Submacular Hemorrhage Research Articles

Incidence Rate of Massive Submacular Hemorrhage and its Risk Factors in Polypoidal Choroidal Vasculopathy

To investigate the incidence rate of massive submacular hemorrhage (SMH) in patients with polypoidal choroidal vasculopathy (PCV) and analyze the associated risk factors. Retrospective cohort study. Patients diagnosed with PCV from May 2003 to May 2014 were included. Two hundred forty-five eyes of 245 patients were enrolled. The time between the initial visit to the clinic with subjective visual symptoms and the date of massive SMH was recorded. SMH larger than 4 disc diameters was defined as massive SMH. Age; hypertension; visual acuity (VA); indocyanine green angiography findings, including the greatest linear dimension, largest polyp size, and PCV type (cluster vs non-cluster); and treatment methods were reviewed for risk factor analysis using Kaplan-Meier survival and Cox regression analyses. The incidence rate of massive SMH within 1 year after the initial visit was 2.45%. Massive SMH occurred within 3, 5, and 10 years after the first visit in 6.17%, 11.09%, and 29.85% of patients, respectively. Cox regression analysis revealed that the cluster type of PCV was significantly associated with massive SMH (hazard ratio [HR], 3.418; P= .003). Photodynamic therapy followed by anti-vascular endothelial growth factor injection lowered the risk of massive SMH (HR= .242; P= .047]. Final VA in eyes with massive SMH was significantly lower than that in patients without massive SMH (1.34 ± 0.66 vs 0.63 ± 0.53 logMAR; P < .001). Patients with PCV who develop massive SMH experience severe vision loss. The incidence rate of massive SMH in PCV increases with time. The cluster type of polyp in PCV is a significant risk factor for massive SMH.

Early treatment of acute submacular haemorrhage secondary to wet AMD using intravitreal tissue plasminogen activator, C3F8, and an anti-VEGF agent.

PurposeAcute submacular haemorrhage secondary to wet age-related macular degeneration (AMD) has a poor prognosis for which there is currently no 'gold standard' treatment. We evaluated the efficacy of early treatment using intravitreal triple therapy of tissue plasminogen activator (tPA), expansile gas, and an anti-VEGF agent.MethodsThis retrospective case series included eight patients presenting with acute submacular haemorrhage involving the fovea. All patients received treatment with 50 μg (0.05 ml) tPA, 0.3 ml 100% perfluoropropane (C3F8), and an anti-VEGF agent (0.05 mg Ranibizumab or 1.25 mg Bevacizumab in 0.05 ml) administered via intravitreal injection. An anterior chamber paracentesis post injection or vitreous tap was performed before injection to prevent retinal vascular occlusion secondary to raised intra-ocular pressure. Outcomes assessed were visual acuity, change in macular morphology, and complications.ResultsPatients presented promptly with delay between symptom onset and clinic review being 1.9±0.6 days (mean±SD). Treatment was delivered quickly with interval from presentation to treatment being 1.1±1.2 days. Symptom onset to treatment was 3.0±1.0 days. Subfoveal haemorrhage was effectively displaced in all patients. LogMAR visual acuity improved from 1.67±0.47 at presentation to 0.63±0.33 at final follow-up (P<0.0001), a mean of 7.9±4.8 months after treatment. Central retinal thickness improved from 658.1±174.2 μm at presentation to 316.6±142.4 μm at final follow-up (P=0.0028).ConclusionsEarly treatment of submacular haemorrhage using intravitreal tPA, C3F8, and anti-VEGF was effective in significantly improving visual acuity in this series of patients who presented soon after symptom onset. Treatment was well tolerated in this group of elderly and potentially frail patients.

Vitrectomy with subretinal tissue plasminogen activator and ranibizumab for submacular haemorrhages secondary to age-related macular degeneration: retrospective case series of 45 consecutive cases.

