Bullous hemorrhagic retinal detachment because of massive subretinal hemorrhage in patients with age-related macular degeneration

Intravitreal Aflibercept With vs Without Pneumatic Displacement for Submacular Hemorrhage Associated With Polypoidal Choroidal Vasculopathy

Purpose: To compare the visual outcomes of intravitreal (IVT) aflibercept with pneumatic displacement vs without pneumatic displacement for submacular hemorrhage (SMH) associated with polypoidal choroidal vasculopathy (PCV). Methods: This retrospective study assessed patients with SMH associated with PCV who were treated with aflibercept and pneumatic displacement with gas (aflibercept+gas group) or with aflibercept alone (monotherapy group). Patients were followed for at least 12 months, with the best-corrected visual acuity (BCVA) at 12 months the primary outcome measure. Results: Forty-seven eyes of 47 patients were retrospectively analyzed from August 2013 to March 2023. The aflibercept+gas group comprised 25 eyes and the monotherapy group, 22 eyes. The 2 groups had comparable baseline characteristics. The mean logMAR best-corrected visual acuity (BCVA) before treatment was 0.78 ± 0.46 in the aflibercept+gas group and 0.83 ± 0.66 in the monotherapy group (P = .76). The mean BCVA (0.26 ± 0.42 vs 0.85 ± 0.57) and the mean change in (-0.52 ± 0.55 vs 0.02 ± 0.75) 12 months postoperatively was significantly better in the aflibercept+gas group than in the monotherapy group (P < .001 and P < .008, respectively). The BCVA improved by 3 or more lines in 60.0% of eyes in the aflibercept+gas group but in only 18.2% of eyes in the monotherapy group. Vitreous hemorrhage developed in 16.0% of eyes in the aflibercept+gas group and in 13.6% of eyes in the monotherapy group and retinal detachment in 4.0% and 0%, respectively (both P = 1.000). Conclusions: Better visual outcomes were achieved with IVT aflibercept and pneumatic displacement than with aflibercept alone for SMH associated with PCV.

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.

Removal of massive subretinal organized blood clot with fragmatome

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

Characteristics and surgical outcomes of rhegmatogenous retinal detachments that develop after intravitreal injections

PURPOSE

To determine the frequency and characteristics of rhegmatogenous retinal detachments (RRDs) that develop after an intravitreal injection of anti-vascular endothelial growth factor (VEGF) agent.

STUDY DESIGN

A retrospective review of the medical charts.

METHODS

The charts of patients who received intravitreal injections for age-related macular degeneration (AMD), diabetic macular edema (DME), retinal vein occlusion (RVO), or myopic choroidal neovascularization (mCNV) between 2013 and 2020 were reviewed. We included the RRD cases that developed within 90 days of the most recent intravitreal injection. The baseline characteristics and surgical outcomes were analyzed.

RESULTS

A total of 3040 patients received 28,190 intravitreal injections. Seven eyes of 7 cases developed a RRD. There were 6 cases of AMD and one of DME, with an incidence of one in 4027 injections (0.025%). The retinal break was in the superior quadrants in 5 eyes (71%), and in the inferior quadrants in 2 eyes. All eyes had a posterior vitreous detachment. The average number of injections before the development of RRD was 14.1 (range: 2-39). Four eyes were treated by vitrectomy, and 3 by scleral buckling. The primary success rate was 86%, and the final reattachment rate was 100%. The best-corrected visual acuity was 0.41 ± 0.26 logarithm of minimal angle of resolution (logMAR) units before developing the RRD, 0.78 ± 0.78 logMAR units before the surgery for RRD, and 0.45 ± 0.47 logMAR units at the final visit.

CONCLUSIONS

The incidence of RRD after an intravitreal injection is very low (0.025%), and it can be reattached with recovery of the visual acuity.

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

PURPOSE

To evaluate the outcome of vitrectomy combined with a subretinal injection of tissue plasminogen activator (tPA) to treat a massive subretinal hemorrhage.

METHODS

The medical records of 11 eyes of 11 patients (seven men, four women, mean age; 74.5 ± 9.6 years) with a massive (>10 disc area) subretinal hemorrhage were reviewed. The patients were treated with vitrectomy combined with a subretinal injection of tPA with or without external drainage.

