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Shi T, Wen J, Xia H, Chen H. VITRECTOMY WITH SUBRETINAL INJECTION OF RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR FOR SUBMACULAR HEMORRHAGE WITH OR WITHOUT VITREOUS HEMORRHAGE. Retina 2024; 44:1188-1195. [PMID: 38452260 DOI: 10.1097/iae.0000000000004093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE To evaluate the outcomes and prognostic factors of pars plana vitrectomy combined with subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage (SMH) patients with or without vitreous hemorrhage (VH). METHODS Sixty-four eyes of 64 patients with SMH underwent pars plana vitrectomy with subretinal injection of recombinant tissue plasminogen activator. Best-corrected visual acuity, SMH displacement, and postoperative complications were analyzed. Predictive factors of the final best-corrected visual acuity were determined using multivariant linear regression. RESULTS There were 26 eyes with VH and 38 eyes without VH best-corrected visual acuity significantly improved in both VH group (from 2.27 ± 0.40 to 1.25 ± 0.70 logarithm of the minimum angle of resolution) and non-VH group (from 1.76 ± 0.55 to 0.85 ± 0.65 logarithm of the minimum angle of resolution). Complete displacement of SMHs was observed in 47 (73.43%) eyes. Postoperative complications included recurrent SMH (4.69%), recurrent VH (10.94%), rhegmatogenous retinal detachment (3.13%), and epiretinal membrane (4.68%). Treatment-naive condition, early surgery, and younger age were significantly associated with better final best-corrected visual acuity ( B = 0.502, 0.303, and 0.021, respectively, with all P < 0.05). CONCLUSION Pars plana vitrectomy combined with subretinal recombinant tissue plasminogen activator injection is an effective treatment for SMH patients with and without VH.
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Affiliation(s)
- Tingkun Shi
- Department of Ocular Trauma, Joint Shantou International Eye Center, Shantou University & the Chinese University of Hong Kong, Shantou, China
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Maruyama-Inoue M, Kitajima Y, Yanagi Y, Inoue T, Kadonosono K. Intravitreal anti-vascular endothelial growth factor monotherapy in age-related macular degeneration with submacular hemorrhage. Sci Rep 2023; 13:5688. [PMID: 37029159 PMCID: PMC10081992 DOI: 10.1038/s41598-023-32874-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/04/2023] [Indexed: 04/09/2023] Open
Abstract
The purpose of this study was to evaluate the 1-year visual outcomes of patients treated with intravitreal aflibercept (IVA) or brolucizumab (IVBr) for submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD). We retrospectively studied 62 treatment-naïve eyes with SMHs exceeding one disc area (DA) secondary to AMD treated with IVA or IVBr. All patients received three monthly intravitreal injections in the loading phase followed by as-needed injections or fixed dosing. If a vitreous hemorrhage (VH) developed during the follow-up period, injections were discontinued and vitrectomy was performed. We evaluated the changes in the best-corrected visual acuity (BCVA) and factors that affected the BCVA improvement and VH development. A VH during treatment developed in five eyes (8.1%) (VH + group), and the mean BCVA worsened from 0.45 to 0.92. The BCVA improved significantly (P = 0.040) in the remaining 57 eyes (VH - group) from 0.42 to 0.36. The development of VHs was associated with significantly (P < 0.001) less VA improvement. Furthermore, large DAs and younger age at baseline were associated significantly (P = 0.010 and 0.046, respectively) with the development of VHs. Both IVA and IVBr appeared to improve functional outcomes in patients with SMH secondary to AMD when VHs did not develop. However, a VH developed in 8.1% of eyes after treatment. Although anti-vascular endothelial growth factor treatments were well-tolerated, for cases with large SMH at baseline, it should be considered that VH may occur during the monotherapy treatment process using IVA or IVBr, and that achieving good visual outcomes may be difficult in some cases.