PurposeTo assess the efficacy of small-gauge vitrectomy with subretinal recombinant tissue plasminogen activator (rtPA) and ranibizumab for submacular haemorrhages secondary to neovascular age-related macular degeneration (nAMD), and to identify the factors associated with visual outcome.MethodsA retrospective case series was performed, including all patients who had small-gauge vitrectomy with subretinal rtPA and ranibizumab for submacular haemorrhages secondary to nAMD. All patients received three consecutive monthly injections of ranibizumab after the surgery, and were reviewed monthly and treated on a pro re nata regime.ResultsA total of 45 eyes of 45 patients were included in the study. Mean age was 77.07±9.67 years, and 32 of 45 patients (71.1%) were women. Surgery was performed on average 6.98±5.70 days after the onset of symptoms, and patients were observed for a follow-up period of 12.9±10.8 months. On average, visual acuity improved -0.59±0.61 LogMAR between presentation and last follow-up. Visual acuity improved in 33 patients (73.3%), remained unchanged in 10 patients (22.2%), and worsened in 2 patients (4.4%). Multiple linear regression showed that patients with smaller haemorrhages (P=0.012) and prompt surgery (P=0.008) had better final visual acuities. A haemorrhage area of ≤30 mm(2) had 91.3% sensitivity and 73.3% specificity for predicting a final visual acuity ≥6/60.ConclusionSmall-gauge vitrectomy with subretinal rtPA and ranibizumab is effective for improving visual acuity in patients with submacular haemorrhages secondary to nAMD. Small haemorrhage area and prompt surgery are associated with better final visual acuity.

Intravitreal Tissue Plasminogen Activator, Ranibizumab, and Gas Injection for Submacular Hemorrhage in Polypoidal Choroidal Vasculopathy

To investigate the efficacy of intravitreal injection of recombinant tissue plasminogen activator (rt-PA), ranibizumab, and gas without vitrectomy for submacular hemorrhage. Prospective, interventional, consecutive case series. Twenty consecutive patients (20 eyes) with submacular hemorrhage secondary to exudative age-related macular degeneration (AMD) or polypoidal choroidal vasculopathy (PCV). Ranibizumab, rt-PA (25 μg/0.05 ml), and 100% perfluoropropane (0.3 ml) were injected intravitreally, followed by 2-day prone positioning. The primary outcome measure was best-corrected visual acuity (BCVA) 6 months after treatment. Secondary outcome measures included central retinal thickness (CRT), central pigment epithelial detachment (PED) thickness, central ellipsoid zone, recurrence rate, and complications. Underlying disease was exudative AMD in 1 eye and PCV in 19 eyes. Submacular hemorrhage ranged in size from 2 to 31 disc diameters. Complete displacement of submacular hemorrhage was achieved in 17 eyes (85%), and partial displacement was achieved in 3 eyes (15%). Snellen BCVA improved from 20/139 before treatment to 20/65 at 6 months (P= 0.0061). Mean change in Early Treatment Diabetic Retinopathy Study score from baseline was+13 letters (P= 0.0040). Mean CRT decreased from 599 μm before treatment to 208 μm at 6 months (P < 0.0001), and central PED thickness decreased from 188 to 88 μm (P= 0.0140). Three eyes developed vitreous hemorrhage, and 1 eye developed retinal detachment; all were treated surgically, and Snellen BCVA improved at 6 months (P= 0.0012). Recurrence was observed in 10 eyes (50%) within 6 months, but visual acuity was preserved with intravitreal injection of anti-vascular endothelial growth factor (VEGF) pro re nata (PRN). The factors that affect BCVA at 6 months after treatment were pre- and posttreatment central ellipsoid zone (P= 0.0366 and P= 0.0424), pretreatment BCVA (P= 0.0015), and pre- and posttreatment central PED thickness (P= 0.0046, P= 0.0021). Subretinal hemorrhage treatment by intravitreal injection of rt-PA, ranibizumab, and gas is useful to achieve hemorrhage displacement and lesion improvement. To preserve visual acuity, early detection of posttreatment recurrence and intravitreal anti-VEGF injection PRN are necessary.

