Internal Limiting Membrane Peeling and Dexamethasone Intravitreal Implant for the Management of a Retinal Macroaneurysm Rupture

Background: To describe an effective combined surgical and pharmacological approach for the management of a sub-internal limiting membrane (sub-ILM) macular hemorrhage and exudation related to a retinal arterial macroaneurysm (RAM) decompensation. Methods: Pars plana vitrectomy (PPV) was performed, with an accurate forceps-assisted ILM removal, hemorrhage aspiration, and a dexamethasone intravitreal implant injection at the end of the surgery. Anatomical and functional outcomes were evaluated by fundus examination, spectral-domain optical coherence tomography (SD-OCT), optical coherence tomography angiography (OCT-A) and best-corrected visual acuity (BCVA). Results: Postoperative outcome revealed that sub-ILM blood was successfully cleaned, and the RAM became progressively thrombosed with complete resolution of the exudation. Three months after surgery, BCVA improved from 20/400 to 20/80 with no signs of recurrence. Conclusion: This combined surgical and pharmacological approach could be an effective technique for the management of sub-ILM hemorrhage secondary to RAM decompensation, and favors anatomical macular restoration and signicant recovery of the visual acuity.


Background
Sub-internal limiting membrane (ILM) macular hemorrhages have been described in a variety of clinical settings 1 , the most common being Valsalva retinopathy and Terson´s syndrome. However, a retinal arterial macroaneurysm (RAM) acute rupture, which usually presents with retinal and vitreous hemorrhages at different levels, may cause speci c complications such as sub-ILM macular hemorrhage and consequently severe visual dysfunction.
Many therapeutic options [1][2][3][4][5] have been proposed for the management of RAM complications including conservative and surgical procedures. We describe step-by-step a simple and effective combined technique to manage sub-ILM macular bleeding and intraretinal exudation secondary to a RAM decompensation.

Case Presentation
An 86-year-old man attended our o ce with complaints of a fteen days history of sudden central blurred vision in his single right eye. Ocular examination revealed a BCVA of 20/400 related to a dome-shaped macular hemorrhage associated with a focal vascular lesion located in a main branch of the inferotemporal retinal artery, consistent with a RAM (Fig. 1A). Optical coherence tomography (Cirrus 5000, Zeiss, Germany) con rmed the localization of the hemorrhage below the ILM (Fig. 1B). OCT angiography (OCT-A) ndings showed a high ow signal and clearly delineated the arterial focal dilation (Fig. 1C).
Fluorescein and indocyanine green angiography revealed a gradually hyper uorescent signal in the early stages corresponding to the RAM lling and a mild leakage in the latest phases of the angiogram.
Considering clinical symptoms and the central location of the hemorrhage in a single eye, a microincisional pars plana vitrectomy (PPV) was performed adding a dexamethasone intravitreal implant at the end of the procedure. SD-OCT examination at the immediate postoperative stage con rmed the disappearance of the sub-ILM hemorrhage. One month after surgery, an apparently partial RAM sclerosis with blood remnants were observed. Persistent hard exudates in a circinate pattern involving the macula appeared as intraretinal hyperre ective dots in the OCT. Three months after surgery, RAM sclerosis and reduction of the exudation was observed ( Figs. 2A and 2C). OCT-A demonstrated a reduced ow signal through the RAM (Fig. 2B) and the BCVA improved to 20/80 Methods A 23-gauge PPV was performed under peribulbar anesthesia and sedation. After completing the core and peripheral vitrectomy and checking that the posterior hyaloid was already detached, an ILM linear incision above the dome-shaped hemorrhage was done with a 25-gauge microvitreoretinal blade. Then, an ILM circular rhexis was performed with a 23G end-gripping forceps, and the exposed blood was gently aspirated with an active soft-tip extrusion cannula. In order to be sure that the ILM rhexis was complete, a Tano brush was used to check the borders of the dissection. Finally, a slow-release dexamethasone intravitreal implant was injected through the superotemporal sclerotomy using the Eckardt plate to keep the conjunctiva displaced and aligned with the scleral hole during this maneuver (see the edited surgical technique in the video le attached).

Discussion And Conclusion
A prompt microincisional PPV with ILM peeling is a simple and safe procedure that de nitely accelerates visual acuity improvement in single eyes with central sub-ILM bleeding. Early evacuation of sub-ILM hemorrhage also prevents from developing preretinal brosis and contraction.