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Affiliation(s)
- Maiko Maruyama-Inoue
- Department of Ophthalmology and Micro-technology, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Yoko Kitajima
- Department of Ophthalmology, Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Yasuo Yanagi
- Department of Ophthalmology and Micro-technology, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Tatsuya Inoue
- Department of Ophthalmology and Micro-technology, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Kazuaki Kadonosono
- Department of Ophthalmology and Micro-technology, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
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Fibrovascular pigment epithelial detachment in eyes with subretinal hemorrhage secondary to neovascular AMD or PCV: a morphologic predictor associated with poor treatment outcomes. Sci Rep 2020; 10:14943. [PMID: 32913279 PMCID: PMC7483711 DOI: 10.1038/s41598-020-72030-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022] Open
Abstract
To evaluate the influence of fibrovascular pigment epithelial detachment (FVPED) on treatment outcomes in eyes with subretinal hemorrhage secondary to neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). This retrospective study included 83 eyes diagnosed with fovea-involving submacular hemorrhage secondary to neovascular AMD or PCV. All the patients were treated with intravitreal anti-vascular endothelial growth factor. Eyes showing definite FVPED, which involves the subfoveal region, were included in the FVPED group. Eyes without subfoveal PED, shallow irregular PEDs, or serous/hemorrhagic PED were stratified to the non-FVPED group. The best-corrected visual acuity (BCVA) at diagnosis, at 3 months, at 12 months, and lesion re-activation after initial treatment were compared between the two groups. The mean size of hemorrhage was 8.6 ± 7.6 disc diameter areas. In the FVPED group, the mean logarithm of minimal angle of resolution BCVA was 1.11 ± 0.49 at diagnosis, 0.89 ± 0.58 at 3 months, and 1.05 ± 0.63 at 12 months. In the non-FVPED group, the values were 0.97 ± 0.56, 0.56 ± 0.55, and 0.45 ± 0.50, respectively. The BCVA at 3 months (P = 0.036) and at 12 months (P < 0.001) was significantly worse in the FVPED group than in the non-FVPED group. In addition, the incidence of lesion reactivation was greater in the FVPED group (83.3%) than in the non-FVPED group (38.5%) (P < 0.001). The presence of subfoveal FVPED was associated with a high incidence of lesion re-activation and poor treatment outcomes in eyes with subretinal hemorrhage. This result suggests that different treatment strategies are needed between eyes with and without FVPED.
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Kim JH, Kim JW, Kim CG, Lee DW. Long-Term Outcomes of Switching from Fixed-Dose to As-Needed Regimen for Treating Submacular Hemorrhage Secondary to Polypoidal Choroidal Vasculopathy. J Clin Med 2020; 9:jcm9082637. [PMID: 32823822 PMCID: PMC7463565 DOI: 10.3390/jcm9082637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 11/16/2022] Open
Abstract
Background: The aim of this study was to evaluate outcomes in patients with submacular hemorrhage secondary to polypoidal choroidal vasculopathy (PCV) after switching treatment from a fixed-dose to an as-needed regimen. Methods: This retrospective study included 19 patients with submacular hemorrhage secondary to PCV who were treated with fixed-dose intravitreal aflibercept during the first 56 weeks. After 56 weeks, the treatment regimen was switched to an as-needed regimen. The incidence and timing of lesion reactivation during the as-needed phase were evaluated. The best-corrected visual acuity (BCVA) at baseline (beginning of the regimen) and the final follow-up were compared. Multivariate analysis was performed to determine the factors associated with lesion reactivation. Results: During the mean follow-up period of 27 ± 7.3 months, lesion reactivation was noted in 10 patients (52.6%; mean time period: 12.2 ± 9.1 months) in the as-needed phase. Reactivations were treated with anti-vascular endothelial growth factor (VEGF) injections (mean, 4.1 ± 2.6). The mean logarithm of the minimum angle of resolution (logMAR) BCVA was 0.26 ± 0.34 at baseline and 0.31 ± 0.38 at final follow-up (p = 0.212). Deterioration of ≥0.2 logMAR BCVA was noted in two patients (10.5%). In multivariate analysis, large lesion size was closely associated with a high risk of lesion reactivation (p = 0.009). Conclusion: Visual acuity was relatively stable after switching from a fixed-dose to an as-needed regimen, with no definite visual deterioration in the majority of patients. We conclude that patients with large lesions should be carefully monitored when switching to an as-needed regimen.