Injections intravitréennes de bevacizumab dans les hémorragies sous maculaires compliquant la DMLA

To evaluate functional and anatomic results of intravitreal bevacizumab as monotherapy at 12 and 24 months in patients with neovascular age-related macular degeneration (AMD) complicated by large submacular hemorrhage. Retrospective analysis of a total of 21 patients (22 eyes) with large submacular hemorrhage secondary to age-related macular degeneration between May 2008 and December 2011. Patients were treated with three monthly intravitreal bevacizumab injections (1.25mg/0.05 mL) at a four to six week interval and then PRN. Retreatment was based on the presence of hemorrhage on fundus examination or signs of activity on optical coherence tomography. Changes from baseline best corrected visual acuity (BCVA) scores, central retinal thickness, volume of hemorrhage and number of injections were analyzed. The mean patient age was 72 years (range, 60-89 years). All patients completed at least 12 months of follow-up, and 17 patients fulfilled 24 months. The size of hemorrhage varied from 3 to 9 disc areas with a mean duration of 12.8 days. At baseline, mean initial BCVA was 20/400 (1.3 LogMAR) and improved to 20/160 at 12 months (P<0.001) and 20/164 at 24 months (P<0.001). Mean central retinal thickness decreased significantly from 550 μm to 255 μm at 24 months (P<0.001). The mean number of injections was 3.87 during the first 12 months. No case of recurrent bleeding was detected during the second year. Intravitreal bevacizumab may be a beneficial approach for the management of large submacular hemorrhage secondary to AMD.

Anti-Vascular Endothelial Growth Factor with Gas for Submacular Hemorrhage.

To investigate the treatment outcome of pneumatic displacement and intravitreal anti-vascular endothelial growth factor (VEGF) for submacular hemorrhage (SMH) from exudative age-related macular degeneration (AMD). Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were measured at baseline and at 1, 3, and 6 months after initial treatment in 72 eyes of 72 patients treated with a combination of pneumatic displacement and anti-VEGF injection for SMH from exudative AMD. Best-corrected visual acuity and CFT showed significant improvement from baseline during the 6-month follow-up period (logarithm of the minimum angle of resolution BCVA from 1.80 to 1.00, CFT from 886 to 383 μm, p < 0.001, respectively). The decrease in subretinal hemorrhage was greater than that in subretinal pigment epithelial hemorrhage at 1 month after initial treatment (p < 0.001). In eyes with symptoms for less than 30 days, higher reflectivity of hemorrhage on optical coherence tomography and higher CFT were associated with lower BCVA after 6 months of treatment (reflectivity B = 0.335, p = 0.007; CFT B = 0.001, p = 0.003). The combination of pneumatic displacement and intravitreal anti-VEGF is a useful treatment option for SMH secondary to AMD. Higher baseline CFT and higher reflectivity of hemorrhage were associated with lower BCVA 6 months after initial treatment.

Visual prognosis of massive submacular hemorrhage in polypoidal choroidal vasculopathy with or without combination treatment

BackgroundSubmacular hemorrhage associated with polypoidal choroidal vasculopathy (PCV) may cause severe visual loss. The purpose of this study is to report the visual prognosis of massive submacular hemorrhage in patients with PCV. MethodsTwenty patients with PCV and submacular hemorrhage who received either subretinal tissue plasminogen activator (TPA) with vitrectomy or intravitreal injection of TPA and gas to achieve pneumatic displacement of the hemorrhage were enrolled. Additionally, combination treatment with either photodynamic therapy (PDT) or intravitreal injection of vascular endothelial growth factor inhibitors (anti-VEGF) was performed to treat the underlying PCV. ResultsFive patients received subretinal TPA with vitrectomy and 15 patients received intravitreal injection of TPA and gas to remove or displace the submacular hemorrhage. Combination treatment with PDT and intravitreal anti-VEGF was performed in three patients and intravitreal anti-VEGF injection alone in 13 patients. The mean logarithm of the minimal angle of resolution converted from the best corrected visual acuity (BCVA) were improved at 3 months, 6 months, and 12 months. Better initial BCVA, smaller size of submacular hemorrhage and younger age were statistically significant predictors for BCVA. Combination treatment with PDT showed significant efficacy in the improvement of BCVA. ConclusionCombination treatment of submacular hemorrhage secondary to PCV may yield visual and anatomic improvements. Initial BCVA, the initial size of submacular hemorrhage and age were significant predictors for visual prognosis.

