Traumatic submacular hemorrhage: available treatment options and synthesis of the literature

Safety and Long-Term Efficacy of Intravitreal rtPA, Bevacizumab and SF6 Injection in Patients with Submacular Hemorrhage Secondary to Age-Related Macular Degeneration

Purpose: Acute submacular hemorrhage (SMH) is a vision-threatening complication common in patients affected by age-related macular degeneration (AMD). This study evaluates safety, long-term clinical outcomes and associated treatment factors following intravitreal triple injection of recombinant tissue plasminogen activator (rtPA), SF6 gas, and Bevacizumab due to acute SMH secondary to AMD. Methods: A retrospective analysis on patients who received treatment between January 2014 and December 2020 (n = 37) was conducted. Visual acuity (VA), central retinal thickness (CRT), central retinal volume (CRV), and axial pigment epithelial detachment height were analyzed at baseline (B), 4 weeks after triple injection (FU1), after the following anti-VEGF injection series (FU2), after 1 year (FU3), after 2 years (FU4), and at the final follow-up examination after 4.4 ± 1.6 years (FU5). Further, treatment courses and clinical outcomes were compared to a patient cohort treated for exudative AMD without prior SMH. Furthermore, an explorative data analysis on final VA was conducted, and adverse events following triple therapy were investigated. Results: Triple injection was performed on average 5.6 ± 5.7 days after onset of symptoms. Patients received 16 ± 3 additional intravitreal anti-VEGF injections due to persistent macular edema over the subsequent 2 years. Significant improvements were observed at FU1 in VA (p < 0.001), CRT (p = 0.005), and CRV (p = 0.007), as well as at FU2 in axial PED height (p < 0.001), with all improvements being stable until final follow-up examination. In the group comparison, patients with SMH demonstrated significantly worse functional and anatomical outcomes at 24 months except for the 24-month CRT, and patients on average received more intravitreal injections. Five of 37 patients (13.5%) experienced a retinal pigment epithelial tear following triple injection. Final VA correlated positively and significantly with FU1 VA, while no correlation was observed with baseline VA, the size or height of SMH, or the number of additional anti-VEGF injections. Conclusions: Triple injection constitutes a simple and effective therapy with long-term functional and anatomical improvements following treatment due to SMH, although patients have an increased risk for RPE tears. The 4-week postoperative VA following triple injection was predictive for long-term visual function.

Bilateral Foveal Damage Induced by Indirect Picosecond Nd:YAG Laser Exposure: A Case Report

Introduction: Accidental retinal injuries caused by lasers without appropriate eye protection are not rare; most cases are unilateral. We report the case of a medical nurse who sustained bilateral foveal damage through indirect exposure to a picosecond dermal laser. Case Presentation: A 23-year-old nurse working in a cosmetic surgery clinic was using a picosecond KTP/Nd:YAG laser for tattoo removal. Because the procedure was complicated, she neglected the use of protective eyewear and experienced dazzle. Thirty minutes after starting the procedure, she developed central scotomas in both eyes. We examined her eyes the next day. Ophthalmologic examination revealed best-corrected decimal visual acuity (BCVA) of 0.6 in the right eye and 0.3 in the left eye. Spectral domain-optical coherence tomography showed a hyperreflective inner retinal layer with a lamellar defect and focal outer retinal detachment in the right eye; the left eye exhibited intra- and subretinal foveal hemorrhages. Injections of sub-Tenon's triamcinolone acetonide (12 mg/0.3 mL) in the right eye and intravitreal tissue plasminogen activator (30 μg/0.05 mL) in the left eye were administered on the same day. Two weeks later, a full-thickness macular hole (FTMH) was identified in the right eye; pars plana vitrectomy was required 6 weeks after initial presentation. Because the FTMH failed to close, a second procedure was performed 2 months later. One year after initial presentation, BCVA in the right eye had improved to 0.4. Although the FTMH remained closed, an outer retinal layer defect persisted. In the left eye, foveal hemorrhage resolved within 1 month of initial presentation. At the 1-year follow-up, BCVA in the left eye was 0.4; outer retinal layer disruption was evident at the central fovea. Conclusions: Continuous Nd:YAG laser exposure during cosmetic procedures likely caused the bilateral foveal damage observed in this case. All individuals using lasers must be aware of the importance of protective goggles.