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Long-term Clinical Course after Vitrectomy for Breakthrough Vitreous Hemorrhage Secondary to Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy. Sci Rep 2020; 10:359. [PMID: 31941971 PMCID: PMC6962336 DOI: 10.1038/s41598-019-57297-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/10/2019] [Indexed: 11/21/2022] Open
Abstract
To investigate the long-term clinical course after vitrectomy for breakthrough vitreous hemorrhage secondary to neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). This retrospective study included 45 eyes that underwent vitrectomy due to breakthrough vitreous hemorrhage secondary to neovascular AMD. The patients were divided into 2 groups: neovascular AMD group and PCV group. Within each group, the status of the eye within 6 months after the surgery and that at the final follow-up was identified. The visual acuity at the final visit was additionally compared between the 2 groups. The patients were followed up for a mean period of 39.9 ± 19.4 months after the surgery. In the neovascular AMD group (n = 17), re-bleeding requiring vitrectomy was noted in 4 eyes and extensive scar formation was noted in 6 eyes within 6 months after the surgery. At the final visit, treatment was discontinued due to poor visual outcome in 10 eyes. In the PCV group (n = 28), re-bleeding requiring vitrectomy was noted in 1 eye, and extensive scar formation was noted in 4 eyes within 6 months after the surgery. At the final visit, treatment was discontinued in 8 eyes. The visual acuity at the final visit was significantly better in the PCV group (P = 0.003). The long-term clinical course after vitrectomy for breakthrough vitreous hemorrhage was markedly different between neovascular AMD and PCV, showing significantly better long-term visual outcomes in PCV.
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Casini G, Loiudice P, Menchini M, Sartini F, De Cillà S, Figus M, Nardi M. Traumatic submacular hemorrhage: available treatment options and synthesis of the literature. Int J Retina Vitreous 2019; 5:48. [PMID: 31890278 PMCID: PMC6905055 DOI: 10.1186/s40942-019-0200-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/09/2019] [Indexed: 02/08/2023] Open
Abstract
Sub-macular hemorrhage (SMH) is a hematic collection between the neurosensory retina and the retinal pigment epithelium; one of its causes is ocular blunt trauma, that usually affects young patients. Persisting SMH leads to a damage of photoreceptors mediated by three main mechanisms: iron-related toxicity, impairment of diffusion of oxygen and nutriment, mechanical damage due to clot contraction. Since early photoreceptors' damage has been reported within 24 h, it is suggested to provide an early treatment, although there are no guidelines or consensus between authors regarding treatment strategies. The aim of this review was to present and compare available treatment options, like intravitreal tissue plasminogen activator (tPA) associated with pneumatic displacement, pneumatic displacement alone, subretinal tPA injection with pneumatic displacement, and intravitreal anti-vascular endothelial growth factor (VEGF) injection. All procedures obtained consistent results, though the most effective seemed to be pars plana vitrectomy, subretinal tPA and gas tamponade, probably due to a quicker liquefaction and displacement of the clot. Limitations concern the greater invasiveness and the higher incidence of complications. Alternatively, intravitreal injection of tPA and gas may represent a less invasive option with fewer complications. Intravitreal injection of gas and prone position could be preferred in young patients without coexisting ocular pathology, being a minimally invasive treatment, with lower risk of complications and a good visual recovery. Anti-VEGF agent have found, to date, limited employment in cases of traumatic SMH even though they may be useful as alternative or adjuvant therapy. Most of the published literature consists of small studies and case reports, therefore further investigations and larger clinical trials are required to fully understand safety and efficacy of the procedures. A preoperative comprehensive evaluation may be helpful to realize a surgical plan tailored on patient.
