Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration

PURPOSE

To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration.

METHODS

This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200.

RESULTS

Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement.

CONCLUSION

Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.

Current Management of Subretinal Hemorrhage in Neovascular Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss among individuals aged 65 years and older in the USA. For individuals diagnosed with AMD, approximately 12% experience varying levels of subretinal hemorrhage (SRH), which can be further classified by size into small, medium, and massive measured in disc diameters. SRH is an acute and rare sight-threatening complication characterized by an accumulation of blood under the retina arising from the choroidal or retinal circulation. Released iron toxins, reduced nutrient supply, fibrin meshwork contraction, and outer retinal shear forces created by SRH contribute to visual loss, macular scarring, and photoreceptor damage. SRH treatment strategies aim to displace hemorrhage from the foveal region and prevent further bleeding. Although there are no standardized treatment protocols for SRH, several surgical and nonsurgical therapeutical approaches may be employed. The most common surgical approaches that have been utilized are pars plana vitrectomy (PPV) combined with multiple maneuvers such as the removal of choroidal neovascularization lesions, macular translocation, retinal pigment epithelium patch repair, SRH drainage, intravitreal injection of recombinant-tissue plasminogen activator (tPA), expansile gas and air displacement, and anti-vascular endothelial growth factor (anti-VEGF) injections. Nonsurgical therapeutical approaches include intravitreal anti-VEGF monotherapy, intravitreal tPA administration without PPV, and photodynamic therapy. This review article aims to explore the current treatment strategies and supporting literature regarding both surgical and nonsurgical, of SRH in patients with AMD. Moreover, this article also aims to highlight the distinct treatment modalities corresponding to different sizes of SRH.

Visual prognosis of submacular hemorrhage secondary to age-related macular degeneration: A retrospective multicenter survey

Purpose

To investigate the clinical features, treatment options, and visual outcomes of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).

Design

A retrospective, observational case series.

Methods

Setting: Multicenter institutional setting. Patient Population: A total of 127 patients (127 eyes; 88 men, 39 women; (mean age, 74.2 years)) diagnosed with AMD-associated SMHs exceeding 2 disc diameters involving the fovea. Observation: The AMD types, previous treatments, treatment options, anatomic findings, and best-corrected visual acuity (BCVA) were assessed. Main Outcome Measures: Clinical features, treatment options, and visual outcomes of SMHs secondary to nAMD.

Results

Thirty-two eyes had typical AMD, 94 eyes polypoidal choroidal vasculopathy (PCV), and one eye retinal angiomatous proliferation. Eighty-five eyes were treatment-naïve; 42 eyes were treated previously: anti-vascular endothelial growth factor (VEGF) therapy (n = 26), photodynamic therapy (n = 3), and combined therapy (n = 13). Treatment of SMHs included vitrectomy (36 eyes), pneumatic displacement (49 eyes), and anti-VEGF monotherapy (42 eyes). The final BCVA improved significantly in treatment-naïve cases from 0.86 to 0.62 logarithm of the minimal angle of resolution (logMAR) unit (Snellen equivalent from 20/145 to 20/83) and from 0.80 to 0.56 (Snellen equivalent from 20/126 to 20/73) in PCV cases. Meanwhile, the BCVA logMAR values improved from 1.15 to 0.75 (Snellen equivalent from 20/283 to 20/112) and from 0.87 to 0.63 (Snellen equivalent from 20/148 to 20/85) in eyes that underwent vitrectomy or pneumatic displacement, respectively. In eyes with BCVAs between 20/133 to 20/40 at SMH onset, the final VA in the pneumatic displacement group was better than in the anti-VEGF monotherapy group. One eye had a retinal detachment and 1 eye had a macular hole in the vitrectomy group, and 5 eyes had a vitreous hemorrhage in the pneumatic displacement group.

Conclusions

The recommended treatment for SMHs secondary to nAMD exceeding 2 disc area and with BCVA below 20/40 is vitrectomy or pneumatic displacement for visual improvement.