Delayed-Onset White-Dot Syndrome in the Setting of Traumatic Choroidal Rupture

Purpose

To describe a patient with a traumatic choroidal rupture and a submacular hemorrhage, the course of which was complicated by delayed-onset posterior uveitis resembling a white-dot syndrome.

Methods

A single case was evaluated.

Results

A 34-year-old man presented after being struck in the left eye with a tennis ball. The visual acuity (VA) was 20/30 with otherwise normal ophthalmic vitals. An examination showed traumatic iritis and choroidal rupture with a submacular hemorrhage without subfoveal involvement. Despite treatment of anterior segment inflammation and a worsening hemorrhage with topical agents and intravitreal aflibercept, the VA decreased to 20/600. A repeat examination with optical coherence tomography showed new optic disc edema, placoid outer retinal lesions adjacent to the choroidal rupture, and corresponding ellipsoid zone atrophy. A broad workup was unremarkable, and the patient completed a long taper of high-dose oral prednisone without recurrence.

Conclusions

Traumatic exposure of the immunologically privileged subretinal space to high-flow choroidal circulation likely triggered a pathway involving self-autoantigenicity and a uveitic response.

Multimodal imaging-based treatment recommendations for managing submacular hemorrhage

Submacular haemorrhage (SMH) is an emergency, and the most important immediate action in the treatment of SMH is the early displacement or evacuation of subretinal heme from below the fovea, followed by simultaneous or sequential treatment of the underlying cause. Photoreceptor damage can occur immediately after the onset of SMH for a variety of reasons, including toxins released from the blood, the diffusion barrier created by the blood for oxygen delivery and nutrition to the outer retinal layers, and shearing forces on the outer retinal layers, resulting in permanent visual deterioration. A clinician's decision to treat SMH is influenced by a number of factors, including presenting visual acuity, duration of visual symptoms, SMH aetiology and characteristics, availability of intraocular gases and tissue plasminogen activator, and pars plana vitrectomy facilities. For many clinicians, the duration of visual symptoms is the most important and first consideration when planning SMH treatment. Very little emphasis is given to the SMH's imaging characteristics. Currently, there are several treatment options for SMH removal. There is a need to develop a simplified treatment algorithm for SMH that is less reliant on the patient's visual complaints, considers heme characteristics on basic retinal imaging, and has the potential to achieve uniform and predictable treatment outcomes in real-world situations. In this short article, we discuss the various factors that can assist clinicians in the management of SMH and present a simplified treatment algorithm based on the SMH's retinal imaging characteristics.

Vitrectomy With tPA for Submacular Hemorrhage Following Domestic Abuse

A 35-year-old woman presented with visual acuity of 20/400 due to submacular hemorrhage 24 hours after confirmed domestic abuse with blunt trauma to the head. Surgical intervention with pars plana vitrectomy, subretinal tissue plasminogen activator (tPA) injection, and fluid-air exchange yielded prompt resolution of the pathology, regaining functional vision of 20/40 and an ability to return to work within one week. [Ophthalmic Surg Lasers Imaging Retina 2024;55:734-736.].

Characteristics of submacular hemorrhage with bacillary layer detachment and intrabacillary hemorrhage

PURPOSE

To study the outcomes of patients presenting with submacular hemorrhage (SMH) and bacillary layer detachment (BALAD) following intervention.

METHODS

This retrospective study examined fundus photographs and optical coherence tomography (OCT) scans to identify treatment-naive SMH and BALAD cases. Two groups were formed: SMH cases with and without BALAD. The treatment outcomes of these cases were assessed.