Intravitreal tPA Injection and Pneumatic Displacement for Submacular Hemorrhage in a 10-Year-Old Child.

Background. Submacular hemorrhage can occur after blunt trauma to the eye. Intravitreal tissue plasminogen activator (tPA) and gas injection are often used for treatment and are effective for submacular hemorrhage caused by age-related macular degeneration. This report describes the clinical outcome in a child with submacular hemorrhage caused by traumatic choroidal rupture who underwent successful intravitreal tPA injection and pneumatic displacement. Case Presentation. A 10-year-old boy developed sudden decrease of vision and a central scotoma in his right eye after trauma. Submacular hemorrhage was found in the eye. Visual acuity was 20/70 OD. Tissue plasminogen activator (12.5 μg in 0.05 mL) and 0.3 mL of pure sulfur hexafluoride were injected into the vitreous cavity under general anesthesia. After surgery, the patient was instructed to maintain a prone position. Displacement of the submacular hemorrhage from the fovea revealed a choroidal rupture, presumed to be the cause of the hemorrhage. After 4 months of follow-up, visual acuity was restored and final visual acuity is 20/16. Conclusion. Intravitreal tPA and gas injection can be an effective treatment for children with submacular hemorrhage.

The Efficacy of Intravitreal Aflibercept in Submacular Hemorrhage Secondary to Wet Age-related Macular Degeneration.

PurposeTo evaluate the efficacy of intravitreal aflibercept monotherapy in submacular hemorrhage (SMH) secondary to wet age-related macular degeneration (AMD).MethodsThis study included 25 eyes in 25 patients with SMH involving the fovea secondary to wet-AMD. All patients were treated with three consecutive monthly intravitreal aflibercept (2.0 mg/0.05 mL) injections, followed by as-needed reinjection. They were followed for at least 6 months. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and area of SMH were measured at diagnosis, as well as at 3 and 6 months after treatment initiation.ResultsThe BCVA significantly improved from 0.79 ± 0.41 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.54 ± 0.41 logMAR at 6 months (p < 0.001). BCVA ≥3 lines and stable vision were observed in 96% of the eyes. The CFT significantly decreased from 560.8 ± 215.3 µm at baseline to 299.8 ± 160.2 µm at 6 months (p < 0.001). The area of SMH significantly decreased from 10.5 ± 7.1 mm2 at baseline to 1.8 ± 6.5 mm2 at 6 months (p < 0.001). The BCVA, CFT, and area of SMH at baseline, as well as duration of symptoms, all correlated with BCVA at the 6-month follow-up.ConclusionsIntravitreal injection of aflibercept is an effective treatment option for patients with SMH secondary to wet-AMD; however, there may be limited efficacy in eyes with large SMH area and cases in which treatment is delayed.

Modified Approach in Management of Submacular Hemorrhage Secondary to Wet Age-Related Macular Degeneration.

