observou-se ainda a regressão dos neovasos, das hemorragias retininanas e do edema. Apesar da intensa isquemia retiniana não houve complicações relacionadas à angiogênese como hemorragia vítrea e/ou glaucoma neovascular. Descreve-se, neste relato, a associação entre retinopatia hemorrágicas com características de Purtscher-like e síndrome hemolítico-urêmica.

Submacular hemorrhage secondary to congenital toxoplasmosis / Hemorragia submacular secundária à toxoplasmose congênita

We report the case of a patient with congenital toxoplasmosis and submacular hemorrhage caused by a neovascular membrane who underwent an intravitreal injection of C3F8 and bevacizumab, and had a good visual recovery.

Relatamos o caso de uma paciente com toxoplasmose congênita e hemorragia submacular por uma membrana neovascular submetida à injeção intravítrea de C3F8 e bevacizumabe, com boa recuperação visual.

Hemorragia submembrana limitante interna em paciente após Valsalva: relato de caso / Sub-internal limiting membrane hemorrhage in Valsalva retinopathy: case report

Relatar o caso de uma paciente com retinopatia por Valsalva que evoluiu com hemorragia submembrana limitante interna e foi submetida à vitrectomia via pars plana, tendo tido melhora da acuidade visual. Paciente hígida de 35 anos evoluiu com redução súbita e indolor da acuidade visual do olho direito, após crise de tosse. Ao exame oftalmológico, apresentava hemorragia pré-macular, sem outras alterações. Inicialmente, optou-se pela conduta expectante, porém não houve regressão completa da hemorragia. Então, foi indicada a vitrectomia via pars plana associada à remoção da membrana limitante interna, havendo melhora considerável da acuidade visual, sem complicações peri-operatórias e sem alterações significativas à tomografia de coerência óptica, autofluorescência ou eletrorretinograma multifocal. Neste caso, o tratamento da hemorragia sub-membrana limitante interna com a cirurgia vitreorretiniana resultou em melhora da acuidade visual e regressão da hemorragia.

To report a case of a patient with Valsalva retinopathy that developed sub-internal limiting membrane hemorrhage, underwent pars plana vitrectomy and had visual acuity improvement after that. A 35-year-old healthy patient presented with sudden and painless vision loss of her right eye, after coughing. During the ophthalmologic evaluation, she had a pre-macular hemorrhage and no other abnormalities. Initially, we chose for expectant management, but the hemorrhage did not clear totally. Thus, pars plana vitrectomy associated with internal limiting membrane peeling was indicated, with considerable improvement of her visual acuity, without perioperative complications or significant findings in the optical coherence tomography, autofluorescence and multifocal electroretinogram. In this case, sub-internal limiting membrane hemorrhage treatment with vitreoretinal surgery was relatively useful, with visual acuity improvement and resolution of sub-internal limiting membrane hemorrhage.

Traumatic endophthalmitis presenting as isolated retinal vasculitis and white-centered hemorrhages: Case report and review of literature.

The article reports a case and review of the literature of endophthalmitis presenting as isolated retinal vasculitis. A 26-year-old male was observed to have white-centered retinal hemorrhages and retinal vasculitis following an occult scleral perforation. At presentation, the visual acuity was 20/60. With clinical suspicion of early endophthalmitis, he underwent wound exploration, scleral tear repair, vitreous biopsy and administration of intravitreal antibiotics. Microbiology evaluation revealed significant presence of methicillin-resistant coagulase-negative Staphylococcus epidermidis. Final visual acuity improved to 20/20 at 6 weeks postoperatively. Literature search revealed eight similar cases, all of them due to Staphylococcus species. Retinal vasculitis and white-centered retinal hemorrhages can be a presenting sign of early endophthalmitis, especially with non-fulminant pathogens like S. epidermidis.

Frosted branch angiitis, neuroretinitis as initial ocular manifestation in Behçet disease.

