Treatment of Persistent Vitreous Hemorrhage in Proliferative Diabetic Retinopathy

Vitreous hemorrhage (VH), including preretinal hemorrhage, is a major aspect of proliferative diabetic retinopathy (PDR) and an important cause of vision loss (Michels, Retina 1:1–17, 1981). The presence and growth of NV are the most important risk factors for VH. Conventional treatment methods include indirect laser panretinal photocoagulation (PRP) if the VH is not too dense or panretinal cryotherapy intended to enhance blood reabsorption and inhibit neovascularization (Avery et al., Ophthalmology 113:1695 e1–e15, 2006; Mason et al., Ophthalmol 142:685–688, 2006; Spaide and Fisher, Retina 26:275–278, 2006). However, PRP is usually inadequate in the presence of VH, and panretinal cryotherapy may have other limitations, such as causing significant intraocular inflammation or inducing traction retinal detachment (TRD) (Mosier et al., Am J Ophthalmol 100:440–444, 1985; Benedett et al., Ophthalmology 94:612–619, 1987). Recently, antivascular endothelium growth factor (anti-VEGF) has been shown to be effective in reducing the severity of recurrent vitreous hemorrhage (Spaide and Fisher, Retina 26:275–278, 2006). Ultimately, vitrectomy may be needed for persistent vitreous hemorrhage. The optimal timing of vitrectomy for persistent/nonclearing VH has been debated. The Diabetic Retinopathy Vitrectomy Study (DRVS) showed a benefit of early surgery (1–6 months after the onset of VH) for patients with type 1 DM and severe VH (Group TDRVSR, Arch Ophthalmol 103:1644–1652, 1985; Group TDRVSR, Arch Ophthalmol 108:958–64, 1990). However, advances in VR surgery have led many to advocate earlier surgery for all patients. The proper presurgical management, surgical timing, and surgical features will be discussed in this chapter.