Massive Subretinal Hemorrhage Research Articles

Multiple Choroidal Neovascularizations in Choroidal Osteoma Treated with Anti-VEGF Injections: A 6-Year Follow-Up Case Report.

To report a case of multiple choroidal neovascularizations (CNVs) secondary to choroidal osteoma injected with a total of 13 anti-vascular endothelial growth factor (VEGF) drugs over a long-term follow up of 6-year period. Case report. A 29-year-old female presented with a peripapillary choroidal osteoma in her left eye with the best-corrected visual acuity (BCVA) of 20/25. After 2 years of follow-up, two foci of CNV (one was at the infra-nasal of the optic disc, and the other was near the sub-temporal vascular arch), and massive subretinal hemorrhage developed overlying the osteoma, causing decreased BCVA of 20/33. The patient was treated with four consecutive intravitreal injections of conbercept and the two CNVs regressed with BCVA recovered to 20/25. While 17 months later, the third CNV lesion locating at the fovea appeared and nine more injections of aflibercept were given during which repeated recurrence of it occurred. At last follow-up, 6 years from baseline, all the three CNV foci were controlled, with final BCVA of 20/33. Multiple CNVs may appear simultaneously at different locations in one osteoma and prompt treatment with intravitreal anti-VEGF may be a good option to control the progression and recurrence of these CNVs. Long-term follow-up and multimodal imaging are vital in the management of CO-associated CNV.

How do polypoidal choroidal vasculopathy patients fare long term - A real world data

The objective of this 5-year retrospective study of PCV eyes was to assess the clinical presentation and long-term real world visual and anatomical outcomes following therapy. Data included the baseline clinical and demographic profile, visual acuity and treatment details. Main outcome measured were anatomical and visual outcomes with treatment, treatment compliance and complications. Out the 45 PCV eyes (51 patients), 76.4% lesions occurred predominantly at the macula. Clinical presentations were variable though visible polyps (16.6%) and massive subretinal hemorrhage (17.7%) were less frequent. DLS with diffuse PEDs or thumb shaped PEDs were the most common finding in SD-OCT. OCTA was sensitive in identifying BVNs compared to ICGA but were poor in identifying polyps. Vision improvement was achieved in 42% eyes, while loss occurred in 26.6% eyes, with deterioration more in type 1 PCV. Baseline good vision, thicker CCT, smaller lesions and minimum recurrences at year 1 were risk factors associated with good outcomes. Mean number of injections was 18.7. 22% received primary PDT while 11% eyes received rescue PDT. Low fluence PDT was found to be as effective as standard fluence. Though not significant, PDT eyes required lesser injections than monotherapy. As an agent Aflibercept seemed to be better than Ranibizumab and was the most preferred switching agent (55% needed switch). Loading dose followed by PRN was the only feasible regimen with relatively reasonable compliance. Complications included RIP (11%) and 2 eyes requiring Vitrectomy for breakthrough vitreous hemorrhage. The superiority of aflibercept and the feasibility of a PRN approach is underlined in this study. In spite of suboptimal compliance this study reveals that nearly half the eyes demonstrated visual gains and anatomic stability.

Clinical features and outcomes of breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy.

Polypoidal choroidal vasculopathy (PCV) with hemorrhagic complications is at higher risk for breakthrough vitreous hemorrhage (VH). This study aimed to evaluate the clinical features and outcomes of breakthrough VH secondary to PCV. Data of patients receiving pars plana vitrectomy for breakthrough VH secondary to PCV (VH group) were evaluated retrospectively and compared statistically to data of age and sex-matched PCV patients without breakthrough VH (control group). Among PCV patients, 36 eyes with breakthrough VH and 62 eyes without VH were included. Compared with baseline, best corrected visual acuity (BCVA) was worse in the VH group (P < 0.001), and improved postoperatively (P < 0.001). Percentages of pigmented epithelial detachment (PED), hemorrhagic PED, massive subretinal hemorrhage, hemorrhagic retinal detachment (RD), and hemorrhagic choroidal detachment (CD) (P = 0.007) were higher in the VH group (P < 0.001). Incidence of choroidal vascular hyperpermeability (P < 0.001), massive subretinal hemorrhage (P = 0.001), hemorrhagic retinal detachment (P = 0.001) and hemorrhagic type PCV (P = 0.001) was higher in patients with pachychoroid PCV, while fibrovascular type had lower incidence (P < 0.001). Better initial BCVA (P < 0.001), higher frequency of anti-VEGF treatment (P = 0.009), and previous photodynamic therapy (P = 0.017) showed better visual outcomes. Breakthrough VH risk is higher in PCV patients with massive subretinal hemorrhage, hemorrhagic PED and hemorrhagic RD. BCVA and hemorrhagic complications improve significantly postoperatively. Higher frequency of anti-VEGF treatment and previous photodynamic therapy are associated with better visual prognosis in PCV patients with breakthrough VH.

