Ocular Decompression Retinopathy

Key Points at a Glance

Key Points of This Disease

• Ocular decompression retinopathy (ODR) is a rare retinal hemorrhagic complication that occurs after interventions involving a rapid decrease in intraocular pressure.
• It has been reported after various procedures, not only glaucoma surgery but also anterior chamber paracentesis and cataract surgery.
• Characteristic findings include scattered punctate to patchy intraretinal hemorrhages and hemorrhages with white spots (Roth spots) in the posterior pole and equator.
• Approximately 80% of patients are asymptomatic and are often discovered incidentally during fundus examination.
• Accurate differentiation is important because fundus findings are similar to central retinal vein occlusion.
• Most cases resolve spontaneously without treatment, and vision returns to preoperative levels.

1. What is Ocular Decompression Retinopathy?

Ocular decompression retinopathy (ODR) is a rare postoperative complication resulting from interventions involving a rapid decrease in intraocular pressure. It is characterized by multiple round intraretinal hemorrhages with white spots in the posterior retina.

The term “ocular decompression retinopathy” was coined in 1992 by Fechner et al. to describe retinal changes associated with iatrogenic intraocular pressure reduction after glaucoma filtration surgery. Initially reported in relation to glaucoma surgery, it has since been observed after various procedures including anterior chamber paracentesis, cataract surgery, vitrectomy, and silicone oil removal.

A systematic review of ODR after anterior chamber paracentesis reported 10 cases¹⁾. Men accounted for 70%, and the mean age was 40.1±22 years¹⁾. The most common underlying disease was uveitis, accounting for 4 of the 10 cases¹⁾. Other causative diseases reported include neovascular glaucoma, macular branch artery occlusion, primary open-angle glaucoma, and endophthalmitis¹⁾.

Retinal hemorrhage occurring during retinopathy of prematurity (ROP) screening is also considered a form of ODR²⁾.

Q Can it occur even with a small procedure like anterior chamber paracentesis?

A

Ten cases of ODR after anterior chamber paracentesis have been reported in the literature¹⁾. Regardless of the scale of the procedure, ODR can occur if there is a rapid decrease in intraocular pressure. For details, see the “Causes and Risk Factors” section.

2. Main Symptoms and Clinical Findings

Subjective Symptoms

Although fundus findings of ODR can be prominent, approximately 80% of patients remain asymptomatic. When symptoms are present, patients complain of the following in the early postoperative period.

• Decreased visual acuity: It may be difficult to determine the contribution of retinal hemorrhage alone due to the influence of coexisting factors such as corneal edema.
• Central scotoma: Perceived in association with macular hemorrhage.
• Floaters: Occur when vitreous hemorrhage is present.

Clinical Findings

The most common fundus finding is superficial and deep punctate to patchy intraretinal hemorrhages scattered in the posterior pole and equatorial retina. Some hemorrhages with white centers (Roth spots) are also observed.

The frequency of each bleeding type in a systematic review of ODR after anterior chamber paracentesis is shown below ¹⁾.

Bleeding type	Frequency
Blot hemorrhage	90%
Roth spots	70%
Preretinal hemorrhage	60%
Superficial hemorrhage	30%

• Retinal vessels: Usually appear normal, with no venous tortuosity or dilation
• Vitreous hemorrhage / subvitreal hemorrhage: Relatively rare but may be observed
• Choroidal detachment and macular edema: Extremely rare

Fluorescein angiography shows only blocked fluorescence due to hemorrhage; delayed arteriovenous transit time and vascular leakage are usually not observed¹⁾.

In ODR occurring during ROP examination, intraretinal hemorrhages (flame-shaped, dot-blot, or hemorrhages with white centers) are diffusely distributed in the vascularized retina, tending to concentrate near the posterior pole and the vascularized border²⁾. Hemorrhages completely resolved in a median of 2 weeks²⁾.

Q How to differentiate from central retinal vein occlusion?

