A retinal aftermath post-procedure

A 49-year-old male, hypertensive, was referred as a case of acute central retinal vein occlusion in the right eye (OD). The best corrected visual acuity (BCVA) was 6/12 in OD and 6/7.5 in the left eye (OS). The patient was diagnosed elsewhere to have both eyes (OU) primary angle closure glaucoma and started on anti-glaucoma medications (AGMs). He underwent bilateral YAG laser peripheral iridotomy (PI) 3 days ago. Anterior segment OU showed immature cataract with an intraocular pressure (IOP) of 10 mmHg. OD fundus examination revealed cupped disc (0.9), multiple retinal hemorrhages with central clearing, and attached retina [Fig. 1a]. OS fundus examination [Fig. 1b] was normal except for disc cupping (0.7).Figure 1: (a) is the pseudocolor fundus photo of the right eye showing white-centered deep retinal hemorrhages with normal caliber of retinal veins. (b) is the pseudocolor fundus photo of the left eye showing no hemorrhages. (c) is the enlarged image of (a), clearly depicting the central white area within the hemorrhages. (d) is the OCT image showing compact fovea. (e) and (f) are the OCT angiography images revealing normal flow signals in the superficial plexus at macula and around disc, respectivelyWhat is Your Next Step? Complete blood count with hemoglobin and peripheral smear Fundus fluorescein angiography To observe Anti-VEGF (Vascular Endothelial Growth Factor) Injection Findings The presence of white-centered retinal hemorrhages [Fig. 1c] following IOP reduction pointed toward ocular decompression retinopathy (ODR). The pre-PI IOP was 60 mmHg in OD and 14 mmHg in OS, which explains the ODR in OD. Additional AGMs were added in OD to reduce the pressure to 28 mmHg, followed by PI. Gonioscopy revealed closed angles (iris root) in OD and anterior trabecular meshwork in OS, which opened after PI to posterior trabecular meshwork and scleral spur, respectively. ODR can be confused with retinal vein occlusion (RVO) and blood dyscrasias. The absence of venous dilatation and tortuosity rules out RVO. Retinal hemorrhages seen in blood dyscrasias are usually bilateral. Optical coherence tomography (OCT) [Fig. 1d] and OCT angiography (OCTA) [Fig. 1e and f] were normal. Diagnosis Right eye ocular decompressive retinopathy Correct Answer C) to observe Discussion ODR is a rare complication that can occur following rapid IOP reduction after procedures such as trabeculectomy, iridotomy, paracentesis, vitrectomy, phacoemulsification, and iridoplasty.[1–3] Hemorrhages can occur in all retinal layers with minimal/no symptoms and are self-resolving.[1–3] Rapid IOP reduction leads to a sudden increase in capillary blood flow, causing multiple blot hemorrhages.[1–3] Fibrin plug repairing these capillaries appears as a white center within the hemorrhages.[2] ODR has excellent prognosis, preventable by gradual IOP reduction, and must be differentiated from other vision-threatening retinal vascular diseases. In this case, ODR was due to sudden IOP reduction caused by AGMs and PI. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.