Current Trends in Clinical Characteristics, Diagnosis, and Treatment of Polypoidal Choroidal Vasculopathy: A Perspective from Vietnam.

Polypoidal choroidal vasculopathy (PCV) is a common choroidal disease in the Asian population including Vietnam and is characterized by subretinal red-orange nodules, pigmented epithelium detachment, and massive subretinal hemorrhage. The recent focus on PCV in Vietnam can be attributed to advancements in PCV diagnosis and treatment. However, there is a scarcity of published literature and clinical data on PCV in the Vietnamese population, highlighting a key knowledge gap in this region. In order to address this gap, we gathered the opinions of experienced clinicians and retinal experts in Vietnam and reviewed available medical literature with the aim of: (i) providing an overview of PCV in the Vietnamese population—in terms of epidemiology, clinical characteristics, and management; (ii) tailoring international/national guidelines for the diagnosis and management of PCV, in line with available resources and medical equipment in Vietnam; and (iii) identifying gaps in clinical data in order to guide future PCV research in Vietnam and other countries with similar clinical conditions. The present review will enable healthcare providers and researchers to gain insight into current clinical practices and the limitations of PCV management in Vietnam and provide optimal and effective solutions.

MACULAR HOLE ASSOCIATED WITH AGE-RELATED MACULAR DEGENERATION: Pathogenesis and Surgical Outcomes.

To ascertain the pathogenesis of macular hole (MH) associated with age-related macular degeneration (AMD) and its surgical outcomes. Patients with full-thickness MH associated with AMD (higher grades than intermediate) were enrolled. The mechanism of MH formation and closure rate after vitrectomy (surgical outcome) were determined using optical coherence tomography imaging. The mechanism of MH formation (35 eyes) associated with AMD was classified into four types: vitreomacular traction (42.9%), gradual retinal thinning caused by subretinal drusen or pigment epithelial detachment (22.9%), massive subretinal hemorrhage (20.0%), and combined (14.3%). In the 41 eyes that underwent vitrectomy, the logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.82 (0.10-2.30) preoperative to 0.69 (0.10-2.30) postoperative (P = 0.001). Successful closure of the MH was achieved in 33 eyes (80.5%) after vitrectomy. No significant association was observed between the closure rate of MH after vitrectomy and mechanism of MH formation (P = 0.083). The mechanism of MH formation associated with AMD was classified into four types and was not related to its surgical outcome. Considering visual improvement and surgical outcome after vitrectomy in our study, active surgical treatment can be considered for MH associated with AMD.

Successful delivery of subretinal aflibercept (new surgical technique) for the treatment of submacular hemorrhage in idiopathic polypoidal choroidal vasculopathy.

Submacular hemorrhage (SMH) is often a result of trauma, wet age-related macular degeneration or IPCV and frequently leads to blindness secondary to extreme toxicity of hemoglobin products on photoreceptors. We describe a new technique of subretinal aflibercept injection during pars plana vitrectomy for the treatment of SMH in idiopathic polypoidal choroidal vasculopathy (IPCV). A 55-old male presented with sudden loss of vision (HM) secondary to massive subretinal hemorrhage associated with IPCV. Subretinal injection of aflibercept with a 25 g/42 g cannula coupled to the viscous fluid control unit of a standard vitrectomy system was performed during parsplana vitrectomy. Controlled injection of aflibercept intra-operatively has resulted in a resolution of SMH (confirmed with OCT and ICG). Visual acuity improved from HM to 20/20. This combined approach delivered anti-VEGF agent to target tissue in controlled fashion with the assistance of VFC system (similar to gene therapy) and restored full vision with resolution of SMH.

Removal of massive subretinal organized blood clot with fragmatome.

