Surgery for hemorrhagic choroidal neovascular lesions of age-related macular degeneration: ophthalmic findings: SST report no. 13

Both hemoglobin and hemin cause damage to retinal pigment epithelium through the iron ion accumulation

Subretinal hemorrhages result in poor vision and visual field defects. During hemorrhage, several potentially toxic substances are released from iron-based hemoglobin and hemin, inducing cellular damage, the detailed mechanisms of which remain unknown. We examined the effects of excess intracellular iron on retinal pigment epithelial (RPE) cells. A Fe2+ probe, SiRhoNox-1 was used to investigate Fe2+ accumulation after treatment with hemoglobin or hemin in the human RPE cell line ARPE-19. We also evaluated the production of reactive oxygen species (ROS) and lipid peroxidation. Furthermore, the protective effect of-an iron chelator, 2,2'-bipyridyl (BP), and ferrostatin-1 (Fer-1) on the cell damage, was evaluated. Fe2+ accumulation increased in the hemoglobin- or hemin-treated groups, as well as intracellular ROS production and lipid peroxidation. In contrast, BP treatment suppressed RPE cell death, ROS production, and lipid peroxidation. Pretreatment with Fer-1 ameliorated cell death in a concentration-dependent manner and suppressed ROS production and lipid peroxidation. Taken together, these findings indicate that hemoglobin and hemin, as well as subretinal hemorrhage, may induce RPE cell damage and visual dysfunction via intracellular iron accumulation.

Outcomes in the Treatment of Subretinal Macular Hemorrhage Secondary to Age-Related Macular Degeneration: A Systematic Review

Background: Subretinal macular hemorrhage (SRMH) secondary to age-related macular degeneration (AMD) is a relatively rare condition in ophthalmology characterized by blood collection between the neurosensory retina and the retinal pigment epithelium (RPE). Without prompt treatment, visual prognosis is poor. A plethora of treatment approaches have been tried over the past years ranging from intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy to direct subretinal surgery, with no conclusive superiority of one over the other. Materials and Methods: We conducted a systematic review of the outcomes and treatment modalities of SRMH from inception to 14 June 2022, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). The level of evidence was assessed for all included articles according to the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: A total of 2745 articles were initially extracted, out of which 1654 articles were obtained after duplicates were removed and their abstracts screened. A total of 155 articles were included for full-text review. Finally, 81 articles remained that fulfilled the inclusion criteria. Conclusions: Even though there are solid results supporting a variety of treatments for SRMH, the best treatment modality has still not been conclusively demonstrated and further research is needed.

RHEGMATOGENOUS RETINAL DETACHMENT AFTER INJECTION OF TISSUE PLASMINOGEN ACTIVATOR AND GAS FOR SUBMACULAR HEMORRHAGE SECONDARY TO AGE-RELATED MACULAR DEGENERATION

PURPOSE

The purpose of this study was to describe the rate, clinical characteristics, and outcomes of rhegmatogenous retinal detachment (RRD) after injection of tissue plasminogen activator (TPA) and gas for submacular hemorrhage displacement.

METHODS

Retrospective analysis of consecutive cases developing RRD after TPA injection and gas for submacular hemorrhage displacement. The rate of RRD was calculated, and a description of RRD clinical characteristics was performed. Anatomic and visual outcomes after RRD repair were analyzed.

RESULTS

Ninety eyes of 90 patients were analyzed. Tissue plasminogen activator was given intravitreally in 53 eyes (59%) and subretinally in 37 eyes (41%). RRD occurred in 6 of 90 eyes (7%). Of these, one had intravitreal TPA and five had vitrectomy with subretinal TPA ( P = 0.04). The mean age was 75 (64-93) years. The median time of RRD occurrence was 42 (1-134) days. All cases had macular involvement. Two cases had PVR at presentation. Vitrectomy was performed in all cases and silicone oil used in five, all of which resulted in permanent silicone oil retention. One case (17%) achieved primary single surgery success. The median final visual acuity was 1.8 logMAR (20/1,260 Snellen).

CONCLUSION

The RRD rate after submacular hemorrhage displacement was 7% in our case series. Rhegmatogenous retinal detachment occurred more commonly after vitrectomy with subretinal TPA injection. The visual and anatomic outcomes were poor, with a high rate of retained silicone oil and recurrent RRD.

Surgery, Tissue Plasminogen Activator, Antiangiogenic Agents, and Age-Related Macular Degeneration Study: A Randomized Controlled Trial for Submacular Hemorrhage Secondary to Age-Related Macular Degeneration

PURPOSE

To compare the efficacy and the safety of submacular hemorrhage (SMH) management using either surgical pars plana vitrectomy (PPV) or pneumatic displacement (PD) with tissue plasminogen activator (tPA) and vascular endothelial growth factor (VEGF) inhibitor added to each arm.

DESIGN

Randomized, open-label, multicenter superiority study.

PARTICIPANTS

Ninety patients with neovascular age-related macular degeneration (nAMD) 50 years of age or older with recent SMH (≤ 14 days) of more than 2 optic disc areas and predominantly overlying the retinal pigment epithelium.

METHODS

Patients were assigned randomly to surgery (PPV, subretinal tPA [maximum, 0.5 ml/50 μg], and 20% sulfur hexafluoride [SF6] tamponade) or PD (0.05 ml intravitreal tPA [50 μg] and 0.3 ml intravitreal pure SF6). Both groups were asked to maintain a head upright position with the face forward at 45° for 3 days after intervention and received 0.5 mg intravitreal ranibizumab at the end of the intervention, at months 1 and 2, as the loading phase, and then on a pro re nata regimen during a 6-month follow-up.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was mean best-corrected visual acuity (VA) change at month 3. The secondary endpoints were mean VA change at month 6, 25-item National Eye Institute Visual Function Questionnaire composite score value at months 3 and 6, number of anti-VEGF injections, and complications during the 6-month follow-up.

RESULTS

Of the 90 patients randomized, 78 patients (86.7%) completed the 3-month efficacy endpoint visit. The mean VA change from baseline to month 3 in the surgery group (+16.8 letters [95% confidence interval (CI), 8.7-24.9 letters]) was not significantly superior to that in the PD group (+16.4 letters [95% CI, 7.1-25.7 letters]; adjusted difference β, 1.9 [-11.0; 14.9]; P = 0.767). Both groups achieved similar secondary outcomes at month 6. No unexpected ocular safety concerns were observed in either group.

CONCLUSIONS

Surgery did not yield superior visual gain nor additional benefit for SMH secondary to nAMD compared with PD at 3 months, with intravitreal anti-VEGF added to each arm. Both treatment strategies lead to a clinical improvement of VA without safety concerns for SMH over 6 months. Both design and results of the trial cannot be used to establish equivalence between treatments.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The MATE trial: a multicentre, mixed-methodology, pilot, randomised controlled trial in neovascular age-related macular degeneration

BACKGROUND/OBJECTIVES

In healthcare research investigating complex interventions, gaps in understanding of processes can be filled by using qualitative methods alongside a quantitative approach. The aim of this mixed-methods pilot trial was to provide feasibility evidence comparing two treatment regimens for neovascular age-related macular degeneration (nAMD) to inform a future large-scale randomised controlled trial (RCT).

SUBJECTS/METHODS

Forty-four treatment-naïve nAMD patients were followed over 24 months and randomised to one of two treatment regimens: standard care (SC) or treat and extend (T&E). The primary objective evaluated feasibility of the MATE trial via evaluations of screening logs for recruitment rates, nonparticipation and screen fails, whilst qualitative in-depth interviews with key study staff evaluated the recruitment phase and running of the trial. The secondary objective assessed changes in visual acuity and central retinal thickness (CRT) between the two treatment arms.

RESULTS

The overall recruitment rate was 3.07 participants per month with a 40.8% non-participation rate, 18.51% screen-failure rate and 15% withdrawal/non-completion rate. Key themes in the recruitment phase included human factors, protocol-related issues, recruitment processes and challenges. Both treatment regimens showed a trend towards a visual acuity gain at month 12 which was not maintained at month 24, whilst CRT reduced similarly in both regimens over the same time period. These were achieved with one less treatment following a T&E regimen.