Behçet disease is an idiopathic, multisystem disorder characterized by recurrent episodes of orogenital ulceration and vasculitis of the veins and arteries of all calibers. Ocular involvement may affect the conjunctiva, sclera, uveal tract, vitreous, blood vessels, and retina. Many theories have pointed toward an autoimmune response behind its pathogenesis, which may be triggered by exposure to an infectious agent. Frosted branch angiitis is characterized by vascular inflammation, sheathing, retinal edema, and retinal hemorrhages. The disease may be idiopathic in a majority of the cases or may be associated with ocular and systemic pathology. Association between Behηet disease, Frosted branch angiitis, and neuroretinitis is not reported in literature. This uncommon combination reflects the varied systemic and ocular manifestations in Behηet disease, especially in patients who are not diagnosed and treated in time. We hereby report a case of bilateral frosted branch angiitis and neuroretinitis in a young male from Middle-east, suffering from Behçet disease.

Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura.

A 42-year-old female presented to us with a complaint of sudden painless loss of vision in both eyes of three days duration. Visual acuity was 20/100 for distance in both eyes. Fundus examination showed bilateral peripapillary hemorrhages, with subhyaloid and vitreous hemorrhage in both eyes. Hematological investigations revealed hemoglobin (HB 7 gm %) and severe thrombocytopenia (12,000/ ul). She was referred to a hematologist where a diagnosis of idiopathic thrombocytopenic purpura (ITP) was made. She was treated for systemic condition with regular ophthalmic follow-up. Over the next nine months, retinal hemorrhages completely resolved and the patient regained her visual acuity. The purpose of this case report is to highlight the clinical presentation of severe anemia, which is different from previous reports and the role of an ophthalmologist in first detecting the Idiopathic thrombocytopenic purpura (ITP), which led to successful recovery.

Inflicted neuro-trauma in infancy.

Two infants with non-accidental inflicted neuro-trauma are reported. One presented with sudden onset lethargy, respiratory difficulty and unexplained seizures. There were bilateral retinal bleeds and extradural hemmorage. Other was a well thriving child who had 2 seizures and was noted to lack visual fixation. Retinal hemorrhages and chronic subdural and intraparenchymal hemorrhages were subsequently discovered. We highlight the importance of suspecting child abuse in infants with sudden unexplained unresponsiveness, seizures or respiratory difficulty and the unusual occurrence of extradual hemorrhage.

Injeção intravítrea de bevacizumab e gás C3F8 para tratamento da hemorragia submacular secundária a degeneração macular relacionada à idade: relato de casos / Intravitreous injection of bevacizumab and C3F8 gas for the treatment of submacular hemorrhage due to age-related macular degeneration: case reports

O objetivo desta série de casos foi demonstrar se a aplicação de bevacizumab e gás perfluoropropano (C3F8) intravítreos beneficiariam o deslocamento da hemorragia sub-retiniana dos pacientes com degeneração macular relacionada à idade. Foi realizada uma série retrospectiva de 5 olhos que tinham recebido injeção intravítrea simultânea de bevacizumab e C3F8. Os resultados foram medidos pelo grau de deslocamento de sangue sob a fóvea, pela acuidade visual final e pelas complicações intraoperatórias. Na apresentação inicial, a idade média dos pacientes foi de 72,6 ± 8,9 anos e a duração média dos sintomas foi de 13 ± 9,7 dias. Dos 5 pacientes do estudo, 3 (60 por cento) eram homens e 2 (40 por cento) mulheres. O sucesso do deslocamento da hemorragia submacular foi alcançado em 4 pacientes. A média de acuidade visual pré-operatória foi de 1,12 ± 0,34 logMAR e pós-operatório foi de 0,92 ± 0,4 logMAR. Não foram observados nenhum caso de descolamento da retina, endoftalmite, hemorragia vítrea, uveíte, catarata e hipertensão ocular. A injeção intravítrea bevacizumab e C3F8, juntamente com a posição pronada pode ser uma valiosa opção terapêutica nos olhos com degeneração macular relacionada à idade neovascular e hemorragia sub-retiniana a fim de deslocar o sangue para fora da área foveal.

