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case_images: (A) Patient 1, first seen by optician at aged 13 who queried temporal retina lesions and hazy view in both eyes. First clinic attendance in 2022 August, confirmed good vision of 6/6 each eye but history of Right eye frequent floaters. Visible in these photos are large auto-infarcted seafan fibrotic scars on traction in peripheral supero-temporal retinae (white arrows) in both eyes; other smaller pre-retina fibrosis (black arrows), ghost vessels (red arrow), flat retina and no evidence of vitreous hemorrhage in either eye. No treatment was offered. (B) By 2023 June, patient 1 re-presented in eye casualty with Right eye vitreous hemorrhage (red arrows) with flat retina and reduced vision of 6/60. Previous supero-temporal large seafan fibrotic scar was also enveloped with hemorrhage (white arrow). Left eye status unchanged, good vision 6/6. Patient was referred to specialist sickle eye clinic for further management. (C) By 2023 September, Right eye vision improved to 6/7 as vitreous hemorrhage gravitated, revealing more auto-infarcted seafan scar on traction in supero-nasal peripheral retina (white arrow), previous blood-enveloped seafan site had part altered blood still masking any underlying reactivation of seafan (double white arrows). Left eye good vision, no vitreous hemorrhage but small "reactivated tips" were noted in previous auto-infarcted seafan scar (red arrow). With the clearing view, patient 1 was advised and received same day localized barrier laser to Right eye, to prevent retinal detachment with future traction bleed. Left eye was to be observed. (D) By 2023 December, Patient 1 maintained good vision 6/9 Right, 6/7 Left. Assessment showed no fresh/added vitreous hemorrhage in Right eye, previous barrier laser appeared inadequate (white arrow). Left eye however had worsened features of reactivation of some seafans on traction (red arrows), with evidence of gravitated vitreous hemorrhage (new). Patient was advised and received further laser top-up to Right eye, barrier laser to left eye. (E) By 2024 April, patient 1 reported no episodes of new floaters, vision remained good and unchanged. Assessment confirmed no clinical evidence of new added vitreous hemorrhage in either eye, previously treated seafans and traction scars (white arrows) were less aggressive and altered blood resolved. Left eye had a new sprouting seafan (not in photo view). Patient received additional sector laser to Left eye new seafan; scheduled for routine review in 6 months, earlier if experienced episode of unsettling floaters.
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case_images: Initial examination confirmed existing advanced sickle retinopathy in peripheral retinae of both eyes, with main concern of large fibrosed seafan retinal neovascularization already on traction but flat retina (Figure 1A). Over the course of 1 year, patient experienced recurrence vitreous hemorrhage in his right eye from existing traction scars with no retinal detachment and no new active seafan, worse recorded vision over this period had been 6/60 (Figure 1B and C). Left eye vitreous hemorrhage happened later, bled from traction as well as from new active seafans (Figure 1D and E).
case_images: (A) Patient 2 first attended eye casualty in 2020 December, aged 12 having referred by optician for queried Right eye retinal detachment, left odd retinal lesion. Patient was asymptomatic. Assessment confirmed excellent vision 6/5 each eye, both eyes had auto-infarcted seafans scars on traction (white arrows). Right eye had vitreous hemorrhage (red arrows), flat retina. Left eye lesion previously queried by optician was a salmon patch in mid-temporal retina (black arrow). Patient was referred to specialist sickle eye clinic for management. (B) In 2021 April clinic assessment, vision remains good at 6/5. Both eyes had auto-infarcted seafans on traction as previously seen but also numerous smaller new sprouts of seafans (white arrows, better seen on slit-lamp). Right eye still limited view but clearer as old vitreous hemorrhage gravitated, flat retina, no fresh bleed. Left eye had no vitreous hemorrhage, previous salmon patch in mid-temporal had resolved, seen as a round shadowy mark (black arrow), revealing no underlying seafan. There were other smaller salmon patches in resolution (grey arrows). Patient was advised and received limited barrier laser to Right eye tractional seafan (supero-temporal) to reduce risk of retinal detachment in future traction bleeds, and additional sector laser around new sprouting seafans. Left eye was to be observed. (C) Patient 2 reattended 4 months later with fresh bleed in Right eye giving hazy fundus view, localized supero-temporal traction bleed was heavier (red arrow). Both eyes maintained good vision 6/6 as center macula was clear, retinae were also flat. Left eye numerous small seafans on traction, some were larger in size, but no evidence of vitreous hemorrhage. Patient was advised and received sector/barrier laser treatment to Left eye seafans but additional laser treatment to Right eye was not possible at this visit due to poor view. (D) Having missed a few appointments, patient was re-examined 10 months later (2022 June), maintained good vision 6/6 and improved Right eye floaters. Fundoscopy of Right eye however remained a struggle although improved; previous supero-temporal tractional seafan scar appeared more extensive and elevated (white arrow), another resolved salmon patch shadow (black arrow) was seen in nasal retina. Left eye had new active seafans, not yet elevated (white arrows) around previous resolved salmon patch; previous treated lesions appeared adequate, no evidence of vitreous hemorrhage yet in this eye. Left eye received further sector laser; Right eye was to await for further vitreous hemorrhage clearing to allow any possible effective laser top-up. (E) Patient re-attended clinic in 2023 September, having missed a few appointments, attended eye casualty once in 2023 June with further Right eye bleed. Vision was still good 6/7 Right, 6/5 Left. Right eye status relatively unchanged with some new bleed, old bleed slow to resolve; previous supero-temporal traction was mimicking localized retinal detachment but no subretinal fluid and not advancing. Left eye continued to have few more new seafans and residual active tip of an inadequately lasered seafan (white arrow), other adequately treated seafans resolved, no vitreous hemorrhage. Left eye received further sector laser. Plan for Right eye was to perform heavier barrier laser to supero-temporal traction as soon as view was clearer. Consideration for vitrectomy was discussed if rebleed and tractional detachment worsen.
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case_images: His left eye had less severe tractional seafan neovascularization, a salmon patch but no vitreous hemorrhage (Figure 2A). The salmon patch in left eye resolved in 4 months, with more new salmon patches developed in different parts of the retina of the same eye (Figure 2B). However, patient's right eye vision did improve to normal at 6/6 at most clinic visits despite dense vitreous hemorrhage which was slow to clear obscuring most of peripheral retina view (Figure 2C and D). However, barrier laser/sector laser were performed more easily to Left eye when new sprouting seafans were found at each clinic visit, before any vitreous hemorrhage happened (Figure 2D). Keeping good vision of 6/7 right, 6/5 left, lacking window opportunity for effective laser treatment through the unclearing peripheral vitreous hemorrhage, patient eventually developed a localized peripheral tractional retinal detachment in his right eye, which had enough surrounding barrier laser to be secured and non-progressive at the last clinic visit (Figure 2E).