The aim of this study was to evaluate the surgical outcomes of a modified approach in the management of thick submacular hemorrhage in patients with wet age-related macular degeneration. This was a retrospective study. A retrospective chart review was performed on 10 eyes of 10 patients with submacular hemorrhage secondary to wet age-related macular degeneration treated with 23-gauge pars plana vitrectomy, followed by submacular injection of recombinant tissue plasminogen activator (12.5 μg/0.1 mL), bevacizumab (2.5 mg/0.1 mL), and air (0.3 mL). Gas tamponade was given with 20% SF6 and postoperative propped-up positioning. Patients were evaluated for displacement of hemorrhage, preoperative and postoperative best-corrected visual acuity, occurrence of intraoperative and postoperative complications, and recurrence of hemorrhage. All patients were followed up for 6 months. Displacement of the submacular bleed was achieved in all cases. Improvement of best-corrected visual acuity was seen in 8 of 10 patients. Rebleed was seen in 2 eyes that were retreated with intravitreal injection of recombinant tissue plasminogen activator, bevacizumab, and 20% SF6 gas. This modified technique aids in the effective displacement of thick submacular hemorrhage with simultaneous treatment of the underlying choroidal neovascular membrane, which halts the disease progression resulting in significant improvement of visual acuity.

Management of Acute Submacular Hemorrhage with Intravitreal Injection of Tenecteplase, Anti-vascular Endothelial Growth Factor and Gas

PurposeTo evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas.MethodsThis study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed.ResultsThe mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied.ConclusionsA triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration.

Intravitreal Aflibercept for Treatment-Resistant Neovascular Age-Related Macular Degeneration: 12-Month Safety and Efficacy Outcomes

Purpose: To prospectively assess the safety and efficacy of intravitreal aflibercept for treatment-resistant neovascular age-related macular degeneration (nAMD). Methods: This prospective, non-randomized clinical trial included 49 patients with treatment-resistant nAMD who received 2 mg intravitreal aflibercept as 3 monthly loading doses, followed by injections every 2 months over 12 months. Inclusion criteria included active nAMD on fluorescein angiography at baseline and persistent intra- or subretinal fluid on optical coherence tomography (OCT) for ≥6 months prior to baseline with a minimum of 4 injections of bevacizumab and/or ranibizumab. Patients were assessed monthly for best-corrected visual acuity (BCVA), central retinal thickness (CRT) measured with OCT and occurrence of adverse events. Retinal pigment epithelium atrophy (RPEA) was assessed at baseline and at 12 months. Results: Mean BCVA improved by 4.7 letters (95% CI: 2.1-7.3, p < 0.001) and CRT decreased by 97.2 µm (95% CI: 54.4-140.1, p < 0.001) at 12 months compared to baseline. Median RPEA area increased by 0.48 mm² (range = -0.1 to 19.9, p < 0.001). There was 1 arterial thromboembolic event and 2 cases of submacular haemorrhage. Conclusion: In this cohort of treatment-resistant nAMD patients, intravitreal aflibercept was effective in improving vision and reducing exudation. Early visual and anatomic outcomes may predict longer-term response to treatment, but further assessment is required.

OPTICAL COHERENCE TOMOGRAPHY FINDINGS AND SURGICAL OUTCOMES OF TISSUE PLASMINOGEN ACTIVATOR-ASSISTED VITRECTOMY FOR SUBMACULAR HEMORRHAGE SECONDARY TO AGE-RELATED MACULAR DEGENERATION.

To study the relationship between morphologic findings using spectral domain optical coherence tomography and surgical outcomes in patients with submacular hemorrhage (SMH) secondary to age-related macular degeneration. Medical charts of nine eyes of nine patients who underwent tissue plasminogen activator-assisted vitrectomy for SMH secondary to age-related macular degeneration were retrospectively reviewed. The preoperative height and lateral width of both SMH and pigment epithelial detachment documented with optical coherence tomography, were measured. The status of ellipsoid layers was also analyzed. Complete displacement of SMH from the fovea was achieved in all nine eyes. The preoperative status of the ellipsoid layer under the fovea was detectable in four eyes and absent in the remaining five eyes. Postoperative best-corrected visual acuity was significantly better in eyes with preoperative detectable ellipsoid layers (P < 0.01). Eyes with preoperative SMH heights <400 μm also exhibited better best-corrected visual acuity (P < 0.05). There was no significant correlation between postoperative best-corrected visual acuity and the specific features of pigment epithelial detachment, including height, lateral width, and number. The preoperative presence of detectable ellipsoid layers and a lower height of SMH may predict good visual prognosis. In contrast, no specific features of pigment epithelial detachment correlated with postoperative best-corrected visual acuity.

