What if they have a hemorrhage when they present

First of all, remember the caveats in Chapter 12—make sure that you are dealing with proliferative disease and not another cause, such as a retinal tear. If the patient does have proliferative disease, then the treatment protocol depends on the amount of blood present. If there is a dense hemorrhage with no view—and they have no history of prior laser—you should refer for early vitrectomy to clear the blood out and get in laser before permanent damage occurs.

If there is a dense hemorrhage but you can see some retina, you should treat as much as you can (assuming you can be sure the posterior retina is safe with a B scan). The goal of the faster treatment is to get laser in before further hemorrhage obscures your ability to treat the eye. If you can get in enough laser, you may be able to stabilize the eye and give it a chance to clear without the need for vitrectomy. If there is not a lot of room, you might want to just treat all the retina you can see at the first session. This is especially true if there are areas of loculated hemorrhage being held in place by the cortical vitreous. These locula-tions can rupture and if the blood spreads throughout the central vitreous you will lose your ability to treat previously visible portions of the retina.

If there is more room, you may want to be a bit more conservative in order to avoid complications related to an excessive PRP; perhaps treat in two sessions a week apart using a fairly large number of spots (say 500 to 1,000 to treat the inferior retina, followed by enough to fill in the remaining fundus at the next session). This is more aggressive than usual, but not enough to pulverize the eye. Whether you treat all at once or in divided doses, recognize that there really is no incorrect approach as long as you are thinking about what you are doing. (By the way, patients with a vitreous hemorrhage are often best treated first with a wide-field indirect lens to slip around the blood as much as possible, then with a Goldmann three mirror for squeaking treatment out to the far periphery. You will often have a clear view of the far anterior retina because the blood can't get through the vitreous base.)

If the hemorrhage is mild and the patient has good vision, you should consider going slower if the proliferative disease is not very aggressive-looking. There is often more time than you would expect between hemorrhages in eyes with mild disease, and you are unlikely to "miss an opportunity" by dividing the treatments in patients who are less sanguineous. Although the presence of the blood is often as scary to you as it is to the patient, consider restraining yourself in order to avoid damaging the macula. (If you are going to treat over multiple sessions, it does make sense to tell such patients to give you a call if they think the hemor-rahge is getting worse—you can bring them in and finish the treatment quickly if necessary.)

Also, remember that if you are treating a diabetic with a mild hemorrhage, you have to remind them that you can only indirectly control their "bad blood vessels" with the laser. They need to know that the blood may get much worse, depending on the capricious nature of their disease. You especially need to remind them that the laser will not make the blood in their vision disappear overnight. Don't be surprised if you have to repeat this last point if you call the patient to see how they are doing after the laser. Patients have a strong tendency to assume that the laser will immediately solve a problem that the diabetes has been working for years to create.

It turns out that patients with hemorrhages may end up being some of your most grateful patients if the hemorrhage clears after the laser (and it usually does if the disease is relatively mild). They will understand exactly where they were headed, and even if it takes a few months for the blood to wash out, they will greatly appreciate the fact that you saved them with your laser skills. It makes one wish that every diabetic would just have a little teeny hemorrhage as soon as they start to get some neovascularization. Then they would understand why we do this...

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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