Abstract
ObjectiveTo evaluate the incidence and associated risk factors of massive subretinal hemorrhage (SRH) in patients with retinal angiomatous proliferation (RAP).MethodsA total of 187 eyes of 135 treatment-naıve patients diagnosed with RAP were evaluated retrospectively. Clinical records including the time between the initial visit, last anti-vascular endothelial growth factor (VEGF) treatment, last stable examination, and the date of massive SRH were reviewed. Imaging findings including indocyanine green angiography (ICGA) and optical coherence tomography (OCT) were analyzed.ResultsMassive SRH developed in 18 eyes (9.6%) a median of 20 months after the initial presentation. Kaplan-Meier survival analysis revealed that the incidence (2.8, 5.8, 13.1, and 21.0% after 1,2,5 and 10 years, respectively) continuously increased. Among 14 eyes with discernable vascular anastomosis on baseline ICGA, 13 (92.8%) showed retinal arteriole involvement. On spectral-domain OCT imaging of the last visit prior to the massive SRH, a layered lamellar tissue complex was noted under the retinal pigment epithelium in 9 of 13 eyes, which was significantly associated with massive SRH[hazard ratio(HR),5.883;P = .010]. The average time between the last stable examination/last injection and the massive SRH was 2 and 5 months, respectively. The patients were treated with anti-VEGF, gas and recombinant tissue plasminogen activator injection; however, all except one eye had visual acuity worse than 20/1000 at the final visit.ConclusionsMassive SRH can occur in RAP in the course of anti-VEGF treatment, resulting in severe vision loss. A proactive dosing regimen may be more appropriate for these RAP eyes.
Highlights
Clinical records including the time between the initial visit, last anti-vascular endothelial growth factor (VEGF) treatment, last stable examination, and the date of massive subretinal hemorrhage (SRH) were reviewed
Massive SRH developed in 18 eyes (9.6%) a median of 20 months after the initial presentation
On spectral-domain optical coherence tomography (OCT) imaging of the last visit prior to the massive SRH, a layered lamellar tissue complex was noted under the retinal pigment epithelium in 9 of 13 eyes, which was significantly associated with massive SRH[hazard ratio(HR),5.883;P = .010]
Summary
Retinal angiomatous proliferation (RAP) is a subtype of neovascular age-related macular degeneration (nAMD) characterized by proliferation of deep retinal capillaries, with the later stages involving the progression from subretinal to choroidal neovascularization (CNV) with or without pigment epithelial detachment (PED).[1, 2] The pathogenesis of RAP is complex and the origin of the neovascular process (from the retina or from the choroid) remains controversial.[1, 3, 4] The term “type 3 neovascularization” has been proposed for this condition to emphasize the intraretinal location of the vascular complex.[4, 5] RPE dysfunction and subsequent deposits in the subretinal space and thickening of Bruch membrane (reticular pseudodrusen) may reduce inner retinal oxygenation and upregulate angiogenic growth factor, leading to intraretinal neovascularization.[1, 6]On angiography, RAP lesions exhibit retinal-retinal anastomosis and retinal-choroidal anastomosis, which are thought to contribute to a high blood supply to the lesions.[2]. The response of RAP lesions to anti-vascular endothelial growth factor (VEGF) agents is encouraging, and studies including short to intermediate-term data have reported promising results.[8,9,10] it has been suggested that long-term visual outcomes of RAP might be limited due to the development of geographic atrophy (GA) after repeated anti-VEGF injections.[11, 12]
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