The purpose of this case series is to describe if the intravitreal use of bevacizumab and perfluoropropane gas (C3F8) would be beneficial to the displacement of subretinal hemorrhage in patients with age-related macular degeneration (AMD). A retrospective study of 5 eyes that received concurrent intravitreal injection of bevacizumab and C3F8 was performed. The results were graded according to blood displacement under the fovea, best final visual acuity and intraoperative complications. At the initial presentation, mean age of patients was 72.6 ± 8.9 years-old and duration of symptoms was 13 ± 9.7 days. From the 5 patients, 3 (60 percent) were male and 2 (40 percent) female. The success of submacular hemorrhage full displacement was achieved in 4 patients. The mean preoperative visual acuity (VA) was 1.12 ± 0.34 logMAR and the mean postoperative VA was 0.92 ± 0.4 logMAR. No cases of retinal detachment, endophthalmitis, vitreous hemorrhage, uveitis, cataracts and increased intraocular pressure were noted during the follow-up period. Intravitreal bevacizumab and C3F8 injection, associated to prone position can be a valuable therapeutic option for eyes with neovascular age-related macular degeneration and subretinal hemorrhage to the blood displacement out of the foveal area.

Ativador do plasminogênio tecidual e gás intravítreo no tratamento da síndrome de Terson: relato de caso: [revisão] / Tissue plasminogen activator and intravitreal gas for the treatment of Terson's syndrome: case report: [review]

Relata-se o caso de um paciente de 35 anos de idade, sexo masculino, com história de trauma cranioencefálico, que evoluiu com hemorragia pré-macular da síndrome de Terson no olho esquerdo. Após 45 dias de conduta expectante, sem resolução da hemorragia, foi realizada injeção intravítrea de gás hexafluoreto de enxofre e tPA, evoluindo com absorção quase completa da hemorragia após uma semana e considerável melhora da acuidade visual. Descreve-se também aspectos importantes da síndrome de Terson e da injeção intravítrea de gás e tPA por meio de revisão da literatura.

The case of a 35 year-old male patient is reported. The patient had a clinical history of craniocerebral trauma and premacular hemorrhage of Terson syndrome in the left eye. After waiting for 45 days, without hemorrhage resolution, the patient received an intravitreal injection of sulfur hexafluoride gas and tPA; an almost complete hemorrhage absorption occurred after a week as well as a considerable improvement of visual acuity. In the report, relevant aspects of Terson syndrome and of intravitreal injection of gas and tPA are also described through a literature review.

Pneumatic displacement and intravitreal bevacizumab: a new approach for management of submacular hemorrhage in choroidal neovascular membrane.

Choroidal neovascular membrane (CNVM) is one of the most common causes of submacular hemorrhage (SMH). Conventional treatment involves management of the SMH with pneumatic displacement with or without tissue plasminogen activator (TPA) followed by intravitreal injection of bevacizumab in a second sitting. We decided to assess the efficacy of treating SMH secondary to CNVM with pneumatic displacement using sulphur hexafluoride (SF6) gas and intravitreal bevacizumab. Four patients with SMH secondary to CNVM were included in this study. Intravitreal bevacizumab, 0.05 ml, along with 0.5 ml of SF6 was injected through the pars plana into the vitreous cavity. Postoperative best corrected visual acuity improved in all eyes with complete or partial displacement of SMH out of the foveal area.

Ocular decompression retinopathy after trabeculectomy with mitomycin-C for angle recession glaucoma.

A 45-year-old male presented with intractable glaucoma following 360-degree angle recession after blunt trauma. He underwent an uncomplicated trabeculectomy with mitomycin-C (MMC). Adequate precautions were taken to reduce the chances of sudden lowering of intraocular pressure (IOP). He did not have any intraoperative shallowing of the anterior chamber or postoperative hypotony, but still developed ocular decompression retinopathy. On detailed review of the previously reported cases we discovered that besides a large IOP drop after surgery, either the preoperative rise of IOP in all these cases was over a relatively short period or the course of their glaucomatous process was likely to have exposed them to intermittent spikes of high IOP. To our knowledge this factor has not been previously postulated in the pathophysiology of ocular decompression retinopathy. We illustrate this with a rare case of ocular decompression retinopathy after trabeculectomy with MMC for post-traumatic angle recession glaucoma.