A

In ODR, fluorescein angiography shows no venous dilation or delayed arteriovenous transit time, only blocked fluorescence¹⁾. Additionally, Roth spots are present in 70% of ODR cases but are rare in central retinal vein occlusion¹⁾. These two points are useful for differentiation.

3. Causes and Risk Factors

ODR occurs after various procedures that can cause a rapid decrease in intraocular pressure. Reported causative procedures are as follows.

• Glaucoma filtration surgery: such as trabeculectomy. Most commonly reported.
• Glaucoma drainage device implantation: such as Ahmed glaucoma valve.
• Anterior chamber paracentesis: can also occur during aqueous humor collection for uveitis workup¹⁾.
• Cataract surgery
• Vitrectomy / silicone oil removal
• Pars plana sclerotomy: Even with a small incision, transient hypotony may occur.
• Scleral indentation during ROP screening: Compression and release of the eye by the examination instrument can cause ODR²⁾

Risk Factors

• Preoperative high intraocular pressure: The most important risk factor. In reports of ODR after anterior chamber paracentesis, the mean initial IOP was 44.8 mmHg (range 26–74 mmHg)¹⁾
• Comorbid uveitis: Disruption of the inner blood-retinal barrier may contribute to retinal vascular endothelial fragility¹⁾
• Immaturity of vascular autoregulation: In preterm infants, blood vessels and autoregulatory mechanisms are underdeveloped, contributing to ODR during ROP screening²⁾
• Valsalva maneuver: A sudden rise in central venous pressure can contribute to increased capillary pressure²⁾

Prevention and Daily Care

• Ocular decompression retinopathy is caused by a rapid drop in intraocular pressure. If preoperative intraocular pressure is high, the attending physician will pay close attention to intraocular pressure management during surgery.
• If you experience sudden vision loss or changes in vision after surgery, contact your doctor promptly.
• In most cases, it resolves naturally, so there is no need to worry excessively.

4. Diagnosis and Examination Methods

The diagnosis of ODR is primarily based on clinical findings. Differentiation from central retinal vein occlusion (CRVO) is clinically most important.

Fundus Examination

After a procedure involving a rapid decrease in intraocular pressure, ODR is suspected when multiple scattered intraretinal hemorrhages and Roth spots are observed in the posterior pole and equator. The absence of tortuosity and dilation of retinal vessels is a distinguishing feature from CRVO.

Fluorescein Angiography

This is the most useful test for differentiating ODR from CRVO.

ODR

Blocked fluorescence: Hypofluorescence corresponding to the hemorrhage site only.

Arteriovenous transit time: No delay.

Vascular leakage: None.

Roth spots: Present in 70% of cases ¹⁾.

CRVO

Blocked fluorescence: Hypofluorescence corresponding to the hemorrhage site.

Arteriovenous transit time: Delayed.

Venous findings: Dilatation and tortuosity are observed.

Roth spots: Rare.

Cases where ODR was misdiagnosed as CRVO have been reported¹⁾. If retinal hemorrhage is observed immediately after a procedure involving intraocular pressure reduction, it is important to always consider the possibility of ODR.

Optical Coherence Tomography (OCT)

It is useful for confirming the localization of multilayered retinal hemorrhages (preretinal, intraretinal, subretinal)¹⁾.

5. Standard Treatment

The prognosis of ODR is extremely good, and most cases do not require specific treatment.

Observation

In a systematic review of ODR after anterior chamber paracentesis, no additional intervention was needed in all 10 cases ¹⁾. The mean time for hemorrhage resolution was 3.5 months (median 3 months), and visual acuity recovered to preoperative levels ¹⁾. In ODR during ROP examination, resolution occurred at a median of 2 weeks ²⁾.

Surgical Treatment

Vitrectomy may be necessary for non-resolving vitreous hemorrhage. However, such cases are rare.