STEP-WISE APPROACH TO THE MANAGEMENT OF SUBMACULAR HEMORRHAGE USING PNEUMATIC DISPLACEMENT AND VITRECTOMY: The Manchester Protocol

PURPOSE

To evaluate a sequential approach of pneumatic displacement followed by vitrectomy (pars plana vitrectomy) in failed cases to deal with submacular hemorrhage (SMH) of various etiologies.

METHODS

Retrospective, nonrandomized interventional case series of consecutive patients with SMH of up to 2 weeks' duration, who were treated with a stepwise approach. Step 1 involved intravitreal injection of 0.3 mL 100% C3F8 and recombinant tissue plasminogen activator 50 μg/0.1 mL. If unsuccessful, a prompt pars plana vitrectomy with subretinal recombinant tissue plasminogen activator 50 μg/0.1 mL and 20% SF6 gas tamponade was performed as a second attempt to displace the SMH.

RESULTS

Thirty-one patients with SMH underwent pneumatic displacement; 24 (77.4%) had a successful outcome without further intervention. The mean presenting visual acuity of the "successful cohort" was 1.34 logMAR (20/440 Snellen), improving to 0.83 logMAR (20/135 Snellen) 1 month after treatment. Five of the seven patients with failed pneumatic displacement underwent pars plana vitrectomy with subretinal recombinant tissue plasminogen activator at an average of 5 days poststep 1, with successful SMH displacement in 3 patients, giving an overall success of 87.1% for this treatment protocol.

CONCLUSION

A sequential approach of expansile gas injection followed by prompt pars plana vitrectomy, aided by recombinant tissue plasminogen activator at both steps, is a coherent, logical pathway to treat SMH with high anatomical and functional success.

HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AFTER INTRACAMERAL VANCOMYCIN USE IN CATARACT SURGERY AFTER INTRAVENOUS EXPOSURE

PURPOSE

To report a case of hemorrhagic occlusive retinal vasculitis after cataract surgery.

METHODS

A 74-year-old woman presented with blurry vision and distorted vision, which started 2 days after an uncomplicated cataract surgery in the left eye. Intracameral vancomycin was injected during the case. The patient reported being treated with systemic vancomycin in the past.

RESULTS

The visual acuity was 20/80 in the left eye. She had trace cells in the anterior chamber with no hypopyon and intraocular lens implant within the capsular bag in the left eye. Dilated fundus examination revealed no vitritis, There were large patches of peripheral retinal hemorrhages and retinal ischemia. The patient was diagnosed with hemorrhagic occlusive retinal vasculitis likely secondary to hypersensitivity reaction to intracameral vancomycin. The patient was started on oral prednisone, and the topical difluprednate course was escalated. Within 3 weeks, vision improved to 20/30 in the left eye. She underwent pan retinal photocoagulation targeting the ischemic areas in the periphery.

CONCLUSION

The patient had previous exposure to systemic vancomycin, which may have sensitized her immune system. Later on, the hypersensitivity reaction took place after exposure to intracameral vancomycin during cataract surgery. Our hemorrhagic occlusive retinal vasculitis case had a favorable visual outcome, and recognition of this entity will ensure that vancomycin will not be used for infection prophylaxis in the fellow eye at the time of cataract surgery.

Eyes With Acute, Treatment-Naïve CRVO and Foveal Intraretinal Hemorrhage: Characteristics and Outcomes

BACKGROUND AND OBJECTIVE

To compare outcomes in eyes with central retinal vein occlusion (CRVO) presenting with (group 1) or without (group 2) fovea-involving intraretinal hemorrhage (IRH).

PATIENTS AND METHODS

Retrospective review of patients diagnosed with acute, treatment-naïve CRVO between January 2009 and July 2016.