Outcomes of 27 Gauge Microincision Vitrectomy Surgery for Posterior Segment Disease

To report the initial experience, clinical outcomes, and safety profile of 27 gauge pars plana vitrectomy (PPV) in eyes with posterior segment disease. Multicenter, retrospective, interventional case series. setting: Private practice and tertiary care settings. Eyes undergoing 27 gauge PPV for a vitreoretinal surgery indication. Three-port, transconjunctival 27 gauge PPV. Change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 90 days. Ninety-five eyes met the inclusion criteria. Surgical indications included epiretinal membrane (n = 26), diabetic tractional retinal detachment (n = 14), full-thickness macular hole (n = 11), rhegmatogenous retinal detachment with (n = 7) or without (n = 9) proliferative vitreoretinopathy (PVR), vitreous hemorrhage (n = 10), vitreous opacities (n = 8), endophthalmitis (n = 4), sub-silicone oil retinal detachment (n = 3), retained lens material (n = 1), submacular hemorrhage (n = 1), and aqueous misdirection (n = 1). Mean logMAR visual acuity improved from 1.08 ± 0.71 (20/240 Snellen equivalent) preoperatively to 0.53 ± 0.65 (20/67 Snellen equivalent) postoperatively (P < .001). Mean follow-up was 144 days (median 127 days, range 90-254 days). There were no intraoperative complications and no case required conversion to 20, 23, or 25 gauge instrumentation. A total of 3 sclerotomy sites (1.1%) were sutured at the conclusion of surgery. Postoperative complications included transient ocular hypertension in 8 eyes (8.4%), transient hypotony in 5 eyes (5.3%), and vitreous hemorrhage in 5 eyes (5.3%). No cases of postoperative endophthalmitis, sclerotomy-related retinal tears, or choroidal detachments were encountered in the follow-up period. The 27 gauge PPV was well tolerated with low rates of intraoperative and postoperative complications across varied surgical indications.

Management of acute submacular haemorrhage: Royal free hospital experience

PurposeTo evaluate visual outcomes of patients presenting with acute submacular haemorrhage (SMH) secondary to neovascular Age Related Macular Degeneration (nAMD) treated with pars plana vitrectomy (PPV), subretinal recombinant tissue plasminogen activator (rTPA) and air.MethodsRetrospective, clinical case series. 7 patients with acute SMH secondary to nAMD, underwent PPV, instillation of 50 μg/0.1 ml subretinal alteplase and air tamponade. Data was obtained from Electronic Medical Records (EDRM) of the Royal Free Hospital from October 2013 to March 2015. Patient demographics (age, gender, and laterality), duration between onset and treatment, visual acuity (VA) and any concurrent treatment were recorded.Results7 patients were included in our study with mean age ‐ 69.1 years (Range: 60–87). 3 patients had cataract. No other ocular comorbidities. Mean period between onset of symptoms to treatment was 13.7 days (Range: 1–56). At presentation, six patients had hand movement (HM) VA and one patient had counting fingers (CF) VA. At one month post‐operatively, 6 patients (85.7%) demonstrated VA improvement ≥1 line, of whom 3 (42.9%) improved by ≥2 lines. At 6 months post‐operatively however, only 3 (42.9%) patients had sustained VA improvement. Post‐operative OCT demonstrated complete displacement of SMH in 4 patients (57.1%), while 3 patients had residual submacular organised blood.ConclusionsSubretinal rTPA following vitrectomy with air tamponade may be used to dissolve submacular blood mass enabling physicians to resume NHS funded anti‐VEGF therapy. Long‐term visual outcome is often limited by underlying disease progression.