The purpose of the study was to describe using fragmatome in removing subretinal organized blood clot in eyes of age-related macular degeneration and massive subretinal hemorrhage. This study was an interventional, consecutive case series. Patients with massive subretinal hemorrhage with total or subtotal retinal detachment from age-related macular degeneration and organized subretinal blood clot were managed by creating large retinectomy. The less organized blood was removed with vitrector. The subretinal organized blood clot was removed by fragmatome. The retina was reattached with perfluorocarbon liquid, and laser was applied at the margin of retinectomy. Silicon oil was infused at the end of surgery. All patients had subretinal blood totally or subtotally removed. The organized blood clot, which was difficult to be removed by vitrector was easily and efficiently removed by fragmatome. Visual acuity improved in all eyes, and retina was well attached under silicon oil. Fragmatome offers a more efficient way in removing organized blood clot, which will much shorten the duration of operation.

Хирургическое лечение массивных субмакулярных кровоизлияний при влажной форме возрастной макулодистрофии с автоматизированной субретинальной инъекцией

Purpose. The purpose of the study was to assess the results of the proposed method of surgical treatment of massive subretinal macular hemorrhage in the wet form of age-related macular degeneration. Material and methods. A comparative study of the results of treatment of massive subretinal hemorrhage associated with the exudative AMD-related. 17 patients (17 eyes) were being observed in the clinic with submacular hemorrhages of varying severity, which occurred against the background of exudative AMD-related. The average age of the subjects was 71.47±6.15 years. The maximum corrected visual acuity at the time of admission averaged 0,04±0.03. All patients were previously treated with anti-VEGF therapy, and number intravitreal injections was in the range from 3 to 14. The experience of the disease was 2,35±0,77 years, the prescription of hemorrhage – 5,47±3,55 days. The mean size of the subretinal hemorrhage was 21.41±3.37 DD. According to optical coherence tomography, the average value of retinal thickness in the macular region was 1081,29±389,67 microns. The day before surgery all patients underwent surgical treatment according to the author's method (patent No. 2696056) – intravitreal injection Gemase® 3000 ME, 0,2 ml. The next day was performed vitrectomy 25G, local removal of the ILM and subretinal injection Gemase® 3000 ME – 0.3 ml and 0.2 ml of sterile air, fluid-air exchange 70% of the volume vitreal cavity, intravitreal injection Eylea® 0.05 ml, tamponade of vitreous cavity with 20% SF6. After the operation, the patient was placed «horizontally on the back» for 2 hours, then he had to be in an upright position to move the blood clot to the lower parts of the ocular floor. Results. Intraoperative complications were not observed in any of the cases. A complete dislocation of subretinal hemorrhage from under fovea zone was achieved in every patient's postoperative period. Conclusion. The proposed surgical method provides rapid recovery of subject vision and can be used in the treatment of massive submacular hemorrhages of any etiology. Key words: AMD, submacular hemorrhages, vitrectomy, prourokinase.

Clinical features of red blood cell-coated intraocular lens after breakthrough vitreous hemorrhage secondary to neovascular age-related macular degeneration.

To investigate the incidence and clinical features of red blood cell (RBC)-coated intraocular lens (IOL) in breakthrough vitreous hemorrhage (VH) with subretinal hemorrhage (SRH) secondary to neovascular age-related macular degeneration (nAMD). Seoul National University Bundang Hospital, Seongnam, Korea. Retrospective cohort analysis. A total of 30 patients diagnosed as breakthrough VH with SRH in nAMD who underwent pars plana vitrectomy were included in this study. Demographics and clinical characteristics of the subjects, visual acuities, and SRH sizes measured as disc diameters were analyzed. The correlation analysis between SRH size and absorption duration of RBC-coated IOL were performed. Out of 30 eyes in 30 patients, RBC-coated IOLs were observed in 11 patients (37%). Appearance of RBC-coated IOLs was noted 1 month postoperatively, and the mean duration of SRH absorption was 8.6 ± 2.6 months. SRH sizes were significantly different between eyes with RBC-coated IOL and clear IOL (62.8 ± 20.7 vs 27.4 ± 14.2, P < .001). There was definite correlation between SRH size and absorption duration of RBC-coated IOL (correlation coefficient 0.899, P < .001, R2 = 0.831). There were no statistically significant differences according to age, sex, laterality, underlying medical conditions, preoperative lens status, history of antivascular endothelial growth factor treatment, and visual acuities. The degenerated RBC on the surface of IOL was confirmed by electron and light microscopy. RBC-coated IOL could develop after vitrectomy surgery for breakthrough VH with massive SRH secondary to nAMD, and it can be confused with IOL opacification. Because it spontaneously disappears gradually, observation without IOL removal is warranted.