Prevention

• In eyes with high preoperative intraocular pressure, care should be taken to prevent hypotony at the end of surgery.
• Performing anterior chamber paracentesis more slowly is considered effective in reducing risk¹⁾.
• For ROP examinations, it is recommended to minimize scleral depression and release it slowly²⁾.

Caution

ODR resembles central retinal vein occlusion in fundus findings, so it is important to avoid inappropriate treatment due to misdiagnosis. If retinal hemorrhage is observed after a procedure involving a rapid decrease in intraocular pressure, differentiation should be performed using fluorescein angiography.

Q Is treatment necessary?

A

Treatment is unnecessary in most cases. Hemorrhage resolves spontaneously within an average of 3.5 months, and visual acuity recovers to preoperative levels ¹⁾. Vitrectomy is considered only when vitreous hemorrhage does not resolve.

6. Pathophysiology and Detailed Mechanism

The mechanism of ODR is not fully understood, but several hypotheses have been proposed.

Vascular Autoregulation Dysfunction Hypothesis

This is the most plausible hypothesis. When ocular perfusion pressure deviates outside the normal range, the autoregulatory mechanism of retinal vessels fails, leading to hemorrhage ¹⁾.

• In glaucoma, the balance between nitric oxide and endothelin-1 is disrupted, limiting the autoregulation of retinal blood vessels in response to intraocular pressure fluctuations¹⁾
• Animal models have shown that elevated intraocular pressure induces endothelial dysfunction, leading to autoregulatory failure¹⁾

The ODR during ROP screening can also be explained by this hypothesis²⁾.

Matei et al. (2021) proposed a mechanism: scleral indentation increases intraocular pressure → metabolic changes (hypoxia, hypercapnia) → arteriolar dilation → rapid pressure drop upon release → transmission of high intravascular pressure through dilated arterioles to capillaries → capillary wall damage → hemorrhage²⁾.

Anterior lamina cribrosa shift hypothesis

This hypothesis suggests that a rapid drop in intraocular pressure causes the lamina cribrosa to shift anteriorly, compressing the central retinal vein and producing fundus findings similar to central retinal vein occlusion¹⁾.

Mechanism of Roth spots

Roth spots (retinal hemorrhages with white centers) are thought to occur due to rupture of retinal capillaries from structural stress caused by a rapid drop in intraocular pressure¹⁾.

Contribution of uveitis

Uveitis disrupts the inner blood-retinal barrier and causes dysfunction of retinal vascular endothelium¹⁾. This is considered the reason for the high incidence of ODR in uveitis patients. However, selection bias has also been noted, as anterior chamber paracentesis is often performed for uveitis workup¹⁾.

Factors in premature infants

In premature infants, retinal blood vessels and autoregulation are underdeveloped, making them vulnerable to intraocular pressure fluctuations caused by scleral indentation and release during ROP examination²⁾.

Difference from hypotony maculopathy

Hypotony maculopathy is a condition in which persistent low intraocular pressure (generally 5 mmHg or less) causes chorioretinal folds and optic disc edema, and its pathogenesis and clinical features differ from ODR. ODR is a transient retinal hemorrhage due to rapid intraocular pressure fluctuations, whereas hypotony maculopathy is essentially a structural change associated with sustained low intraocular pressure.

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8. References

1. Hsu ST, Lai YJ, Chan WC, Chiu FY. Ocular decompression retinopathy after anterior chamber paracentesis - Case series and systematic review. Taiwan J Ophthalmol. 2025;15:580-588.
2. Matei VM, He YG. Retinal hemorrhages during examination for retinopathy of prematurity: a form of ocular decompression retinopathy. J Vitreoretinal Dis. 2021;5(1):72-76.
3. Mukkamala SK, Patel A, Dorairaj S, McGlynn R, Sidoti PA, Weinreb RN, et al. Ocular decompression retinopathy: a review. Surv Ophthalmol. 2013;58(6):505-12. PMID: 24160727.