Spontaneous subretinal pigment epithelium hemorrhage

PurposeTo describe a case of spontaneous subretinal pigment epithelium hemorrhage in a high myopic patient.SettingSubretinal hemorrhage is an accumulation of blood between the neurosensory retina and the retinal pigment epithelium. Sub‐RPE (retinal pigment epithelium) hemorrhage is located between the RPE and Bruch's membrane.MethodsA 22 year old high myopic Brazilian man complained of acute blurred vision in his left eye over the past 2 days. The patient had no trauma and systemic pathology. Visual acuity in the right eye was 20/20 and in the left eye counting fingers (3 m). The intraocular pressure and biomicroscopy were normal. Fundus examinationof the right eye was normal. Fundus examination of the left eye showed a macular hemorrhage with well‐defined borders.ResultsThe patient underwent optical coherence tomography (OCT), fluorescein angiography (FA) and Indocyanine green (ICG) angiography. In the OCT was evident the sub‐RPE hemorrhage. Choroidal neovascularisation was not detected in any exam including ICG. No surgery was performed, only observation. At 30‐days follow‐up, the visual acuity in the left eye was 20/40. Fundus examinationshowed an absorption of the sub‐RPE hemorrhage.ConclusionsSubretinal hemorrhage may cause retinal damage through a number of mechanisms. Sub‐RPE hemorrhages have well‐defined borders attributed to the tight cell junctions among RPE cells. Good visual outcome is sometimes possible in selected patients with submacular hemorrhage managed without surgical intervention. The OCT is an important tool to localize the level of the hemorrhage. The recover of the visual acuity of the present case is probably due to the healthy retinal pigment epithelium and photoreceptors prior to the hemorrhage.

Polypoidal choroidal vasculopathy in patients aged less than 50years: characteristics and 6-month treatment outcome.

To investigate the characteristics and 6-month treatment outcome of polypoidal choroidal vasculopathy (PCV) in patients aged <50years. This retrospective study included 22 eyes from 22 patients who were <50years old and had been diagnosed with treatment naïve PCV. Analyses of treatment outcome were performed in eyes treated with anti-vascular endothelial growth factor (VEGF) therapy. Eyes that exhibited submacular hemorrhage of ≥1 disc diameter and involving the fovea were included in the hemorrhage group. The remaining eyes were included in the no-hemorrhage group. The baseline best-corrected visual acuity (BCVA) was compared with that at 6months within each group. The mean age of the 22 patients was 46.5 ± 1.8 (range, 43-49) years. Submacular hemorrhage was noted in ten eyes (45.5%). The presence of drusen was noted in one eye and pseudodrusen was not noted in any of the eyes included. Treatment outcome was analyzed in 18 eyes. A mean number of 2.9 ± 0.5 intravitreal anti-VEGF injections were administered during the 6-month follow-up period. In the no-hemorrhage group (n = 10), the BCVA at diagnosis and at 6months was 0.55 ± 0.32 and 0.35 ± 0.22 respectively (P = 0.011). In the hemorrhage group (n = 8), the values were 0.99 ± 0.45 and 0.74 ± 0.63 respectively (P = 0.128). A relatively high proportion of young PCV patients exhibited submacular hemorrhage at initial presentation. In those without submacular hemorrhage, intravitreal anti-VEGF therapy was found to be beneficial.

Intravitreal anti-vascular endothelial growth factor monotherapy for large submacular hemorrhage secondary to neovascular age-related macular degeneration.