Vitrectomy combined with subretinal injection of tissue plasminogen activator for successful treatment of massive subretinal hemorrhage.

To evaluate the outcome of vitrectomy combined with a subretinal injection of tissue plasminogen activator (tPA) to treat a massive subretinal hemorrhage. The medical records of 11 eyes of 11 patients (seven men, four women, mean age; 74.5 ± 9.6 years) with a massive (>10 disc area) subretinal hemorrhage were reviewed. The patients were treated with vitrectomy combined with a subretinal injection of tPA with or without external drainage. The mean baseline visual acuity was 2.10 ± 0.45 logarithm of the minimum angle of resolution (logMAR) units. The hemorrhage was externalized in three eyes due to bullous hemorrhagic retinal detachment. The subretinal hemorrhage was displaced away from the fovea in 10 eyes (91%) and reduced in one eye. Retinal reattachment was achieved in all eyes however reoperations were needed in five eyes (45%) among the eight eyes (73%) with recurrent vitreous and/or subretinal hemorrhages. The postoperative vision at 3 months was significantly improved to 1.32 ± 0.65 logMAR units (p = 0.0076). The vision in the two eyes without postoperative subretinal hyperreflective material at the fovea recovered to 0.4 logMAR units but none of the nine eyes with the foveal subretinal hyperreflective material had vision better than 0.1 logMAR units. Vitrectomy with subretinal injection of tPA with or without external drainage of the subretinal hemorrhage was effective in treating massive subretinal hemorrhages.

Subretinal alteplase injections in massive subretinal hemorrhage due to age-related macular degeneration: A case report series.

This report describes a series of cases with massive subretinal hemorrhage (SRH) due to age-related macular degeneration (AMD) treated by subretinal alteplase injections. In all cases, the surgical technique consisted in 25-gauge pars plana vitrectomy (PPV) and alteplase injection under the retina using a 38-gauge cannula. After the fluid-gas exchange, bevacizumab injection was performed in all patients. Three cases of SRH in which this technique was used, as well as their evolution at one week and one month postoperatively are described. Visual acuity was hand motion in all three cases at presentation. After surgery, a significant anatomical and functional improvement was noted in all cases. One month postoperatively, none of the patients had blood under the macula, and visual acuities significantly improved to 0.8, 0.2 and 0.16 (decimal fraction). A consistent reduction of central retinal thickness was observed on optical coherence tomography (OCT) from the first week postoperatively. No intra and postoperative complications were noted. Subretinal alteplase injection proved as a viable solution in these severe SRH with early presentation. There was no need to change the systemic anticoagulant and antiaggregant therapy. Bevacizumab intravitreal injection at the end of surgery has an important role in preventing further bleeding.

Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage

We describe the surgical technique of managing a case of massive subretinal hemorrhage (SRH) using tissue plasminogen activator [tPA], followed by vitrectomy and SRH drainage.

Predictive Factors And Long-Term Visual Outcomes After Anti-Vascular Endothelial Growth Factor Treatment Of Retinal Angiomatous Proliferation.

PurposeTo report the results of 9-year follow-up examinations and predictive factors for visual acuity outcome after intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents to treat retinal angiomatous proliferation (RAP).MethodsWe conducted a retrospective observational study of 85 treatment-naïve eyes in 61 patients (21 men, 40 women; age range, 70–95 years; mean age, 84.0 years) treated with intravitreal injections of anti-VEGF agents. All patients received three consecutive monthly injections as an induction treatment. During the maintenance phase, the patients received intravitreal injections as needed or fixed dosing. The primary outcome measures were best-corrected visual acuity (BCVA) during the follow-up period. Furthermore, we investigated potential predictive factors of improvement in visual acuity. The proportion of patients who developed specific complications were also analyzed.ResultsThe mean BCVA gradually decreased from 0.58 at baseline to 0.70 at 36 months (P = 0.146), 0.82 at 48 months (P = 0.004), and 0.92 at 108 months (P = 0.021). Improvement in visual acuity at the final visits was associated with baseline visual acuity and central foveal thickness. Massive subretinal hemorrhage, fibrotic scars, and macular atrophy developed in 4 (4.7%), 9 (10.6%), and 50 (56.8%) eyes, respectively, at the final visits, and were all significantly associated with final visual acuity (P = 0.013, P < 0.001, and P = 0.001, respectively).ConclusionLong-term stabilization of vision in patients with RAP, regardless of treatment modality, was difficult to achieve by using intravitreal injections of anti-VEGF agents. Earlier detection and treatment are important to maintain visual acuity in patients with RAP.