RESULTS

Thirteen (65%) of the 20 eyes with SMH had BALAD. Blunt trauma was the most common cause of SMH (n = 10, 50%). Median age was 46 years (IQR range: 28-70). Demographic, clinical, or OCT imaging findings between the groups (p > 0.05) were comparable. Nine (45%) patients each underwent intravitreal gas injection alone or along with PPV and TpA injection. At 1-month post-treatment, VA improved (logMAR VA - 0.89; p = 0.017). BALADs and intrabacillary hemorrhage had resolved in eight (61%) cases. Intraretinal, subretinal, and sub-RPE fluids resolved in 100%, 70%, and 43% of cases, respectively. Eyes with resolved BALAD showed greater improvement in VA (logMAR VA - 0.98) than eyes with persisting BALAD (logMAR VA - 1.1) and resulted in significant decrease in central macular (p = 0.016) and retinal thicknesses (p = 0.031). SMH eyes without pre-treatment BALAD also observed statistically significant improvement in visual acuity following intervention (p = 0.031).

CONCLUSION

BALAD and intrabacillary hemorrhage in SMH are relatively common. A significant proportion of cases had their BALAD and intrabacillary haemorrhage resolved following treatment. Persistence of BALAD had no effect on VA.

Role of fundus autofluorescence imaging in the management of submacular hemorrhage

PURPOSE

To evaluate the baseline characteristics of fundus autofluorescence (FAF) in patients with submacular hemorrhage (SMH).

METHODS

This retrospective study included patients diagnosed with treatment-naive, foveal-involving subretinal hemorrhage (size > 2-disc diameters) of any etiology, presenting between June 2017 and June 2023. Only cases with good-quality color fundus photographs, optical coherence tomography (OCT) scans, and blue-light FAF images at baseline were included. SMH imaging characteristics were documented and correlated with treatment outcomes. A successful treatment outcome was defined as the reduction, displacement or clearance of the SMH from beneath the fovea.

RESULTS

Nineteen cases of SMH (13 males, 6 females), ranging from 14 to 85 years, were analyzed. Neovascular age-related macular degeneration (nAMD) was the most common etiology (n = 11, 58%). Baseline visual acuity ranged from 6/9 to counting fingers at ½ meter, with a median presentation time of 7 days from symptom onset (range: 1-57 days). Treatment success was observed in 13 eyes (68%). Hypoautofluoroscence on FAF was significantly associated with SMH resolution (p = 0.021). However, no association was found between treatment success and clinical hemorrhage characteristics (p = 0.222), OCT findings (p = 0.222), or specific treatments (p > 0.05). Hypoautofluoroscence on FAF was the sole predictor of treatment success, as demonstrated by Spearman's correlation (r = 0.637; p = 0.003) and linear regression analysis (p = 0.003).

CONCLUSION

FAF, in conjunction with color fundus photography and OCT, may provide valuable insights for clinicians in formulating treatment strategies for patients with SMH. Hypoautofluoroscence on FAF was a significant predictor of successful SMH resolution in this study.

Combined treatment of submacular hemorrhage with low-dose subretinal recombinant tissue plasminogen activator and intravitreal conbercept

BACKGROUND

Pars Plana Vitrectomy (PPV) combined with subretinal injection of low-dose recombinant tissue plasminogen activator (rt-PA) and intravitreal injection of Conbercept as a novel therapy for submacular hemorrhage (SMH) requires evaluation.

METHODS

In a retrospective interventional clinical study, 14 eyes of 14 patients with SMH underwent PPV along with rt-PA (subretinal) and Conbercept (intravitreal) injections. The main outcomes included best-corrected visual acuities (BCVAs), degrees of blood displacement, and adverse events. All patients completed at least 6-month follow-up visits.