RESULTS

The mean baseline visual acuity was 2.10 ± 0.45 logarithm of the minimum angle of resolution (logMAR) units. The hemorrhage was externalized in three eyes due to bullous hemorrhagic retinal detachment. The subretinal hemorrhage was displaced away from the fovea in 10 eyes (91%) and reduced in one eye. Retinal reattachment was achieved in all eyes however reoperations were needed in five eyes (45%) among the eight eyes (73%) with recurrent vitreous and/or subretinal hemorrhages. The postoperative vision at 3 months was significantly improved to 1.32 ± 0.65 logMAR units (p = 0.0076). The vision in the two eyes without postoperative subretinal hyperreflective material at the fovea recovered to 0.4 logMAR units but none of the nine eyes with the foveal subretinal hyperreflective material had vision better than 0.1 logMAR units.

CONCLUSION

Vitrectomy with subretinal injection of tPA with or without external drainage of the subretinal hemorrhage was effective in treating massive subretinal hemorrhages.

Multimodal imaging of spontaneous subretinal hemorrhage in a young male: a case report

Background

Spontaneous subretinal hemorrhage (SSRH) is a rare disease that severely affects the visual function, and is difficult to diagnose. This study aimed to describe the multimodality imaging characteristics of SSRH in a young male patient.

Case presentation

A 28-year-old male was presented to our hospital with “sudden drop of left eye vision for one week.” Three weeks ago, he was admitted to other hospital due to sudden severe pain and unclear vision in the left eye for 1 h. The intraocular pressure was 69 mmHg, and the blood pressure was 230/120 mmHg. Skull CT and MRI detected abnormal signal shadows in the left eye and no abnormalities in the brain. B-ultrasonography indicated occupying lesions in the left eye. Two weeks later, the patient came to our hospital for treatment as the vision of the left eye had decreased sharply. Admission examination: blood pressure was 200/120 mmHg, best-corrected visual acuity was 20/20 in the right eye and hand motion in the left eye. Fundus details could not be evaluated in the left eye because of hemorrhage in the vitreous cavity. B-ultrasonography of the left eye revealed a dense, diffuse intravitreal hemorrhage. Skull MRI showed an abnormal signal shadow in the left eyeball, suggesting intraocular hemorrhage. Vitrectomy revealed a dome-shaped lesion in the peripheral part of the inferotemporal region during the operation. Postoperative indocyanine green angiography (ICGA) of the lesion showed hypofluorescence and no leakage or altered morphology during the whole imaging process. Follow-up showed gradual reabsorption of SSRH.

Conclusions

In this case, SSRH was considered to be associated with high blood pressure. Multimodal imaging provides accurate data for the diagnosis and follow-up of the disease.

Long-term observation of vitrectomy without subretinal hemorrhage management for massive vitreous hemorrhage secondary to polypoidal choroidal vasculopathy

AIM

To describe the long-term observation of vitrectomy without subretinal hemorrhage (SRH) management for massive vitreous hemorrhage (VH) secondary to polypoidal choroidal vasculopathy (PCV).

METHODS

This is a retrospective, consecutive case series. A total of 86 eyes of 86 patients with >14d of massive VH associated with PCV were included. All patients underwent vitrectomy without SRH management, followed by intravitreal ranibizumab injections and/or photodynamic therapy (PDT) as needed. The main outcome measures were best-corrected visual acuity (BCVA), postoperative adverse events and the recurrence of VH.

RESULTS

The average follow-up period was 25.5±9.2mo (range 12-35mo). Mean BCVA at baseline (2.16±0.39 logMAR) had improved significantly, both 3mo after surgery (1.42±0.66 logMAR, P<0.001) and by the last visit (1.23±0.74 logMAR, P<0.001). The common postoperative complications included macular subretinal fibrosis in 14 eyes (16.3%) and ciliary body detachment in 4 eyes (4.7%). Nineteen eyes (22.1%) received following treatment with ranibizumab injections without/with PDT, and 15 (17.4%) were resolved. Four eyes (4.7%) had recurrent hemorrhage during the follow-up period. In multiple regression analysis, thicker SRH (beta=0.33, P=0.025) in the preoperative B-scan and the presence of foveal subretinal fibrosis (beta=0.28, P=0.018) in the follow up were associated with poor postoperative BCVA.

CONCLUSION

Vitrectomy without SRH management for massive VH secondary to PCV improved/stabilized visual function in the long-term observation. Eyes presenting with thicker SRH preoperatively and forming foveal subretinal fibrosis in the follow-up period tended to have worse BCVA.