Autologous translocation of the choroid and retina pigment epitelial cells(RPE) in age-related macular degeneration: Monitoring the viability of choroid and RPE patch with indocyanine green angiography(ICGA) and fundus autofluorescence(FAF).

To investigate the functional and anatomical results of autologous retinal pigment epithelial(RPE) cells and choroidal translocation after removal of the subfoveal choroidal neovascular membrane(CNVM) in patients with exudative age-related macular degeneration(AMD). To monitor the viability of choroidal patch with indocyanine green angiography(ICGA) and fundus autofluorescence(FAF) METHODS: This study was conducted as a retrospective, interventional case series, and evaluation of 8 patients ;4 patients had large (> 1 disk diameter) subfoveal choroidal membranes, 3 with massive subretinal hemorrhage and 1 case with suprachoroidal hemorrhage(SCH) + rhegmatogenous retinal detachment(RRD). After removal of the CNVM, the autologous full-thickness patch of the RPE, bruch's membrane, choriocapillaris, and choroid was excised from the midperiphery and placed under the macula. At the 1 st month, 3rd month, 6th month and final examination, color fundus pictures and optical coherence tomography (OCT) were performed by preferred fixation of the OCT-light. Visual test with the early treatment of diabetic retinopathy study(ETDRS), OCT imaging with fixation, scanning with laser ophthalmoscopy autofluorescence, and ICGA were performed to evaluate the viability of choroidal patch at each visits. This study was carried out in 8 patients with a mean follow-up of 14.12 ± 8.16 (range 7-30 months) months. The mean age was 73 ± 7.17(range, 60-80 years) years. Pre-operative visual acuity ranged from hand motion (HM) (20/2000) to light perception (LP)(20/20000). Post-operative vision ranged from HM (20/2000) to 0.15(20/125). In 6 patients, autofluorescence was reflected in FAF imaging and lipofuscin activity was evaluated as viable. Post-operative subretinal hemorrhage was encountered in 1 (12.5%) patient and it also resolved spontaneously. There was a statistically significant increase in visual acuity at the postoperative final visit compared to baseline. (p = 0.027) CONCLUSIONS: After removal of the CNVM, translocation of a full-thickness patch with the autologous peripheral RPE and choroid can be performed at the macula, resulted in survival and functional graft for 6 months and moreover, hereby viability of the choroid and RPE patch were monitored by imaging methods such as FAF and ICGA.

Chinese Guideline on the Management of Polypoidal Choroidal Vasculopathy (2022)

BackgroundIn mainland China, patients with neovascular age-related macular degeneration (nAMD) have approximately an 40% prevalence of polypoidal choroidal vasculopathy (PCV). This disease leads to recurrent retinal pigment epithelium detachment (PED), extensive subretinal or vitreous hemorrhages, and severe vision loss. China has introduced various treatment modalities in the past years and gained comprehensive experience in treating PCV. MethodsA total of 14 retinal specialists nationwide with expertise in PCV were empaneled to prioritize six questions and address their corresponding outcomes, regarding opinions on inactive PCV, choices of anti-vascular endothelial growth factor (anti-VEGF) monotherapy, photodynamic therapy (PDT) monotherapy or combined therapy, patients with persistent subretinal fluid (SRF) or intraretinal fluid (IRF) after loading dose anti-VEGF, and patients with massive subretinal hemorrhage. An evidence synthesis team conducted systematic reviews, which informed the recommendations that address these questions. This guideline used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach to assess the certainty of evidence and grade the strengths of recommendations. ResultsThe panel proposed the following six conditional recommendations regarding treatment choices. (1) For patients with inactive PCV, we suggest observation over treatment. (2) For treatment-naive PCV patients, we suggest either anti-VEGF monotherapy or combined anti-VEGF and PDT rather than PDT monotherapy. (3) For patients with PCV who plan to initiate combined anti-VEGF and PDT treatment, we suggest later/rescue PDT over initiate PDT. (4) For PCV patients who plan to initiate anti-VEGF monotherapy, we suggest the treat and extend (T&E) regimen rather than the pro re nata (PRN) regimen following three monthly loading doses. (5) For patients with persistent SRF or IRF on optical coherence tomography (OCT) after three monthly anti-VEGF treatments, we suggest proceeding with anti-VEGF treatment rather than observation. (6) For PCV patients with massive subretinal hemorrhage (equal to or more than four optic disc areas) involving the central macula, we suggest surgery (vitrectomy in combination with tissue-plasminogen activator (tPA) intraocular injection and gas tamponade) rather than anti-VEGF monotherapy. ConclusionsSix evidence-based recommendations support optimal care for PCV patients’ management.