CONCLUSION

This mixed-methodology, pilot RCT achieved its pre-defined recruitment, nonparticipation and screen failure rates, thus deeming it a success. With some minor protocol amendments, progression to a large-scale RCT will be achievable.

Subretinal Transplant of Human Amniotic Membrane in Advanced Age-Related Macular Degeneration

Macular neovascularization (MNV) and geographic atrophy can complicate age-related macular degeneration (AMD) and lead to severe visual acuity reduction. Despite the medical treatments available, with a defect in the retinal pigmented epithelium (RPE) there is no possibility of restoring acceptable visual acuity. We evaluated postoperative outcomes in patients affected by advanced AMD who underwent subretinal implant of the human amniotic membrane (hAM) as a source of pluripotent stem cells. This retrospective, consecutive, non-randomized interventional study included 23 eyes of 21 patients affected by AMD complicated by MNV, and five eyes of five patients affected by geographic atrophy. All eyes underwent a pars plana vitrectomy, neovascular membrane removal for the MNV group, a subretinal implant of hAM, and gas tamponade, and were followed for 12 months. The primary study outcome was visual acuity improvement. Secondary outcomes were postoperative complications, OCT-angiography parameters correlated with best-corrected visual acuity (BCVA) and MNV recurrence. The mean preoperative BCVA was 1.9 logMAR, and the mean final BCVA value was 1.2 logMAR. In the MNV group, the mean BCVA improved from 1.84 logMAR to 1.26 logMAR, and from 1.84 logMAR to 1.32 logMAR in the geographic atrophy group. No MNV recurrence was evident in 12 months of follow-up. An OCT-angiography scan was used to evaluate the retinal vascularization in the treated eye, which showed a high correlation between BCVA and deep vascular density. This study demonstrates the hAM potential and safety in promoting a partial restoration of retinal function together with an increase in visual acuity.

Prognostic Features of Preoperative OCT in Retinal Detachments: A Systematic Review and Meta-analysis

TOPIC

To evaluate the prognostic association between preoperative features seen on OCT imaging and postoperative visual acuity (VA) outcomes in rhegmatogenous retinal detachments (RRDs).

CLINICAL RELEVANCE

Currently, there is limited literature on the prognostic value of preoperative RRD OCT features.

METHODS

A literature search was conducted on Ovid MEDLINE, Ovid Embase, and Cochrane CENTRAL from inception to September 15, 2022. A meta-analysis was performed using a random-effects model. Quality of studies and evidence were assessed using the Joanna Briggs Institute tools and the Grading of Recommendations, Assessment, Development and Evaluation framework, respectively.

RESULTS

A total of 1671 eyes of 1670 patients from 29 observational studies were included. Of these, 89% of eyes had a macula-off RRD at presentation. The mean average duration of detachment was 15 ± 10 days. Most eyes (62%) underwent pars plana vitrectomy. Six preoperative OCT features were analyzed: height of retinal detachment (HRD) at the fovea, central macular thickness (CMT), disruption of the ellipsoid zone (EZ) and/or external limiting membrane (ELM), intraretinal cystic cavities (ICCs), outer retinal corrugations (ORCs), and macular detachment. A greater HRD was weakly associated with postoperative VA (Pearson correlation r = 0.35; 95% confidence interval [CI], 0.20-0.48; P < 0.01), and there was no change in this association throughout the postoperative follow-up period. The CMT was not associated with postoperative VA. Eyes with disruption of the EZ and/or ELM had a postoperative VA worse by 0.35 logarithm of the minimum angle of resolution (logMAR) (95% CI, 0.15-0.54; P < 0.01) or 3 Snellen lines. Eyes with ICCs had a postoperative VA worse by 0.14 logMAR (95% CI, 0.01-0.26; P < 0.01) or 2 Snellen lines. Eyes with ORCs did not have a significantly different postoperative VA than eyes without ORCs. Eyes with macular detachment had a postoperative VA worse by 0.15 logMAR (95% CI, -0.31 to 0.00; P = 0.02) or 2 Snellen lines. Overall, the quality of studies ranged from moderate to good (73%-100%). All associations had a low quality of evidence, with CMT being of very low quality.

CONCLUSION

Despite the low quality of evidence, a greater HRD, disruption of the EZ and/or ELM, presence of ICCs, and macular detachment were associated with a poor postoperative VA. We propose a standardized nomenclature for consistency and accuracy in reporting preoperative RRD OCT features for future studies.

Pars plana vitrectomy and subretinal tissue plasminogen activator for large exudative submacular hemorrhage: a case series

BACKGROUND

To evaluate anatomical and functional outcomes of patients with large submacular hemorrhage (SMH) who treated by pars plana vitrectomy (PPV) in combination with subretinal tissue plasminogen activator (TPA) injection, intraocular gas tamponade, and with additional post-operative interventions.

METHODS

Medical records of 9 patients who presented with large SMH secondary to age-related macular degeneration (AMD) and underwent PPV, subretinal TPA injection, and gas tamponade at Chiang Mai university hospital between January 2012 and January 2020 were reviewed. Collected data included preoperative visual acuity (VA), SMH extent and duration, intraoperation and post-operation complications, post-operative anatomical and VA responses, and the need for administer post-operation additional treatments.

RESULTS

Overall, five patients were male and four patients were female with a mean (SD) age of 66.9 (7.7) years and a mean (SD) follow-up of 21.1 (16.1) months. A mean (SD) duration of SMH was 15.1 (10.9) days with a mean (SD) extent of SMH was 6.2 (3.4) disc diameters. At 1-month post-operation, complete SMH displacement was noted in eight (88.9%) patients. The mean (SD) VA significantly improved from LogMAR 1.9 (0.4) to 1.1 (0.4), (P = 0.004). During follow-up, eight patients (88.9%) were given additional therapy (anti-vascular endothelial growth factor (anti-VEGF) monotherapy, photodynamic therapy, or in combination). At final follow-up, a mean (SD) LogMAR VA of 0.9 (0.4) was significantly improved compared to baseline (P = 0.004). For intra- and post-operation complications, none developed intraoperative retinal break and retinal detachment.

CONCLUSIONS

Vitrectomy with subretinal TPA injection, intraocular gas tamponade, and additional post-operation treatments provide benefit for anatomical and visual outcomes for patients with large SMH. It may consider as one of effective treatment in this group of patients.

Comparison of the regressive effects of aflibercept and brolucizumab on pigment epithelial detachment

Background

To compare the regressive effects of aflibercept and brolucizumab on pigment epithelial detachment (PED) in age-related macular degeneration.

Methods

Eighty-three eyes of 83 patients diagnosed with type 1 macular neovascularization were included and retrospectively analysed using multimodal imaging. Forty-nine eyes were treated with intravitreal aflibercept injections (IVA group), and 34 eyes were treated with brolucizumab (IVBr group), with three consecutive injections administered as induction therapy. Before treatment and 1, 2, and 3 months after the first treatment, the maximum height (MH) and maximum diameter (MD) of the PED were measured using optical coherence tomography in each treatment group.

Results

In the IVA group, MH at baseline (228 ± 169 μm) diminished to 180 ± 150 (P = 0.2558), 165 ± 140 (P = 0.0962), and 150 ± 129 µm (P = 0.0284) at 1, 2, and 3 months after treatment, respectively; the reduction at 3 months was significant. In contrast, in the IVBr group, the MH was 307 ± 254 µm before treatment, and it decreased to 183 ± 156 µm (P = 0.0113), 139 ± 114 µm (P = 0.0003), and 125 ± 126 µm (P < 0.0001) at 1, 2, and 3 months after treatment, respectively, and the reduction at 1 month was significant. In both groups, the MD did not regress significantly.

Conclusions

The results suggested that the MH of PED after IVBr treatment regressed faster than that after IVA treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02617-2.