RESULTS

Mean BCVAs significantly improved at 7 days (22.29 ± 15.35), 1 month (30.71 ± 16.42), 3 months (38.29 ± 13.72), 4 months (38.86 ± 14.15), and 6 months (41.21 ± 14.91) post-treatment compared to baseline (16.36 ± 13.97) (F = 12.89, P = 0.004). The peak improvement in BCVAs occurred at 6 months postoperatively. The procedure effectively eliminated subfoveal hemorrhages in all eyes, with clots removal and absorption occurring within one month and complete regression by 3-month follow-up visits. Postoperatively, two cases of AMD resulted in discoid scars on the fundus. No instances of rt-PA-related retinal toxicity were observed during the follow-up period.

CONCLUSION

The combined approach of PPV with low-dose rt-PA and anti-VEGF shows promise in enhancing both vision and anatomical structure in SMH therapy. Individualized treatment plans tailored to the primary disease should be developed to optimize visual prognoses.

TRIAL REGISTRATION

Retrospectively registered No.ChiCTR2100053034. Registration date: 10/11/2021.

Long-term follow-up of a patient with partial optic nerve avulsion associated with submacular hemorrhage who underwent pneumatic displacement

Purpose

We report the case of a 16-year-old boy with partial optic nerve avulsion (ONA) and submacular hemorrhage (SMH) resulting from blunt ocular trauma who underwent pneumatic displacement and subsequent monitoring with optical coherence tomography (OCT) and fundus photography.

Observations

Reduced visual acuity was observed in the right eye at presentation (20/2400). Vitreous hemorrhage, partial ONA, and SMH were observed during dilated fundus examination. SMH was managed via pneumatic displacement. Subsequent examination revealed improvement in the visual acuity of the right eye with a substantial reduction in the subfoveal hemorrhage. Further improvement in visual acuity was observed 6 months after the injury (20/150). A smaller optic nerve head excavation defect, foveal atrophy, and reabsorption of SMH were observed during fundus examination. OCT of the optic nerve revealed that glial growth had covered the avulsion excavation. However, atrophy of the outer retinal layer of the fovea was observed during macular OCT.

Conclusions and importance

This case emphasizes the importance of performing multimodal imaging in cases of ONA as it enables the identification of alterations in the retinal layers and optic nerve. The subretinal hemorrhage was displaced from the subfoveal region without any adverse effects.

Intraoperative OCT-Guided Volumetric Measurements of Subretinal Therapy Delivery in Humans

Purpose: To evaluate a recently developed technique using intraoperative optical coherence tomography (OCT) to measure subretinal tissue plasminogen activator (tPA) volumes in patients with submacular hemorrhage secondary to exudative age-related macular degeneration (AMD). Methods: Three patients (72 to 83 years old) had 25-gauge pars plana vitrectomy, subretinal tPA, and a partial gas fill. An investigational intraoperative OCT system with a modified widefield noncontact indirect viewing apparatus was used to image subretinal tPA blebs. Using the recently developed technique, the volume and surface area in the segmented region of interest were determined. Results: In each case, the delivered tPA volume measured from the syringe differed from the intraoperative OCT-measured subretinal tPA volume: Patient 1, 130 µL from syringe, 118 µL based on intraoperative OCT, 9% difference; Patient 2, 140 µL, 50 µL, 64%; Patient 3, 110 µL, 122 µL, 11%. The total bleb surface area was 129 mm2 in Patient 1, 55 mm2 in Patient 2, and 106 mm2 in Patient 3. Conclusions: This was the first human study to implement and evaluate intraoperative OCT image-based methods to obtain volumetric bleb measurements in patients receiving subretinal tPA for exudative AMD. This proof-of-concept study showed that intraoperative OCT-obtained bleb volume differed from intraoperative recordings, which could be explained by tPA delivery into the vitreous, efflux through the retinotomy, or human error. Intraoperative OCT can provide visualization and quantification of subretinal tPA bleb volume and surface area, which has implications for improved safety, efficacy, and analysis of the effects of subretinal drug delivery.