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Affiliation(s)
- Giamberto Casini
- 1Ophthalmology Unit, Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Pasquale Loiudice
- 1Ophthalmology Unit, Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Martina Menchini
- 1Ophthalmology Unit, Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Francesco Sartini
- 1Ophthalmology Unit, Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Stefano De Cillà
- 2Department of Health Sciences, Eye Clinic, University of Piemonte Orientale, Novara, Italy
| | - Michele Figus
- 1Ophthalmology Unit, Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Marco Nardi
- 1Ophthalmology Unit, Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
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Intravitreal aflibercept for submacular hemorrhage secondary to neovascular age-related macular degeneration and polypoidal choroidal vasculopathy. Graefes Arch Clin Exp Ophthalmol 2019; 258:107-116. [DOI: 10.1007/s00417-019-04474-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/21/2019] [Accepted: 09/07/2019] [Indexed: 12/13/2022] Open
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Kim JH, Chang YS, Kim JW, Kim CG, Lee DW. Abrupt visual loss during anti-vascular endothelial growth factor treatment for type 3 neovascularization. Int J Ophthalmol 2019; 12:480-487. [PMID: 30918819 DOI: 10.18240/ijo.2019.03.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 01/02/2019] [Indexed: 11/23/2022] Open
Abstract
AIM To investigate the incidence of abrupt visual loss and its associated factors, during anti-vascular endothelial growth factor (VEGF) treatment for type 3 neovascularization. METHODS This retrospective study included 137 eyes that were newly diagnosed with type 3 neovascularization. All eyes were treated with anti-VEGF therapy. Abrupt visual loss was defined as loss of 5 or more lines in best-corrected visual acuity (BCVA) in comparison to the previous visit. The incidence and timing of abrupt visual loss as well as the factors associated with it, were determined. In addition, the BCVA at the final follow-up was compared between the eyes with and those without abrupt visual loss. RESULTS The mean follow-up period was 42.4±18.9mo after diagnosis, and abrupt visual loss was noted in 22 eyes (16.1%) at a mean of 19.6±13.9mo. Abrupt visual loss was found to be associated with subretinal hemorrhage in 11 eyes (50.0%), development of or increase in the height of pigment epithelial detachment with fluid in 8 eyes (36.4%), and tears in the retinal pigment epithelium in 3 eyes (13.6%). The logarithm of minimum angle of resolution (logMAR) mean BCVA at the final follow-up was 2.07±0.67 (Snellen equivalents: 20/2349) and 1.00±0.55 (20/200) in eyes with and without abrupt visual loss, respectively. BCVA was significantly worse in the eyes with abrupt visual loss (P<0.001). CONCLUSION Abrupt visual loss is noted in 16.1% of patients with type 3 neovascularization and is associated with poor visual outcome. Additional studies are needed to determine how abrupt visual loss can be prevented.
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Affiliation(s)
- Jae Hui Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul 150-034, Korea
| | - Young Suk Chang
- Department of Ophthalmology, Konyang University College of Medicine, Daejeon 35365, Korea
| | - Jong Woo Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul 150-034, Korea
| | - Chul Gu Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul 150-034, Korea
| | - Dong Won Lee
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul 150-034, Korea
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SPECKLED HYPOAUTOFLUORESCENCE AS A SIGN OF RESOLVED SUBRETINAL HEMORRHAGE IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2018; 39:1925-1935. [PMID: 30355956 DOI: 10.1097/iae.0000000000002367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To describe patterns of hypoautofluorescence in eyes with neovascular age-related macular degeneration occurring after subretinal hemorrhage. METHODS This was a retrospective descriptive analysis of neovascular age-related macular degeneration eyes presenting with subretinal hemorrhage over the last 5 years that underwent serial multimodal imaging. A review of color fundus photographs, fundus autofluorescence, near-infrared reflectance, and optical coherence tomography was performed at baseline and all available follow-up visits to document the course and evolution of subretinal hemorrhage in these eyes. RESULTS Eleven eyes of 10 patients (9 female, 1 male; mean age: 84.1 years, range: 72-99 years) with a mean follow-up of 19.8 months (range: 3-68 months) were included. Color fundus photographs showed subretinal hemorrhage that resolved over a mean of 5.5 months. During and after hemorrhage resolution, all eyes showed hypoautofluorescence, which appeared distinct from that due to retinal pigment epithelium loss. Discrete multifocal punctate hyperpigmented lesions were observed in 90% of eyes and were markedly hypoautofluorescent, producing a speckled pattern on fundus autofluorescence. CONCLUSION Areas of hypoautofluorescence in the absence of retinal pigment epithelium atrophy, often with a speckled pattern, delineate areas of prior subretinal hemorrhage long after its resolution in patients with neovascular age-related macular degeneration. Potential mechanisms for the development of this pattern are proposed.
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