Comparison of treatment methods for submacular hemorrhage in neovascular age-related macular degeneration: conservative versus active surgical strategy

The optimal treatment of submacular hemorrhage (SMH) following neovascular age-related macular degeneration (nAMD) is controversial. This study aimed to compare visual outcomes of conservative versus active surgical treatment. Two hundred thirty-six eyes of 236 patients with SMH (≥ 1 disc diameter) were stratified into four groups: observation (n = 21); anti-vascular endothelial growth factor (VEGF) monotherapy (n = 161); non-surgical gas tamponade (n = 31); and subretinal surgery (n = 23). The primary outcome was best-corrected visual acuity (BCVA) at 12 months. The baseline BCVAs of the observation, anti-VEGF monotherapy, non-surgical gas tamponade, and subretinal surgery groups were 1.50 ± 0.70, 1.09 ± 0.70, 1.31 ± 0.83, and 1.62 ± 0.77 logarithm of minimal angle resolution (LogMAR), respectively. The mean BCVAs at 12 months were 1.39 ± 0.84, 0.90 ± 0.83, 1.35 ± 0.88, and 1.44 ± 0.91 LogMAR, respectively. After adjusting for age, baseline BCVA, SMH size, and the number of intravitreal anti-VEGF injections before SMH, the mean BCVA showed no significant difference among treatments at 12 months (P = 0.204). The anti-VEGF monotherapy group showed better mean BCVA significantly at 3 months (P < 0.001). Only baseline BCVA was associated with VA gain at 12 months (Odds ratio = 3.53, P < 0.001). This study demonstrated that there was no difference in 12 month visual outcomes among treatments and a better early visual outcome can be expected with anti-VEGF monotherapy.

New Prospects for Retinal Pigment Epithelium Transplantation

ABSTRACT

Retinal pigment epithelium (RPE) transplants rescue photoreceptors in selected animal models of retinal degenerative disease. Early clinical studies of RPE transplants as treatment for age-related macular degeneration (AMD) included autologous and allogeneic transplants of RPE suspensions and RPE sheets for atrophic and neovascular complications of AMD. Subsequent studies explored autologous RPE-Bruch membrane-choroid transplants in patients with neovascular AMD with occasional marked visual benefit, which establishes a rationale for RPE transplants in late-stage AMD. More recent work has involved transplantation of autologous and allogeneic stem cell-derived RPE for patients with AMD and those with Stargardt disease. These early-stage clinical trials have employed RPE suspensions and RPE monolayers on biocompatible scaffolds. Safety has been well documented, but evidence of efficacy is variable. Current research involves development of better scaffolds, improved modulation of immune surveillance, and modification of the extracellular milieu to improve RPE survival and integration with host retina.

[Modern aspects of the treatment of submacular hemorrhages secondary to macular degeneration]

Age-related macular degeneration complicated by submacular hemorrhage if not treated timely leads to permanent loss of central vision. The basis of effective therapy is its early start, dislocation of blood from central parts of the retina and blockage of neovascularization. This review examines the current methods of treatment of submacular hemorrhages, anatomical and functional outcomes, risks of postoperative complications, as well as trends in the use of combined methods of surgical intervention.

Postoperative follow-up of submacular hemorrhage displacement treated with vitrectomy and subretinal injection of tissue plasminogen activator: ultrawide-field fundus autofluorescence imaging in gas-filled eyes

PURPOSE

To investigate the utility of Optos ultrawide-field fundus autofluorescence (UWF-FAF) imaging for postoperative follow-up of gas-filled eyes after vitrectomy with subretinal tissue-plasminogen activator (t-PA) injection for subretinal hemorrhage (SRH) displacement.

STUDY DESIGN

Retrospective consecutive case series.

METHODS

This study included 24 eyes with SRH. Vitrectomy with subretinal t-PA injection was performed, followed by postoperative prone positioning. FAF images acquired using Optos California were examined and the SRH occupancy in the macula was calculated. The main outcome measures were displacement rate and direction of SRH for 3 days postoperatively, and postoperative best-corrected visual acuity (BCVA).

RESULTS

The postoperative BCVA ranged from improvement (23 eyes; 95.8%) to no change (one eye; 4.2%). Analysis was done using postoperative Optos FAF images for 20 eyes (83.3%). Postoperative SRH occupancy was significantly reduced, by 27.4%, compared with the preoperative occupancy (P = 0.03). A statistically significant reduction was found between the preoperative and postoperative day (POD)1 (P = 0.04), but not between POD1 and POD2 (P = 0.7), or between POD2 and POD3 (P = 1.0).

CONCLUSION

UWF-FAF imaging is useful for postoperative follow-up of gas-filled eyes after vitrectomy with subretinal t-PA injection for SRH displacement.

Treatment of old submacular hemorrhage by subretinal endoscopic surgery and intraoperative subretinal endoscopic findings

Purpose

We report a case of old submacular hemorrhage (SMH) due to polypoidal choroidal vasculopathy (PCV). Subretinal endoscopic surgery (SES) was performed, which improved visual function. In addition, we show the intraoperative findings of subretinal aberrant PCV vessels as seen under endoscopic observation, which cannot be observed by microscopic surgery.

Observations

A 71-year-old Japanese man presented with an old dehemoglobinized SMH due to PCV in his left eye. At the time of presentation, three weeks had already passed after the onset of the patient's symptoms, and the best-corrected visual acuity (BCVA) was 20/200. SES was performed to remove the SMH and treat the subretinal PCV lesions. After creating retinal detachment using a 38-gauge cannula, three subretinal 25-gauge trocars were inserted from the sclera to the subretinal space. Then, SES was performed under ophthalmic endoscopic observation with continued subretinal irrigation for maintaining the retinal detachment. After removal of the SMH, subretinal polyp-shaped nodular vascular lesions (polyps) and a branching vascular network, which is located inside the retinal pigmented epithelium, were identified. The sites that presumably originated from the aberrant vessels of the PCV and the associated polyps were coagulated using endodiathermy. After the subretinal procedure, the retina was flattened with fluid/air exchange, and silicone oil (SO) was injected into the vitreous cavity. The SMH completely disappeared after surgery. Although at one-month follow-up BCVA (20/250) was slightly worse than that before surgery, there was an improvement in postoperative retinal sensitivity in the macula compared to that before surgery. At the three-month follow-up, the SO was removed. The BCVA was 20/200 one month after SO removal. No postoperative complications occurred. Additional treatment was not required, including anti-vascular endothelial growth factor therapy, for PCV progression or SMH recurrence in the left eye till the final visit two years after surgery.

Conclusion and importance

SES could effectively remove the old SMH, and the activity of PCV was suppressed by intraoperative subretinal coagulation. The retinal sensitivity of the macula improved after the SES. In addition, we observed subretinal polyps and a branching vascular network located internal to the retinal pigmented epithelium under intraoperative subretinal endoscopic observation. SES is a good surgical option for the removal of old SMH or treatment of subretinal lesions.

Role of intravitreal brolucizumab with intravitreal rtPA and pneumatic displacement for submacular hemorrhage: A case series

Purpose

To evaluate the role of intravitreal injection (IVI) of brolucizumab along with intravitreal recombinant tissue plasminogen activator (rtPA) and C3F8 gas injection for large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).

Observations

This was a prospective uncontrolled non-randomized case series conducted at a single site. Three patients with fresh SMH (≤4 days) secondary to nAMD underwent triple therapy with IVI brolucizumab + intravitreal rtPA (50 μg in 0.1 mL) + 0.3 mL of 100% C3F8 gas injection. Post-injection, a face-down position was advised for 5 days with periodic follow-up visits. All three patients had complete resolution of SMH at the end of 4 weeks with a notable improvement in the best-corrected visual acuity (BCVA). No optical coherence tomographic (OCT) biomarkers of disease activity were noted at the end of 12 weeks in the first and the third case and 4 weeks in the second case respectively. There were no ocular or systemic side effects reported in any of the cases.

Conclusions and importance

Intravitreal brolucizumab administered along with intravitreal rtPA and C3F8 gas injection was found to be efficacious and safe for the management of large SMH secondary to nAMD. Complete displacement of SMH with excellent structural and functional outcomes can be seen with triple therapy.