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) monotherapy for large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD). A total of 49 treatment-naive patients (49 eyes) with large SMH (more than five disc areas (DAs)) secondary to nAMD were retrospectively included. All patients were treated with an initial series of 3 monthly intravitreal anti-VEGF injections, followed by as-needed injections. At the 12-month follow-up, changes in best-corrected visual acuity (BCVA), hemorrhage area, central foveal thickness, and development of vitreous hemorrhage after treatment were evaluated. The mean SMH area was 13.9 ± 8.8 disk areas (DAs) and mean symptom duration was 7.25 ± 5.9 days at baseline. The mean number of injections was 4.49 ± 1.61. Twelve months after treatment, the mean BCVA significantly improved from 1.14 ± 0.61 logarithm of the minimum angle of resolution (logMAR; 20/276, Snellen equivalent) to 0.82 ± 0.53 logMAR (20/132; P = 0.002). Twenty-four eyes (49%) showed improvement of more than three lines of BCVA at 12 months after treatment. Baseline BCVA (odds ratio (OR), 5.119; 95% confidence interval (CI), 1.993-9.545; P = 0.004), duration of symptoms (OR, 0.727; 95% CI, 0.332-0.952; P = 0.024), hemorrhage area (OR, 0.892; 95% CI, 0.721-0.965; P = 0.011), and baseline central foveal thickness (OR, 0.881; 95% CI, 0.722-0.945; P = 0.032) were significantly associated with good visual acuity 12 months after treatment. Intravitreal anti-VEGF monotherapy is a valuable treatment option for large SMH secondary to nAMD.

Submacular predominantly hemorrhagic choroidal neovascularization: resolution of bleedings under anti-VEGF therapy.

PurposeTo report the visual and morphological outcomes following intravitreal bevacizumab in neovascular age-related macular degeneration (nAMD) with submacular, predominantly hemorrhagic, lesions.MethodsRetrospective study of patients with a follow-up after 1 year. All eyes with submacular hemorrhages larger than 50% of the total lesion size and received only anti-VEGF (vascular endothelial growth factor) monotherapy (intravitreous administration of 1.25 mg bevacizumab, PRN). The primary endpoint was the change in hemorrhage size and time to resolution, in association with the mean best-corrected visual acuity (BCVA). The eyes were grouped based on the size of the hemorrhage: group A (≥1 to <4 disc area [DA]), group B (≥4 to <9 DA), and group C (≥9 DA).ResultsForty-six consecutive eyes were included. The mean area of the hemorrhage was 6 DA at baseline. Eyes with smaller bleeding (group A) had better chances of stabilized or improved vision. Complete resolution of the hemorrhage was seen in 96% of the eyes within 1 year. The mean BCVA increased from 0.81 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI]: 0.70–0.92) (Snellen 20/125) at baseline to 0.75 logMAR (95% CI: 0.62–0.88) (20/125) after 1 year (P=0.11). BCVA improved (one or more ETDRS [Early Treatment of Diabetic Retinopathy Study] lines) in 57% of the eyes (13/23) in group A; 53% (8/15) in group B; and 38% (3/8) in group C.ConclusionMany of the eyes with hemorrhagic lesions showed stabilization or improvement of the mean BCVA after treatment within 1 year. Anti-VEGF treatment can be considered as a useful treatment option in eyes with hemorrhages secondary to nAMD.

Triple Therapy Management of Macular Telangiectasia

Hammad Rashid Nasti MS Vitreo-re na Fellow, Sardar Bahadur Dr Sohan Singh Eye Hospital Amritsar 143006, Punjab, India. Email: hrnas @yahoo.com *Address for correspondence We report the case of a 65 year old lady presen ng with sudden diminu on of vision in her right eye (RE) with the best corrected visual acuity (BCVA) being coun ng fi ngers at 1 metre. Complete ocular examina on and op cal coherence tomography (OCT) revealed a sub-macular hemorrhage (SMH) in her RE. She was treated with a triple therapy consis ng of intra vitreal ssue plasminogen ac vator (tPA), bevacizumab and sulphur hexafl uoride (SF6) gas tamponade. At one month into follow up, her SMH had resolved. At this point fl uorescein angiography and OCT revealed a subre nal neovascular membrane in the RE and decreased foveal thickness in both eyes. This led to the diagnosis of Stage 5 macular telangiectasis in the right eye and Stage 1 macular telangiectasis in the le eye (LE). She received another intra vitreal injec on of bevacizumab. At 3 months follow up her BCVA is 20/40, N6 in the right eye signifying the effi cacy of prompt use of triple therapy in cases of sub-macular hemorrhage where an underlying neovascular membrane is suspected as a cause.