RESULTS

One hundred fifteen (39.8%) of 289 CRVO eyes had fovea-involving IRH. At baseline, eyes in group 1 had significantly worse visual acuity (VA) (1.2 ± 0.10 logMAR vs. 0.9 ± 0.06 logMAR; P = .001) and greater central subfield thickness (CST) (610.4 μm ± 35.9 μm vs. 435.0 μm + 21.6 μm; P < .001) than eyes in group 2. Final visual outcomes were comparable between groups (1.24 ± 0.09 logMAR vs. 1.02 ± 0.08 logMAR; P = .08). Group 1 received a significantly greater number of intravitreal anti-vascular endothelial growth factor injections during the first year (7.80 ± 0.40 vs. 5.20 ± 0.40; P = .001).

CONCLUSIONS

Although treatment-naïve eyes with acute CRVO and fovea-involving IRH had worse VA and greater CST at presentation, the final VA was comparable to eyes without such a hemorrhage. Eyes with foveal IRH had a greater treatment burden in the first 12 months. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:752-759.].

[Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results (French translation of the article)]

PURPOSE

To evaluate anatomical and functional outcomes of surgical displacement of macular hemorrhages complicating exsudative age-related macular degeneration (AMD) after vitrectomy, subretinal rtPA (recombinant tissue plasminogen activator) injection, intravitreal bevacizumab injection and gaz tamponade.

METHODS

Retrospective case series, including 26 patients with submacular hemorrhage, who underwent a surgical displacement within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was carried out to measure the diameter of the hemorrhage and to specify the relation with retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage away from the fovea at first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit.

RESULTS

The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5,8 (±7,2) lines (P=0.0003) at 1 month postoperatively, 7,4 (±6,7) lines (P=0.0004) at 6 months and 7,4 (±7,4) lines (P=0.0002) at final postoperative visit (16,5±19,8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient P=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)).

CONCLUSION

Vitrectomy with subretinal rtPA injection was found to be effective for the displacement of AMD hemorrhage in 81 % of the patients. Mean final visual acuity improved by more than 7 lines.

Diagnosis and treatment of peripheral exudative haemorrhagic chorioretinopathy

PURPOSE

Peripheral exudative haemorrhagic chorioretinopathy (PEHCR) is a rare disorder that is often misdiagnosed. The aim of this study was to better characterise PEHCR and to assess treatment options.

MATERIAL AND METHODS

Retrospective multicentric chart review.

RESULTS

Of 84 eyes (69 patients) with PEHCR referred between 2005 and 2017, the most common referral diagnosis was choroidal melanoma (41.3%). Bilateral involvement was found in 21.7% of cases. Haemorrhagic retinal pigment epithelium detachment was the most common peripheral lesion (53.6%). Maculopathy was associated with peripheral lesions in 65.8% of cases. PEHCR lesions were mostly heterogeneous (58.8%) on B-scan ultrasonography. Choroidal neovascularisation was found in 10 eyes (26.3%) out of 38 eyes that underwent fluorescein angiography. Polyps were observed in 14 eyes (58.3%) out of 24 eyes that underwent indocyanine green angiography. Fifty-one eyes were treated (62.2%). Intravitreal injections (IVTI) of antivascular endothelial growth factor (VEGF) were the most used treatment (36.6%) before laser photocoagulation, photodynamic therapy, vitrectomy and cryotherapy. Only vitrectomy improved visual acuity. Most lesions (65.6%) regressed at the last follow-up visit.

CONCLUSION

In case of PEHCR, multimodal imaging is useful to avoid misdiagnosis, to characterise PEHCR lesions and to guide treatment strategies. Regression of PEHCR lesions was observed in two-thirds of the patients. Vitrectomy improved visual acuity. More than a third of patients underwent anti-VEGF IVTI. Further studies are needed to assess IVTI's efficacy.

Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results

INTRODUCTION

Macular subretinal hematoma is a complication of age related macular degeneration (AMD) responsible for a severe change in vision. We evaluated anatomic and functional results of surgical treatment of hematoma by vitrectomy, subretinal injection of r-tPA (recombinant tissue plasminogen activator), intravitreal bevacizumab injection and air tamponade.

METHODS

Retrospective case series including 26 patients with submacular hemorrhage who underwent vitrectomy within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was performed to measure the diameter of the hemorrhage and specify the location in relation to the retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage out of the fovea at the first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit.

RESULTS

The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5.8 (±7.2) lines (P=0.0003) at 1 month postoperatively, 7.4 (±6.7) lines (P=0.0004) at 6 months and 7.4 (±7.4) lines (P=0.0002) at the final postoperative visit (16.5±19.8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient ρ=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)).

CONCLUSION

Vitrectomy with subretinal r-tPA injection was found to be effective for the displacement of AMD hemorrhage in 81% of the patients. Mean final visual acuity improved by more than 7 lines, confirming the efficacy and functional benefit of surgical displacement.

Displacement of Submacular Hemorrhage With Subretinal Injection of Recombinant Tissue Plasminogen Activator and Gas Tamponade in the Setting of Myopic Degeneration

Myopic submacular hemorrhage (SMH) usually arises from either a break in Bruch's membrane (lacquer cracks) that damages the underlying choriocapillaris or the development of a choroidal neovascular membrane (CNVM) at the sites of prior lacquer cracks.1,2 In pathologic myopia (PM), axial elongation leads to thinning of the choroid and retinal pigment epithelium, predisposing to rupture of Bruch's membrane.3 If large hemorrhages involving the fovea are left untreated, subretinal hemorrhage and CNVM can cause devastating long-term vision loss due to irreversible retinal atrophy.4 In this video, the authors describe their technique of using a subretinal injection of recombinant tissue plasminogen activator with a concurrent gas tamponade to displace SMH.

Valsalva retinopathy occurring after general anesthesia

PURPOSE

To report a case of patient who presented with valsalva retinopathy after genral anesthesia for the treatment of ruptured intracranial aneurysm.

OBSERVATION

A forty year-old man presented, after a general anesthesia for treatment of a ruptured intracranial aneurysm, with a severe decrease of the visual acuity in the left eye. Ophthalmic examination, performed one month after surgery showed a retrohyaloid macular hemorhage. After failure of laser Nd-YAG hyaloidotomy, vitrectomy allowed drainage of the hematoma with good visual outcome.

CONCLUSION

Valsalva retinopathy is a rare complication that can occur after genral anesthesia. Vitrectomy may be needed if Nd-Yag laser hyaloidotomy fails.

Retinal Vein Occlusion in a Woman with Heterozygous Fabry's Disease

Fabry's disease is associated with high incidence of thrombosis in hemizygous males and heterozygous females. We describe a woman with Fabry's disease who developed hemi-central retinal vein occlusion during the follow-up. The vein occlusion showed a fulminant course ending with a painful blind eye within a short period. Fabry's disease should be considered in the differential diagnosis of the vascular occlusive disorders especially in young patients.

Laser and Anti-Vascular Endothelial Growth Factor Agent Treatments for Retinal Arterial Macroaneurysm

PURPOSE

To describe the efficacy of laser and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents for patients with symptomatic retinal arterial macroaneurysm (RAM).

DESIGN

From 2009 to 2016, we collected patients with exudative or hemorrhagic RAM all treated by focal laser photocoagulation.

METHODS

Nd:YAG laser was performed in patients with subinternal limiting membrane (sub-ILM) hemorrhage. Intravitreal anti-VEGF agents were given in eyes with macular exudation as adjuncts. Changes of visual acuity and central foveal thickness before and after treatment were recorded and compared with Wilcoxon signed-rank test.