Vitrectomy, subretinal Tissue plasminogen activator and Intravitreal Gas for submacular haemorrhage secondary to Exudative Age-Related macular degeneration (TIGER): study protocol for a phase 3, pan-European, two-group, non-commercial, active-control, observer-masked, superiority, randomised controlled surgical trial

Background

Neovascular (wet) age-related macular degeneration (AMD) can be associated with large submacular haemorrhage (SMH). The natural history of SMH is very poor, with typically marked and permanent loss of central vision in the affected eye. Practice surveys indicate varied management approaches including observation, intravitreal anti-vascular endothelial growth factor therapy, intravitreal gas to pneumatically displace SMH, intravitreal alteplase (tissue plasminogen activator, TPA) to dissolve the clot, subretinal TPA via vitrectomy, and varying combinations thereof. No large, published, randomised controlled trials have compared these management options.

Methods

TIGER is a phase 3, pan-European, two-group, active-control, observer-masked, superiority, randomised controlled surgical trial. Eligible participants have large, fovea-involving SMH of no more than 15 days duration due to treatment-naïve or previously treated neovascular AMD, including idiopathic polypoidal choroidal vasculopathy and retinal angiomatous proliferation. A total of 210 participants are randomised in a 1:1 ratio to pars plana vitrectomy, off-label subretinal TPA up to 25 μg in 0.25 ml, intravitreal 20% sulfahexafluoride gas and intravitreal aflibercept, or intravitreal aflibercept monotherapy. Aflibercept 2 mg is administered to both groups monthly for 3 doses, then 2-monthly to month 12. The primary efficacy outcome is the proportion of participants with best-corrected visual acuity (BCVA) gain of ≥ 10 Early Treatment Diabetic Retinopathy (ETDRS) letters in the study eye at month 12. Secondary efficacy outcomes (at 6 and 12 months unless noted otherwise) are proportion of participants with a BCVA gain of ≥ 10 ETDRS letters at 6 months, mean ETDRS BCVA, Radner maximum reading speed, National Eye Institute 25-item Visual Function Questionnaire composite score, EQ-5D-5L with vision bolt-on score, Short Warwick and Edinburgh Mental Wellbeing score, scotoma size on Humphrey field analyser, and presence/absence of subfoveal fibrosis and/or atrophy and area of fibrosis/atrophy using independent reading centre multimodal image analysis (12 months only). Key safety outcomes are adverse events, serious adverse events, and important medical events, coded using the Medical Dictionary for Regulatory Activities Preferred Terms.

Discussion

The best management of SMH is unknown. TIGER aims to establish if the benefits of SMH surgery outweigh the risks, relative to aflibercept monotherapy.

Trial registration

ClinicalTrials.govNCT04663750; EudraCT: 2020-004917-10.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05966-3.

The Development of Macular Atrophy in Patients with Wet Age-Related Macular Degeneration Receiving Anti-VEGF Treatment

Age-related macular degeneration (AMD) is a leading cause of blindness. Late AMD can be classified into exudative (commonly known as wet AMD [wAMD]) or dry AMD, both of which may progress to macular atrophy (MA). MA causes irreversible vision loss and currently has no approved pharmacological treatment. The standard of care for wAMD is treatment with anti-vascular endothelial growth factors (VEGF). However, recent evidence suggests that anti-VEGF treatment may play a role in the development of MA. Therefore, it is important to identify risk factors for the development of MA in patients with wAMD. For example, excessive blockade of VEGF through intense use of anti-VEGF agents may accelerate the development of MA. Patients with type III macular neovascularisation (retinal angiomatous proliferation) have a particularly high risk of MA. These patients are characterised as having a pre-existing thin choroid (age-related choroidopathy), suggesting that the choroidal circulation is unable to respond to increased VEGF expression. Evidence suggests that subretinal fluid (possibly indicative of residual VEGF activity) may play a protective role. Patients receiving anti-VEGF agents must be assessed for overall risk of MA and there is an unmet medical need to prevent the development of MA without undertreating wAMD.

Novel surgical approach for removing intraretinal loculated foveal hemorrhage in a patient with hypertensive retinopathy

Purpose

To present a surgical approach for removing intra-retinal loculated foveal hemorrhage due to hypertensive retinopathy (HR) in a patient with uncontrolled hypertension (HTN).

Observations

A 67-year-old man presented to a tertiary retina clinic with the complaint of decreased vision in his left eye (OS) for the past six months. He had a history of uncontrolled HTN, which caused HR; otherwise, his past medical and ocular history were insignificant. His best-corrected visual acuity (BCVA) was 20/20 right eye (OD) and 20/400 OS. Fundus examination of OD did not show significant pathology except mild arterial narrowing. Fundus examination of OS revealed arterial narrowing and multiple areas of small retinal hemorrhage. Old, organized hemorrhage with a yellow foveal centered lesion appearance was detected on fundus examination. Spectral-domain optical coherence tomography (SD-OCT) showed a dense hyper-reflective intra-retinal lesion at the fovea. Pars plana vitrectomy was performed. Internal limiting membrane (ILM) was stained with Brilliant Blue G (BBG) and peeled off around the lesion using ILM forceps. Attempts to remove the lesion with cannula-assisted active backflush and aspiration were unsuccessful. Therefore, the lesion was gently dissected and extracted by using 41-gauge needle. After removing the clot, the rotational ILM flap technique was used to repair the developed macular hole-like tissue defect. At the two-month follow-up visit, BCVA improved considerably to 20/50, and significant anatomical restoration was observed.

Conclusion and Importance

HR is relatively common among patients with elevated blood pressure. To date, management of HR and its complications such as retinal hemorrhage is limited to non-surgical methods. For the first time, a surgical approach is utilized to manage one of the HR's complications with prominent visual and structural improvement. The index case report presents a new management option for hypertensive retinal hemorrhage, but only in appropriate patients with ocular indications and understanding of the potential adverse events associated with the surgical procedure.

Management of submacular massive haemorrhage in age-related macular degeneration: comparison between subretinal transplant of human amniotic membrane and subretinal injection of tissue plasminogen activator

PURPOSE

Macular neovascularization (MNV) can complicate age-related macular degeneration (AMD) and lead to severe visual acuity reduction. Massive submacular haemorrhage (SMH) is a sight-threatening complication of MNV and a challenge in the management of complications related to MNV in AMD since the effects of anti-vascular endothelial growth factor treatment alone are insufficient. Here, we evaluate the different postoperative outcomes of patients affected by MNV complicated by SMH that underwent subretinal implant of human amniotic membrane (hAM) or subretinal injection of tissue plasminogen activator (tPA).

METHODS

This is a retrospective, consecutive, comparative, non-randomized interventional study. We included 44 eyes of 44 patients affected by AMD complicated by MNV and SMH. Twenty-two eyes underwent a pars plana vitrectomy (PPV), SMH and neovascular membrane removal, with a subretinal implant of hAM and silicone oil, and 22 eyes underwent PPV, subretinal injection of tPA, and 20% sulphur hexafluoride. The primary study outcome was visual acuity improvement. Secondary outcomes were postoperative complications, and MNV recurrence and optical coherence tomography (OCT)-Angiography parameters correlated with best-corrected visual acuity (BCVA).

RESULTS

Mean preoperative BCVA was 1.9 logarithm of the minimal angle of resolution (logMAR) in the amniotic membrane-group and 2 logMAR in the tPA-group. The mean final BCVA values were 1.25 and 1.4 logMAR, respectively, with a statistically significant difference. Optical coherence tomography (OCT)-Angiography scan was be used to evaluate the retinal vascularization in the treated eye.

CONCLUSION

Both techniques report similar VA improvements and postoperative complications. However, transplantation of hAM seems to have a significant benefit in inhibiting MNV recurrence.

Massive submacular haemorrhage in polypoidal choroidal vasculopathy versus typical neovascular age-related macular degeneration

PURPOSE

To investigate the incidence rate of massive submacular haemorrhage (SMH) and risk factors in polypoidal choroidal vasculopathy (PCV) and typical neovascular age-related macular degeneration (tnAMD).

METHODS

A total of 465 patients who were diagnosed with either PCV (n = 245) or tnAMD (n = 220) from 2003 to 2014 were enrolled. Cumulative incidence of massive SMH in PCV and that in tnAMD were compared. Risk factors of massive SMH were also analysed.