Efficacy of anti-VEGF intravitreal injection in traumatic submacular hemorrhage: a retrospective study

OBJECTIVE

In this study we investigated the efficacy of short-term intravitreal injections of anti-vascular endothelial growth factors (anti-VEGF) in treating traumatic submacular hemorrhage.

METHODS

A total of 115 patients were diagnosed with submacular hemorrhage between 2018 and 2022 at Shenzhen Eye Hospital. In a retrospective analysis, we examined 13 of these patients who presented with submacular hemorrhage and choroidal rupture due to ocular trauma. Eight patients were treated with intravitreal anti-VEGF injection and 5 with oral drugs. We systematically analyzed changes in their ocular conditions pre and post-treatment. The evaluations encompassed best-corrected visual acuity (BCVA), optical coherence tomography, fundus fluorescein angiography, and retinal imaging.

RESULTS

The 13 patients diagnosed with submacular hemorrhage comprised of 10 males and 3 female, with their age ranging between 27 and 64 years, with an average age of 38.1 years (standard deviation [SD]: 11.27). A statistically significant reduction in central foveal thickness (CFT) was observed following intravitreal injections of anti-VEGF drugs (P = 0.03). In control group, the CFT was reduced without statistical significance (P = 0.10). The BCVA of the patients in treatment group improved significantly from 1.15 (SD: 0.62. Range: 0.4-2) to 0.63 (SD: 0.59. Range: 0.1-1.6), indicating an average increase of 4.13 lines (SD: 3.36. Range: 0-9) as measured by the visual acuity test using an eye chart (P = 0.01). The difference between baseline visual acuity and final visual acuity was not statistically significant in control group (P = 0.51).

CONCLUSION

Short-term administration of anti-VEGF drugs exhibited significant efficacy in reducing submacular hemorrhage following ocular trauma and enhancing visual acuity.

Efficacy Evaluation of Tissue Plasminogen Activator with Anti-Vascular Endothelial Growth Factor Drugs for Submacular Hemorrhage Treatment: A Meta-Analysis

Submacular hemorrhage (SMH) is the accumulation of blood in the macular area that can severely damage the macular structure and visual function. Recently, the intraocular administration of tissue plasminogen activator (TPA) with anti-vascular endothelial growth factor (anti-VEGF) drugs was reported to have a positive effect on SMH. This meta-analysis aimed to explore the efficacy and safety of the drug combination. We systematically searched the Web of Science, MEDLINE, EMBASE, and Cochrane Library databases and screened relevant full-length literature reports. The quality of the reports was assessed by two independent reviewers. The best-corrected visual acuity (BCVA) and foveal thickness (FT) were considered the main indicators of efficacy. RevMan 5.4 software was used for this meta-analysis. Twelve studies were analyzed, and the results showed that BCVA at 1 month (p < 0.001), 3 months (p < 0.001), 6 months (p < 0.001), and the last follow-up (p < 0.001) was improved relative to the preoperative value. The postoperative FT was lower than the preoperative FT (p < 0.001). No significant difference in efficacy was observed between subretinal and intravitreal TPA injections (p = 0.37). TPA with anti-VEGF drugs is safe for SMH treatment and can significantly improve BCVA and reduce FT.

A Case of Traumatic Submacular Hemorrhage Treated with tPA and Pneumatic Displacement

This is a case of a 31-year-old female who presented to the emergency department at a London teaching hospital with a 24-h history of visual loss following an assault. The ophthalmological routine examination showed a submacular hemorrhage (SMH), and a computerized tomography scan demonstrated a displaced orbital floor fracture with inferior rectus entrapment and a medial wall fracture. To induce displacement of the SMH, intravitreal injection of 0.25 μg tissue plasminogen activator (tPA) was combined with 0.3 mL of intravitreal 100% perfluoropropane (C3F8) gas. At the 1-day follow-up, there was an inferotemporal displacement of the blood clot, and visual acuity improved from hand motions to 6/5 within 3 months. No complications occurred over 2 years of follow-up, with a final visual acuity of 6/5. This case shows us that intravitreal tPA and gas appear safe and effective as a treatment for traumatic SMHs. Furthermore, our results demonstrate that prompt treatment leads to favorable anatomical and functional outcomes.