Complete regression of branching vascular network in polypoidal choroidal vasculopathy by ranibizumab and photodynamic therapy, two case reports

BackgroundPolypoidal choroidal vasculopathy (PCV) consists of polyps that potentially cause massive subretinal hemorrhage and their branching vascular network (BVN) of feeder vessels. Although conventional indocyanine green angiography (IA) has shown anti-vascular endothelial growth factor (VEGF) agents and/or photodynamic therapy (PDT) to successfully induce polyp closure, the BVN appears resistant to these therapies and serves as the origin of recurrent active polyps. Recently introduced optical coherence tomography angiography (OCT-A) enables more frequent angiographic evaluation of polyps and the BVN than does conventional IA since it does not require intravenous fluorescent dye injection and is thus considered non-invasive.Case presentationCase 1. A 70-year-old male with PCV in his left eye suffered from vision deterioration (20/40) due to persistent subretinal fluid despite 42 intravitreal injections of ranibizumab (IVRs) over 5 years and 7 months. PDT was performed as an adjunct therapy 3 days after the 43rd IVR. IA at 3 months after PDT showed successful polyp closure but persisting BVN. However, more frequent evaluation with OCT-A starting at 1 week after PDT demonstrated complete regression of both the BVN and polyp. OCT-A at every subsequent outpatient visit depicted gradual re-perfusion of the BVN and the restoration of most of its original network at 3 months, which was compatible with IA findings. Neither OCTA nor IA revealed polyp recurrence at 3 months.Case 2. A 65-year-old female suffering from left vision deterioration due to PCV underwent 5 intravitreal injections of aflibercept. Since her subretinal fluid persisted, the treatment was switched to a combination of IVR and PDT. OCT-A revealed marked regression of the BVN and polyp at 2 weeks, but the BVN had regained its original shape at 2 months without any sign of polyp recurrence.ConclusionsDifferently from previous observations obtained by IA alone, more frequent non-invasive OCT-A examination revealed complete but transient regression of the BVN just after combination therapy with IVR and PDT.

Periocular triamcinolone acetonide injection for treating polypoidal choroidal vasculopathy concurrent with hemorrhagic retinal detachment.

To investigate the clinical efficiency of periocular triamcinolone acetonide (TA) injection for treating polypoidal choroidal vasculopathy (PCV) concurrent with hemorrhagic retinal detachment (HRD).Twenty-two cases confirmed with PCV concurrent with HRD characterized by massive subretinal hemorrhage and exudation presented to our department from January 2015 to May 2017 were included in this study. The initial vision varied from counting finger to 0.2. All cases were randomly divided into TA group (n = 12), which received periocular TA injection per month, and anti-VEGF group (n = 10), which were treated by anti-VEGF intravitreous injection per month. The patients were followed up for 6 months, in which fundus examination and visual acuity along with optical coherence tomography (OCT) were carried out.The treatment effect is divided into the following categories. Cure was defined as the elimination of subretinal hemorrhage and exudation accompanied by retinal edema and choroidal neovascularization (CNV) extinction and rise of visual acuity. Improvement was characterized by alleviation of subretinal hemorrhage and exudation accompanied by retinal edema and CNV reduction and rise of visual acuity. Ineffective means remained subretinal hemorrhage and exudation in fundus and no improvement of visual acuity, and polypoid lesions in OCT images. Among the 12 cases in TA group, 1 case was treated by periocular injection of TA twice, and 11 cases were treated by 3 times injection. After that, 3 cases (25%) were cured, 8 cases (66.7%) got improvement, and only 1 case (8.3%) showed no response. Although among 10 cases in the anti-VEGF group, 3 cases were treated by anti-VEGF intravitreous injection twice. Seven cases were treated by 3 times injection. After that, 4 cases (40%) got improvement, and the other 6 case (60%) showed no response. All patients showed no recurrence in the 6-month follow-up. No complications were noticed under periocular injection or intravitreous injection.Periocular TA injection is effective for treating PCV concurrent with HRD.