RESULTS

Massive SMH occurred in 32 patients (13.1%) with PCV and 9 patients (4.1%) with tnAMD. Incidence rates of massive SMH 5 and 10 years after the first visit were 11.1% and 29.9% in PCV and 4.3% and 9.9% in tnAMD, respectively. Incidence rates of massive SMH in PCV were significantly higher than those in tnAMD (hazard ratio [HR], 2.66; p = 0.007). Cox regression analysis revealed that mean number of photodynamic therapies (PDTs) per year (HR, 4.24; p < 0.001), cluster type of polypoidal lesion (HR, 3.42; p = 0.003) in PCV, and mean number of anti-VEGF injections per year (HR, 1.58; p < 0.001) in tnAMD were significantly associated with risk of massive SMH. For patients with severe vision loss, proportion of incident massive SMH was significantly higher in PCV (29.5%) than in tnAMD (6.9%, p < 0.001).

CONCLUSION

The incidence rate of massive SMH in eyes with PCV was about three times higher than that in eyes with tnAMD. Treatment methods that can reduce the incidence of massive SMH should be considered, especially for eyes with PCV.

Long-Term Favorable Visual Outcomes in Patients with Large Submacular Hemorrhage

Submacular hemorrhage (SMH) has been reported to be toxic to the retina based on animal studies. However, observational studies of patients with neovascular-related SMH and those treated with intravitreal anti-vascular growth factor (anti-VEGF) therapy have shown many favorable visual acuity outcomes. We report two cases of neovascular-related SMH with ten or more years of follow-up. The first case was an 83-year old female with a history of nonexudative age-related macular degeneration in both eyes presenting with sudden decrease in vision (20/400) in her right eye due to a large SMH, treated with anti-VEGF therapy. Over the next following months, there was resolution of the hemorrhage and return of good visual acuity. At 10-year follow-up, visual acuity was 20/30 in the right eye. The second case was a 49-year old female with a history of presumed ocular histoplasmosis syndrome (POHS), presenting with sudden vision loss (20/400) in her right eye due to large, thick SMH. With observation and intermittent anti-VEGF therapy, there was resolution of the hemorrhage. At 30-year follow-up, visual acuity was 20/20 in the right eye.

Hints for Gentle Submacular Injection in Non-Human Primates Based on Intraoperative OCT Guidance

Purpose

Delivery of Advanced Therapy Medicinal Products to the submacular space is increasingly evolving into a therapeutic modality. Cell replacement for age-related macular degeneration (AMD) and gene therapy for RPE65 are recent successful examples. Herein, a nonhuman primate (NHP) model was used to investigate surgical means to detach the macula.

Methods

Sixteen eyes of 13 healthy macaques underwent a 25-gauge vitrectomy and subretinal injection of balanced salt solution monitored by microscope-integrated intraoperative optical coherence tomography (miOCT). The animals were followed with OCT and histology.

Results

The miOCT monitoring allowed a more precise definition of surgical trauma ranging from an initial full-thickness foveal tear, or induction of a cystoid macular edema (CME), until no foveal defect was discernible, as the technique improved. However, as the subretinal fluid wave detached the fovea, the aforementioned lesions formed, whereas persistent retinal adhesion reproducibly proved to remain in the distal parafoveal semi-annulus. Measures to reduce foveal trauma during submacular fluid injection included reducing intraocular pressure, injection volume, and velocity, as well as the retinal location for bleb initiation, use of a vitreous tamponade, and a dual-bore subretinal cannula.

Conclusions

A stable very low intraocular pressure and careful subretinal injection may avoid tangential macular stretching or mechanical CME formation, while vitreous tamponade may facilitate a more lamellar subretinal flow, all thereby reducing foveal trauma during submacular injection in NHP.

Translational Relevance

These results can be relevant to any submacular surgery procedure used today, as they synergistically reduce the risk of compromising foveal integrity.

Incomplete response to Anti-VEGF therapy in neovascular AMD: Exploring disease mechanisms and therapeutic opportunities

Intravitreal anti-vascular endothelial growth factor (VEGF) drugs have revolutionized the treatment of neovascular age-related macular degeneration (NVAMD). However, many patients suffer from incomplete response to anti-VEGF therapy (IRT), which is defined as (1) persistent (plasma) fluid exudation; (2) unresolved or new hemorrhage; (3) progressive lesion fibrosis; and/or (4) suboptimal vision recovery. The first three of these collectively comprise the problem of persistent disease activity (PDA) in spite of anti-VEGF therapy. Meanwhile, the problem of suboptimal vision recovery (SVR) is defined as a failure to achieve excellent functional visual acuity of 20/40 or better in spite of sufficient anti-VEGF treatment. Thus, incomplete response to anti-VEGF therapy, and specifically PDA and SVR, represent significant clinical unmet needs. In this review, we will explore PDA and SVR in NVAMD, characterizing the clinical manifestations and exploring the pathobiology of each. We will demonstrate that PDA occurs most frequently in NVAMD patients who develop high-flow CNV lesions with arteriolarization, in contrast to patients with capillary CNV who are highly responsive to anti-VEGF therapy. We will review investigations of experimental CNV and demonstrate that both types of CNV can be modeled in mice. We will present and consider a provocative hypothesis: formation of arteriolar CNV occurs via a distinct pathobiology, termed neovascular remodeling (NVR), wherein blood-derived macrophages infiltrate the incipient CNV lesion, recruit bone marrow-derived mesenchymal precursor cells (MPCs) from the circulation, and activate MPCs to become vascular smooth muscle cells (VSMCs) and myofibroblasts, driving the development of high-flow CNV with arteriolarization and perivascular fibrosis. In considering SVR, we will discuss the concept that limited or poor vision in spite of anti-VEGF may not be caused simply by photoreceptor degeneration but instead may be associated with photoreceptor synaptic dysfunction in the neurosensory retina overlying CNV, triggered by infiltrating blood-derived macrophages and mediated by Müller cell activation Finally, for each of PDA and SVR, we will discuss current approaches to disease management and treatment and consider novel avenues for potential future therapies.

Comparison between different techniques for treatment of submacular haemorrhage due to Age-Related Macular Degeneration

PURPOSE

To compare the outcome of vitrectomy, subretinal tissue plasminogen activator (TPA), and gas with and without subretinal air versus Intravitreal TPA and gas in the treatment of submacular haemorrhage (SMH) due to Neovascular age related macular degeneration.

METHODS

We analysed the notes of 29 cases presented with SMH in the period between 01/2016 and 09/2018 at James Cook University Hospital. Presenting visual acuity (BCVA), size and location of SMH, Procedure done, final BCVA at 6 months and any surgical complications were recorded. 11 Cases (Group 1) received intravitreal TPA (50 µg in 0.1 ML), 0.3 ml of pure sulfur hexafluoride (SF6). 18 cases (Group 2) received 23 G Pars Plana vitrectomy, Subretinal TPA injection (25 µg in 0.1 ml), and 20% SF6 gas filling. Group 2 was further divided into 2A (10 patients) who received only subretinal TPA and group 2B (8 patients) who received additional 0.1 ml subretinal air.

RESULTS

The mean BCVA at presentation was 0.0068 in group 1 and 0.0067 in group 2 (p = 0.8734). The mean postoperative BCVA at 6 months was 0.31 in group 1 and 0.58 in group 2 (p = 0.0015). Subgroup analysis of group 2 didn't show statistically significant difference in outcome when adding subretinal air to the vitrectomy procedure (p = 0.7009).

CONCLUSION

Vitrectomy, gas and subretinal TPA has more successful displacement rate and better visual outcome than Intravitreal TPA & Gas alone in treating SMH involving the fovea in age-related macular degeneration. Additional subretinal air doesn't seem to improve the outcome in cases having vitrectomy.

Long-term clinical outcomes of submacular blood removal with isolated autologous retinal pigment epithelium-choroid patch graft transplantation in long-standing large-sized submacular hematomas: An Indian experience

Purpose:

To study the outcomes of submacular blood removal with isolated autologous full-thickness retinal pigment epithelial (RPE)-choroid patch graft transplantation in long-standing large-sized submacular hematomas in Indian population.