Subretinal neovascularization following ruptured retinal arterial macroaneurysm: case report

A 51-year-old black woman was referred to our Retina Clinic for evaluation of loss of vision in her left eye. She was previously diagnosed with a ruptured retinal arterial macroaneurism (RAM) in the same eye. The ophthalmoscopic examination of the affected eye disclosed a subretinal lesion with some hemorrhage and exudation in the same area previously diagnosed with ruptured RAM. Fluorescein angiography revealed a gradually hyperfluorescent net of vessels located in the subfoveal region, consistent with the diagnosis of subretinal neovascular membrane. In this paper we stress the possibility of subretinal neovascularization following a ruptured RAM, even as a rare event.

Paciente de 51 anos foi encaminhada ao Setor de Retina para avaliação de perda visual no olho esquerdo. A paciente apresentava o diagnóstico prévio de macroaneurisma arterial retiniano (MAR) rôto no referido olho. O exame oftalmológico revelou lesão sub-retiniana hemorrágica associada à exsudação na área previamente diagnosticada com MAR. A angiofluoresceinografia revelou hiperfluorescência gradual localizada na região subfoveal, consistente com o diagnóstico de membrana neovascular sub-retiniana (MNSR). Nosso artigo aponta para a possibilidade, embora rara, da formação de uma MNSR após MAR rôto.

Hemorragia de disco óptico possivelmente secundária a descolamento espontâneo do vítreo posterior / Optic disc haemorrhage possibly secondary to posterior vitreous detachment

Descreve o diagnóstico e conduta em um caso de hemorragia de disco óptico possivelmente secundária a descolamento espontâneo do vítreo posterior. Relata um caso de hemorragia de disco óptico possivelmente secundária a descolamento espontâneo do vítreo posterior, discutindo os aspectos diagnósticos, prognósticos e conduta oftalmológica.Observou-se regressão da hemorragia do disco após 6h de evolução do quadro sem sinais de recidiva durante os registros subseqüentes. A Oftalmoscopia com Laser de Varredura mostrou-se como um avançado método alternativo e eficaz no diagnóstico e seguimento do descolamento vítreo.

To describe the diagnosis and management of a optic disc haemorrhage probably caused by an acute and spontaneous posterior vitreous detachment. A single case-report of an optic disc haemorrhage probably caused by an spontaneous posterior vitreous detachment, in order to discuss the diagnosis, management and prognosis. Optic disc haemorrhage regression was observed after 6 hours of evolution without relapsing signals during the subsequent registers. The Scanning Laser Ophthalmoscopy revealed as an advanced alternative and efficient method in the vitreous detachment diagnosis and follow up.

Severe hemorrhagic retinopathy as initial manifestation of acute retinal necrosis caused by herpes simplex virus.

A case of bilateral acute retinal necrosis due to herpes simplex virus 1, in a child is reported. The case presented as an extensive hemorrhagic retinopathy that was misdiagnosed as non-infective initially. Diagnostic aqueous tap of the blind eye for viral DNA by polymerase chain reaction helped to confirm viral etiology when the other eye was affected. Appropriate antiviral therapy followed by prompt surgeries for subsequent retinal detachment helped to salvage useful vision in the second eye.

Personal apparel endangering life.

Survival after accidental pressure exerted over neck is not common. In the literature also only few cases are available. Further, the victims or their relatives seek medical assistance only if complications arise and also it is not mandatory on the part of treating private practitioner to report such cases to the police. Findings in the living on the 4th day after accidental compression of the neck by the personal apparel are described in this article. Red eyes due to scleral haemorrhages are the most striking feature and the position of knot with ligature mark is also well marked.