Traumatic Maculopathy with Massive Subretinal Hemorrhage after Closed-Globe Injuries: Associated Findings, Management, and Visual Outcomes

To investigate the visual outcomes of patients with traumatic maculopathy and massive subretinal hemorrhage (SRH) after closed-globe injury. Retrospective, noncomparative, and interventional case series. Twenty-four patients with traumatic maculopathy and massive SRH after closed-globe injury. In this retrospective observational case series, we included 25 eyes of 24 patients who had experienced closed-globe injury with massive SRH. The demographics, clinical characteristics, and final visual acuity (VA) of the patients. Twenty-five eyes with massive SRHs involving the macula were studied with initial VAs from light perception to 4/200. At initial presentation, vitreous hemorrhages were present in 22 eyes, hyphema in 13 eyes, lid lacerations in 11 eyes, glaucoma in 8 eyes, iridodialysis in 7 eyes, afferent pupillary defect in 6 eyes, lens dislocation or subluxation in 5 eyes, and cyclodialysis clefts and hypotony in 2 eyes. Retinal detachment developed in 7 eyes during the follow-up period. Pars plana vitrectomy usually was performed in patients with persistent vitreous hemorrhage, retinal detachment, lens dislocation, and cyclodialysis cleft with hypotony. In final visual outcomes, 7 eyes achieved favorable visual outcomes with VA of 20/200 or more. Thirteen eyes showed VA of 2/200 or less with dense macular scars or foveal atrophy. Foveal atrophy showed encompassed foveal thinning, retinal pigment epithelial clumping, and the loss of external limiting membrane (ELM), ellipsoidal zone (EZ), and interdigital zone (IZ) on spectral-domain OCT. Fundus autofluorescence demonstrated interposed, reduced, and increased autofluorescence in traumatic pigment epitheliopathy. Traumatic maculopathy and massive SRH after closed-globe injury often cause poor visual outcomes, especially in eyes with dense macular scars or foveal atrophy. Spectral-domain OCT findings in patients with good visual outcomes revealed partial to complete preservation of the foveal ELM, EZ, and IZ.

Incidence and risk factors of massive subretinal hemorrhage in retinal angiomatous proliferation.

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.

Massive subretinal and subretinal pigment epithelial hemorrhage displacement with perfluorocarbon liquid using a two-step vitrectomy technique.

The purpose of this study was to evaluate the efficacy and visual outcome of massive submacular hemorrhage (SMH) displacement with a planned two-step pars plana vitrectomy (PPV) using tissue plasminogen activator (tPA) and perfluorocarbon liquid (PFCL) tamponade. A retrospective case series of patients with age related macular degeneration and SMH was used. All patients underwent a 23G PPV, subretinal tPA injection and a medium term PFCL tamponade. A second stage PPV for PFCL removal was performed 7-17 days later. The main outcome was the change in macular and sub-RPE thickness after 6 months. Secondary outcomes were visual acuity and complications. Seven patients (seven eyes) with mean age of 79.85 years were enrolled. The average SMH size was 17.5 disc area (range 4.5-33) with mean symptoms of a duration of 9.5 days (range: 2-21). SMH was successfully displaced in six eyes. Mean macular and sub-RPE thickness decreased from 1505μ to 711.3μ and 900 μ to 457μ, respectively. Visual acuity (VA) remained stable in five eyes. Complications included corneal edema and transient intraocular pressure elevation in three patients. SMH displacement using subretinal tPA injection and medium term PFCL tamponade is an effective alternative treatment option. In our experience, it can be safely performed, avoiding complications commonly attributed to other techniques.