Methods:

A retrospective study was done on eight consecutive patients of long-standing large-sized submacular hematoma from east India. In all cases, 23G vitrectomy was performed with the induction of retinal detachment (performed with or without 38G or 41G subretinal cannula) and a temporal 180° retinectomy was done. Submacular blood along with choroidal neovascular tissue was removed. A full-thickness RPE-choroid autologous patch graft was taken from a relatively healthy quadrant at the mid periphery and then the graft transferred under perfluorocarbon liquid (PFCL) to place it in the subfoveal area. Then, retina was re-attached using PFCL and laser completed. Silicone oil (5000 cst) was used as a tamponade. Post-operatively, wide-field fundus photographs (Optos), serial optical coherence tomography (OCT), indocyanine green angiography (ICGA), and multifocal electroretinography (ERG) were done.

Results:

The mean age of the patients at presentation was 67.88 ± 10.03 years. Mean pre-operative best corrected visual acquity (BCVA) was 2.64 ± 0.3 log MAR and mean postoperative BCVA was 1.095 ± 0.27 log MAR (P < 0.05). The mean follow-up was 20 ± 16.57 months. ICG showed re-vascularization of translocated graft in all at 2 months. Multifocal ERG (after 6 months) showed some waveform in all. None of the cases developed re-bleed.

Conclusion:

Removal of submacular blood and neovascular membrane with autologous RPE-choroid graft is a viable option in cases with long-standing large submacular hematomas.

Surgical management of submacular hemorrhage due to n-AMD: a comparison of three surgical methods

Background

To compare and assess the efficacy of three surgical methods for the treatment of acute submacular hemorrhage (ASH): pneumatic displacement with C2F6, in combination with intravitreal injection of bevacizumab and rtPA, pars plana vitrectomy (PPV) with intravitreal injection of gas (C2F6), bevacizumab and subretinal injection of recombinant tissue plasminogen activator (rtPA), pars plana vitrectomy (PPV) with intravitreal injection of gas (C2F6), bevacizumab and intravitreal injection of recombinant tissue plasminogen activator (rtPA).

Methods

The study included 85 patients with ASH. In the group without PPV (A), patients were treated with intravitreal injection of C2F6, bevacizumab and rtPA. In the second and third group, patients underwent a PPV, intravitreal injection of bevacizumab, pneumatic displacement with C2F6 and a subretinal (B) or intravitreal (C) injection of recombinant tissue plasminogen activator (rt PA).

Results

In group A, mean BCVA increased from preop logMAR 1.41 to 1.05, in group B from 1.46 to 1.28 and in group C from 1.63 to 1.33. In group A, CFT changed from 764 ± 340 μm at time point 0 to 246 ± 153 μm at time point 1, in group B from 987 ± 441 μm to 294 ± 166 μm and in group C from 642 ± 322 μm to 418 ± 364 μm. Patients had an average of 5 injections after surgery.

Conclusion

Our study demonstrates that the three methods are equally effective in improving the morphology and the BCVA of patients with ASH.

Human pluripotent stem cells: A toolbox to understand and treat retinal degeneration

Age-related Macular Degeneration (AMD) and Retinitis Pigmentosa (RP) are retinal degenerative disorders that dramatically damage the retina. As there is no therapeutic option for the majority of patients, vision is progressively and irremediably lost. Owing to their unlimited renewal and potency to give rise to any cell type of the human adult body, human pluripotent stem cells (hPSCs) have been extensively studied in recent years to develop more physiologically relevant in vitro cellular models. Such models open new perspectives to investigate the pathological molecular mechanisms of AMD and RP but also in drug screening. Moreover, proof-of-concept of hPSC-derived retinal cell therapy in animal models have led to first clinical trials. This review outlines the recent advances in the use of hPSCs in pathological modeling of retinal degeneration and their use in regenerative medicine. We also address the associated limitations and challenges that need to be overcome when using hPSCs.

The pattern and gender disparity in global burden of age-related macular degeneration

PURPOSE

To explore the trend patterns and gender disparity in global burden of age-related macular degeneration (AMD) by year, age, and socioeconomic status using disability-adjusted life-years (DALYs) from Global Burden of Disease (GBD) study 2017.

METHODS

DALYs and impairment data caused by AMD were extracted from GBD Study 2017. World Bank income level (WBIL) and human development index (HDI) in 2017 were cited as indicators of socioeconomic status. The Gini coefficients and the concentration indexes were calculated to unveil trends in between-country inequality. The association between gender inequality and socioeconomic levels was analyzed by Pearson correlation.

RESULTS

Total age-standardized DALYs of AMD showed a slightly descending pattern in recent years. However, gender disparity has existed since 1990 for almost three decades, with female being more heavily impacted. This pattern became more obvious with aging and varied among different WHO and WBIL regions. Meanwhile, female subjects tended to have higher vision impairments. Gini coefficients of AMD burden increased from 0.423 to 0.448, while the ones of female-to-male ratio fluctuated around 0.11 between 1990 and 2017, with concentration indexes changing from 0.024 to -0.057 and 0.046 to 0.029 respectively. Female-minus-male difference (r = 0.1721, p = 0.0195) and female-to-male ratio (r = 0.2072, p = 0.0048) of age-standardized DALYs rates were positively related to HDI.

CONCLUSIONS

Though global AMD health care is progressing, gender imbalance in disease burden of AMD distribution barely improved. Gender sensitive health policy should be emphasized for the increasing elder population and relieving the higher AMD burden of females.

Influence of pigment epithelial detachment on visual acuity in neovascular age-related macular degeneration

Pigment epithelial detachment (PED), the anatomical separation of the retinal pigment epithelium from the Bruch membrane, is common in many chorioretinal diseases, including neovascular age-related macular degeneration. PED is present in about 30% to 80% of neovascular age-related macular degeneration patients based on the CATT, EXCITE, and VIEW studies. The influence of PED on visual acuity is controversial as a result of inconsistent results reported by various studies. With advances in imaging technologies, it is possible to evaluate not only the presence or absence of PED, but also detailed quantitative parameters, such as height, width, greatest linear diameter, area, volume, and reflectivity within the PED. We performed a comprehensive literature review to evaluate the relationship of PED with visual acuity. In summary, the presence or persistence of a PED may still be compatible with relatively good visual acuity. There is no strong evidence that the presence of a PED or aspects of its morphology has a significant impact on visual acuity. The presence of a PED may be predictive of the need for more regular treatment. More well-designed studies with standardized PED definitions and classifications are needed to evaluate the relationship between PED and visual acuity.

Human Amniotic Membrane Plug to Restore Age-Related Macular Degeneration Photoreceptor Damage

PURPOSE

Age-related macular degeneration (AMD) is the leading cause of legal blindness in adults 65 years of age and older. Choroidal neovascularization (CNV) can complicate AMD and lead to severe visual acuity reduction. Despite the several treatments available, if the retinal pigment epithelium is damaged, we have to cope with the impossibility of restoring acceptable visual acuity using only medical treatments.

DESIGN

Prospective, consecutive, interventional study.

PARTICIPANTS

Eleven patients affected by AMD, 6 patients affected by CNV, and 5 patients affected by geographic atrophy.

METHODS

All patients underwent a pars plana vitrectomy with subretinal implantation of human amniotic membrane (hAM) to induce photoreceptor regeneration and partial visual acuity restoration.

MAIN OUTCOME MEASURES

Primary study outcome was visual acuity improvement. Secondary outcomes were multimodal imaging results.

RESULTS

Mean preoperative best-corrected visual acuity (BCVA) was 20/2000 (2 logarithm of the minimum angle of resolution [logMAR]), and all the patients showed a BCVA of counting fingers or less. Mean final BCVA was 20/400 (1.31 logMAR), ranging from 20/2000 to 20/100 (2-0.7 logMAR). OCT angiography was used to measure retinal vascularization in the treated eye compared with the fellow eye. A high correlation between BCVA and deep vascular density was evidenced. Adaptive optics findings, obtained over the retinal area where the highest functionality was observed, were evaluated using microperimetry. The images showed possible photoreceptor presence over the hAM membrane.

CONCLUSIONS

This work supports the feasibility and safety of the hAM to promote partial retinal function restoration 6 months after surgery with visual acuity improvement. The advanced diagnostics help to understand the interaction between the hAM and photoreceptors and suggest that photoreceptor regeneration may occur.