Not-so-minimal for minimally invasive surgery

Sub-macular hemorrhage poses a potential threat to vision if left untreated. The preferred surgical technique to clear sub-macular hemorrhage includes vitrectomy followed by retinotomy using a 41G needle with subsequent injection of recombinant tissue plasminogen activator (r-tPA) followed by air/SF6 injection into the sub-retinal space. A malleable nature, increased resistance, and the cost of the 41G needle limit its use. We evaluated the safety and efficacy of a 26G needle for retinotomy as a supplement for the 41G needle in a series of six subjects with sub-macular hemorrhage. A slight modification in the procedure was done by injecting air into the sub-retinal space prior to the r-tPA injection. We found that our technique of using the 26G needle for retinotomy is safe and effective due to its stable nature and self-sealing properties. An air injection prior to r-tPA allows for increased bioavailability of the drug by preventing efflux due to its tamponading effect.

Postoperative Multimodal Analysis in Successful Gas Displacement of a Submacular Hemorrhage

In this report, we describe a case of timely gas vitrectomy to displace a moderate submacular hemorrhage from the submacular space without tPA, release vitreoretinal traction along the borders of a posterior retinal tear, and analyze postoperative multimodal imaging findings in a 34-year-old male patient whose right eye was injured by a stone. The patient underwent a successful nontissue plasminogen activator gas vitrectomy 3 days after the accident. A multimodal evaluation with spectral-domain optical coherence tomography (SD-OCT), 10-2 and 30-2 campimetry, microperimetry, multifocal electroretinography (mfERG), and visual evoked potentials was performed 6 months after the accident. The multimodal imaging tests yielded abnormal foveal SD-OCT patterns, with a fibrous sealed tear in the retinal pigment epithelium. Campimetry showed low levels of retinal sensitivity; microperimetry and mfERG revealed a subnormal retinal response and a reduction in the N1 and P1 wave amplitudes. The visual evoked potential responses were normal. Multidisciplinary examination at 6 months postoperatively revealed a structurally and functionally abnormal macula. The retina remained attached. Our functional findings indicate that submacular hemorrhage should be treated in a timely manner to minimize photoreceptor damage.

The choroidal rupture: current concepts and insights

Choroidal rupture is a posterior segment affliction following a traumatic event that results in a break in the retinal pigment epithelium, Bruch membrane, and the underlying choriocapillaris. The visual prognosis may be extremely poor when involving the macular area or in cases with major comorbidities. On funduscopic examination the rupture appears as a whitish/yellowish curvilinear or crescent-shaped lesion with forked or tapered endings. Multimodal imaging including fluorescein angiography, indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography can provide a detailed assessment of the extent of damage and the onset of complications. Although there is no treatment for choroidal rupture per se, associated complications such as angle-recession glaucoma, retinal detachment, or exudative choroidal neovascularization might need therapeutic interventions. We describe the pathophysiology of choroidal rupture, the recent multimodal imaging findings, and the available treatment options for the management of complications.

From Rust to Quantum Biology: The Role of Iron in Retina Physiopathology

Iron is essential for cell survival and function. It is a transition metal, that could change its oxidation state from Fe²⁺ to Fe³⁺ involving an electron transfer, the key of vital functions but also organ dysfunctions. The goal of this review is to illustrate the primordial role of iron and local iron homeostasis in retinal physiology and vision, as well as the pathological consequences of iron excess in animal models of retinal degeneration and in human retinal diseases. We summarize evidence of the potential therapeutic effect of iron chelation in retinal diseases and especially the interest of transferrin, a ubiquitous endogenous iron-binding protein, having the ability to treat or delay degenerative retinal diseases.