Different approaches in the management of macular hemorrhage: Case reports and a literature review

Introduction

Macular hemorrhages result in a sudden and profound loss of vision. The primary treatment modalities include observation, intravitreal injection of antiangiogenic drugs, neodymium-doped yttrium aluminum garnet hialoidotomy, intravitreal injection of gas with or without tissue plasminogen activator, as monotherapy or combined with surgery. In this paper, we report four cases of macular hemorrhages of different causes treated with different approaches, and we review the literature in this regard.

Case presentation

All four patients presented different causes of macular hemorrhage. The first case had a preretinal hemorrhage due to a Valsalva retinopathy and was treated with surgery. Case 2 had a multilevel macular hemorrhage due to a rupture of a retinal arteriolar macroaneurysm and was treated with pneumatic displacement, laser, and intravitreal ranibizumab. Case 3 presented an extensive subretinal hemorrhage due to a choroidal rupture after high-energy ocular trauma that was also successfully treated with surgery. The last case was a preretinal hemorrhage due to diabetic retinopathy managed with neodymium-doped yttrium aluminum garnet laser. Different treatment approaches were successfully performed in all cases with good outcomes.

Conclusion

There is an extensive range of options available for the management of macular hemorrhages, and the best option depends on the characteristics of each particular case. Proper and timely management of these diseases can achieve an excellent visual outcome, especially if the location of the hemorrhage is preretinal.

Intravitreal Recombinant Tissue Plasminogen Activator and Sulphur Hexafluoride Gas for Submacular Haemorrhage Displacement in Age-Related Macular Degeneration: Looking behind the Blood

PURPOSE

To evaluate the effectiveness of recombinant tissue plasminogen activator (rtPA) and sulphur hexafluoride gas (SF6) intravitreal injection for the displacement of large submacular haemorrhages (SMH) secondary to neovascular age-related macular degeneration and for guiding the selection of additional treatments or observations for choroidal neovascularization (CNV).

METHODS

The medical records of consecutive patients with recent-onset, large SMH, treated at Sacro Cuore Hospital from January 2004 to May 2016, were retrospectively analysed. All eyes underwent a 0.05-mL intravitreal injection of 50 μg rtPA, 0.3 mL of 100% SF6, and then face-down positioning. Afterwards, the eyes received additional treatments for CNV or observation, based on the severity and extent of the underlying pathology. The multimodal imaging features revealed after blood displacement were analysed and then correlated to the treatment selected as a second therapeutic option.

RESULTS

A total of 96 eyes met the inclusion criteria and was evaluated in this study. SMH was displaced from the fovea in the majority of the eyes (76%), allowing several diagnostic tools to evaluate the underlying macular features. In 19 cases (19.8%) exhibiting severe macular damage, no additional treatment was applied. In the remaining eyes, subsequent treatments included anti-vascular endothelial growth factor injections (44.8%), photodynamic therapy (n = 2), and submacular surgery (35.4%). Statistically significant correlations were found between the macular findings revealed after blood displacement and the additional treatments or observations selected for the underlying disease. The mean follow-up was 35 months. Improvements in visual acuity were statistically significant up to 3 years.

CONCLUSION

Intravitreal rtPA and gas injection was found to be effective for the displacement of large SMH, allowing postoperative diagnostic testing, and thus guiding the opportunity to apply further treatments. The addition of subsequent individualized treatments may allow long-term visual gain in selected cases.

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)

PURPOSE

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.

RESULTS

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.

Concise Review: Update on Retinal Pigment Epithelium Transplantation for Age-Related Macular Degeneration

Retinal cell therapy can have the objectives of rescue (i.e., modulation of metabolic abnormalities primarily for sight preservation) as well as replacement (i.e., replace cells lost due to injury or disease for sight restoration as well as preservation). The first clinical trials of retinal pigment epithelium (RPE) transplantation for vision-threatening complications of age-related macular degeneration (AMD) have begun with some preliminary signs of success (e.g., improvement in vision in some patients, anatomic evidence of transplant-host integration with some evidence of host photoreceptor recovery, long-term survival of autologous induced pluripotent stem cell-derived RPE transplants without immune suppression) as well as limitations (e.g., limited RPE suspension survival in the AMD eye, limited tolerance for long-term systemic immune suppression in elderly patients, suggestion of uncontrolled cell proliferation in the vitreous cavity). RPE survival on aged and AMD Bruch's membrane can be improved with chemical treatment, which may enhance the efficacy of RPE suspension transplants in AMD patients. Retinal detachment, currently used to deliver transplanted RPE cells to the subretinal space, induces disjunction of the first synapse in the visual pathway: the photoreceptor-bipolar synapse. This synaptic change occurs even in areas of attached retina near the locus of detachment. Synaptic disjunction and photoreceptor apoptosis associated with retinal detachment can be reduced with Rho kinase inhibitors. Addition of Rho kinase inhibitors may improve retinal function and photoreceptor survival after subretinal delivery of cells either in suspension or on scaffolds.

Morphological changes in the diseased retina on a healthy choroid-retinal pigment epithelial complex after full macular translocation for exudative age-related macular degeneration

PURPOSE

To describe the change in the retinal morphology after full macular translocation (FMT) for exudative age-related macular degeneration (AMD) and identify predictive factors for the visual outcome.

METHODS

All patients who underwent FMT from December 2008 through July 2013 were selected. Exclusion criteria were FMT for other disease than AMD, age <60 years, <12 months of follow-up or no available images. Spectral domain optical coherence tomography, fundus autofluorescence, fluorangiography and indocyanine green angiography were evaluated.

RESULTS

In total, 51 patients were included with a mean follow-up of 30 months. The presence of the external limiting membrane (ELM) was a significant predictor for a favourable visual outcome 1 year after FMT (OR = -0.30). Other significant predictive factors were the absence of intraretinal fluid (OR = 0.28) and the mixed choroidal neovascularization type (OR = -0.47), whereas nonresponders (OR = 0.41) and fibrotic lesions (OR = 0.35) were less likely to have a good visual function after surgery.

CONCLUSION

Full macular translocation (FMT), that permits to relocate the diseased macula onto an area of unaffected retinal pigment epithelial and choroid, can restore the anatomy and visual function in some patients with AMD when the outer retina layers are not irreversibly damaged. The presence of the ELM seems to be the most reliable factor in predicting the functional outcome.

Pharmacological Adjuncts to Vitrectomy Surgery

Pharmacological adjuncts to vitrectomy surgery are useful tools to better deal with surgery. Their introduction has enriched the therapeutic choice before, during and after operations. Although several classifications could be made to frame adjuncts to vitrectomy, we preferred to divide the pharmacological adjuncts to vitrectomy surgery for therapeutic use in the pre-operatory procedure (neo-adjuvant), for intraoperative use and for post-operatory practice (adjuvant). This type of classification allowed us to explore all the adjuncts based on the timing of their use. The actual interest in vitrectomy surgery is giving rise to considerable interest in new molecules with and without the pharmacological effect that will soon be available for the aid of vitreoretinal surgery.

Development of Submacular Hemorrhage in Neovascular Age-related Macular Degeneration: Influence on Visual Prognosis in a Clinical Setting

Purpose

This study aimed to evaluate changes in visual acuity before and after the development of submacular hemorrhage secondary to neovascular age-related macular degeneration (AMD) and to compare the visual outcomes between patients with and without hemorrhage.

Methods

This retrospective observational study included 124 patients with neovascular AMD. Patients who developed a submacular hemorrhage involving the fovea were included in the hemorrhage group (n = 55). Patients with no sign of submacular hemorrhage during the follow-up period were included in the no-hemorrhage group (n = 69). Visual outcomes were compared between the two groups.

Results

The logarithm of the minimal angle of resolution best-corrected visual acuity (BCVA) before the development of submacular hemorrhage, once the hemorrhage had developed, and 6 months after the development of hemorrhage was 0.59 ± 0.45, 1.24 ± 0.57, and 0.99 ± 0.64, respectively. BCVA was significantly worse 6 months after the hemorrhage compared to before the hemorrhage (p < 0.001). The BCVA before the development of hemorrhage (measured at a mean of 12.9 months after diagnosis) was comparable to that of the no-hemorrhage group (mean, 0.58 ± 0.37 at a mean of 12.4 months). However, the BCVA 6 months after identification of hemorrhage (mean, 21.5 months) was significantly worse in the hemorrhage group than in the no-hemorrhage group (mean, 0.73 ± 0.44 at mean 21.2 months) (p = 0.018).

Conclusions

Visual acuity was significantly worse after hemorrhage than before hemorrhage, even after treatment. In addition, patients with submacular hemorrhage had markedly worse visual outcomes than patients without hemorrhage. This result suggests that the development of hemorrhage during the treatment course of neovascular AMD has a devastating effect on visual prognosis.

Incidence of submacular haemorrhage (SMH) in Scotland: a Scottish Ophthalmic Surveillance Unit (SOSU) study

PURPOSE

Submacular haemorrhage (SMH) is a cause of severe visual loss in neovascular age-related macular degeneration (nAMD). The incidence is uncertain and furthermore there is no widely used classification system nor agreed best practice. The aim of this national surveillance study was to identify the incidence, presenting features and clinical course of new fovea-involving submacular haemorrhage associated with nAMD.

METHODS

A questionnaire was sent monthly to every ophthalmic specialist in Scotland over a 12-month period asking them to report all newly presenting patients with acute SMH secondary to nAMD of at least two disc diameters (DDs) in greatest linear diameter. A follow-up questionnaire was sent 6 months after initial presentation. Cases related to other causes were excluded.

RESULTS

Twenty-nine cases were reported giving an incidence of 5.4 per million per annum (range 2-15). The mean age was 83 years (range 66-96) and females accounted for 17/29 (59%). Fifteen of the 29 cases (52%) had a past history of AMD, of which 7 had nAMD. Nineteen of the 29 cases (66%) presented within 7 days of onset and the majority had SMH of < 11 DD (20/29, 69%). Treatment options comprised the following: observation (n = 6, 21%), anti-VEGF alone (n = 6, 21%) or vitrectomy with co-application of tissue plasminogen activator (TPA), anti-VEGF and gas (n = 17, 58%). The vitrectomy group experienced the greatest change in vision from logMAR 1.89-1.50 (p = 0.374). Four of 20 (20%) cases with 6 months follow-up suffered a re-bleed at a mean time of 96 days.

CONCLUSIONS

The incidence, clinical features and course of a consecutive national cohort of patients with SMH secondary to nAMD are presented.

Human embryonic stem cell-derived retinal pigment epithelium transplants as a potential treatment for wet age-related macular degeneration

Stem cell therapy may provide a safe and promising treatment for retinal diseases. Wet age-related macular degeneration (wet-AMD) is a leading cause of blindness in China. We developed a clinical-grade human embryonic stem cell (hESC) line, Q-CTS-hESC-2, under xeno-free conditions that differentiated into retinal pigment epithelial cells (Q-CTS-hESC-2-RPE). A clinical trial with three wet-AMD patients was initiated in order to study the safety and tolerance to Q-CTS-hESC-2-RPE cell transplants. The choroidal neovascularization membrane was removed and then a suspension of 1 × 10⁶ Q-CTS-hESC-2-RPE cells were injected into a subfoveal pocket. The patients were followed for 12 months during which no adverse effects resulting from the transplant were observed. Anatomical evidence suggested the existence of new RPE-like cell layer in the previously damaged area. Visual and physiological testing indicated limited functional improvement, albeit to different degrees between patients. This study provides some promising early results concerning the use of transplanted hESC-RPE cells to alleviate wet-AMD.

Submacular hemorrhage secondary to age-related macular degeneration managed with vitrectomy, subretinal injection of tissue plasminogen activator, hemorrhage displacement with liquid perfluorocarbon, gas tamponade, and face-down positioning

Purpose

To investigate the outcomes of vitrectomy, subretinal tissue plasminogen activator (tPA) injection, hemorrhage displacement with liquid perfluorocarbon, gas tamponade, and face-down positioning, in hemorrhagic neovascular age-related macular degeneration (AMD) patients.

Methods

In this retrospective case series, we reviewed the records of patients who were diagnosed as having submacular hemorrhage (SMH) secondary to neovascular AMD between January and June 2016. The main outcome measure was the difference between preoperative and postoperative best corrected visual acuity (BCVA).

Results

In 9 eyes of 9 patients, mean preoperative and postoperative BCVA at the last follow-up were 1.65 and 1.49 LogMAR, respectively (p = 0.1), after a mean follow up time of 12.4 ± 1.0 months. The SMH was successfully displaced in 5 of the 9 patients (55.5%). Four out of 9 patients (44.4%) gained ≥3 lines. The duration of SMH was 3.6 ± 2.1 days (range 1-7) in the successfully displacement group, and was 10.0 ± 1.8 days (range 8-12) in the group in which was SMH could not be displaced (p = 0.002). The mean SMH area was smaller in the successfully displacement group than the group in which was SMH could not be displaced (p = 0.04).

Conclusion

Vitrectomy, subretinal tPA injection, hemorrhage displacement with liquid perfluorocarbon, gas tamponade and face-down positioning was associated with improved visual outcomes in patients with hemorrhagic neovascular AMD. The duration and area of the SMH seemed to be related to the success of displacement.

Reporting quality of randomised controlled trial abstracts on age-related macular degeneration health care: a cross-sectional quantification of the adherence to CONSORT abstract reporting recommendations

OBJECTIVE

To assess the reporting quality of randomised controlled trial (RCT) abstracts on age-related macular degeneration (AMD) healthcare, to evaluate the adherence to the Consolidated Standards of Reporting Trials (CONSORT) statement's recommendations on minimum abstract information and to identify journal characteristics associated with abstract reporting quality.

DESIGN

Cross-sectional evaluation of RCT abstracts on AMD healthcare.

METHODS

A PubMed search was implemented to identify RCT abstracts on AMD healthcare published in the English language between January 2004 and December 2013. Data extraction was performed by two parallel readers independently by means of a documentation format in accordance with the 16 items of the CONSORT checklist for abstracts. The total number of criteria fulfilled by an abstract was derived as primary endpoint of the investigation; incidence rate ratios (IRRs) with unadjusted 95% CI were estimated by means of multiple Poisson regression to identify journal and article characteristics (publication year, multicentre design, structured abstract recommendations, effective sample size, effective abstract word counts and journal impact factor) possibly associated with the total number of fulfilled items.

STUDY CHARACTERISTICS

136 of 673 identified abstracts (published in 36 different journals) fulfilled all eligibility criteria.

RESULTS

The median number of fulfilled items was 7 (95% CI 7 to 8). No abstract reported all 16 recommended items; the maximum total number was 14, the minimum 3 of 16 items. Multivariate analysis only demonstrated the abstracts' word counts as being significantly associated with a better reporting of abstracts (Poisson regression-based IRR 1.002, 95% CI 1.001 to 1.003).

CONCLUSIONS

Reporting quality of RCT abstracts on AMD investigations showed a considerable potential for improvement to meet the CONSORT abstract reporting recommendations. Furthermore, word counts of abstracts were identified as significantly associated with the overall abstract reporting quality.

Phase 1 clinical study of an embryonic stem cell-derived retinal pigment epithelium patch in age-related macular degeneration

Age-related macular degeneration (AMD) remains a major cause of blindness, with dysfunction and loss of retinal pigment epithelium (RPE) central to disease progression. We engineered an RPE patch comprising a fully differentiated, human embryonic stem cell (hESC)-derived RPE monolayer on a coated, synthetic basement membrane. We delivered the patch, using a purpose-designed microsurgical tool, into the subretinal space of one eye in each of two patients with severe exudative AMD. Primary endpoints were incidence and severity of adverse events and proportion of subjects with improved best-corrected visual acuity of 15 letters or more. We report successful delivery and survival of the RPE patch by biomicroscopy and optical coherence tomography, and a visual acuity gain of 29 and 21 letters in the two patients, respectively, over 12 months. Only local immunosuppression was used long-term. We also present the preclinical surgical, cell safety and tumorigenicity studies leading to trial approval. This work supports the feasibility and safety of hESC-RPE patch transplantation as a regenerative strategy for AMD.