RESULTS

Thirty-five eyes that underwent a single session of laser photocoagulation for RAM resulted in macroaneurysm regression. The hemorrhagic group included 24 eyes having ruptured macroaneurysms without macular exudation. Five eyes with simultaneous sub-ILM hemorrhage receiving Nd:YAG laser membranotomy had resolution of preretinal hemorrhage. Exudative RAM having cystoid macular edema or submacular fluid with or without ruptured macroaneurysms was treated by focal laser photocoagulation alone in 3, or combined with single intravitreal anti-VEGF agent in 8 eyes. All patients had significantly improved vision when comparing visual acuity at baseline and final follow-up (P = 0.00016). Significant reduction of macular thickness was also observed after laser monotherapy or combined treatment in exudative RAM (P = 0.018).

CONCLUSIONS

Focal laser photocoagulation was helpful for the management of ruptured or leaky RAM. Combined focal laser and intravitreal anti-VEGF agents could better reduce macular exudation caused by RAM. Additionally, Nd:YAG laser was a safe and effective method to remove the sub-ILM hemorrhage caused by RAM.

Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment

Emergency clinicians are likely to encounter physical abuse in children, and they must be prepared to recognize its many manifestations and take swift action. Pediatric nonaccidental injury causes considerable morbidity and mortality that can often be prevented by early recognition. Nonaccidental injuries present with a wide array of symptoms that may appear to be medically inconsequential (such as bruising in a premobile infant), but are actually sentinel injuries indicative of child abuse. This issue provides guidance regarding factors that contribute to abuse in children, key findings on history and physical examination that should trigger an evaluation for physical abuse, and laboratory and radiologic tests to perform when child abuse is suspected.

A New Variant of Polypoidal Choroidal Vasculopathy With Annular Pigmentary Changes in Haitian Males

The authors report a new variant of idiopathic polypoidal choroidal vasculopathy (IPCV) in middle-aged Haitian men characterized by extramacular polypoidal lesions and bilateral extensive pigmentary alterations in the posterior pole in an annular wreath-like pattern surrounding the optic nerve and macular area. Two patients were seen at Massachusetts Eye and Ear Infirmary and one at Boston University Medical Center between 2010 and 2015. All three patients were middle-aged Haitian men who exhibited bilateral features of IPCV, including subretinal hemorrhages and serosanguinous pigment epithelial detachments. Indocyanine green angiography revealed extramacular polypoidal lesions located mostly along the major vascular arcades. Extensive pigmentary alterations were evident in the posterior pole surrounding the macula and optic nerve in an annular wreath-like pattern. These cases further expand the clinical spectrum of IPCV.

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

BACKGROUND

Submacular hemorrhage associated with polypoidal choroidal vasculopathy (PCV) may cause severe visual loss. The purpose of this study is to report the visual prognosis of massive submacular hemorrhage in patients with PCV.

METHODS

Twenty patients with PCV and submacular hemorrhage who received either subretinal tissue plasminogen activator (TPA) with vitrectomy or intravitreal injection of TPA and gas to achieve pneumatic displacement of the hemorrhage were enrolled. Additionally, combination treatment with either photodynamic therapy (PDT) or intravitreal injection of vascular endothelial growth factor inhibitors (anti-VEGF) was performed to treat the underlying PCV.

RESULTS

Five patients received subretinal TPA with vitrectomy and 15 patients received intravitreal injection of TPA and gas to remove or displace the submacular hemorrhage. Combination treatment with PDT and intravitreal anti-VEGF was performed in three patients and intravitreal anti-VEGF injection alone in 13 patients. The mean logarithm of the minimal angle of resolution converted from the best corrected visual acuity (BCVA) were improved at 3 months, 6 months, and 12 months. Better initial BCVA, smaller size of submacular hemorrhage and younger age were statistically significant predictors for BCVA. Combination treatment with PDT showed significant efficacy in the improvement of BCVA.

CONCLUSION

Combination treatment of submacular hemorrhage secondary to PCV may yield visual and anatomic improvements. Initial BCVA, the initial size of submacular hemorrhage and age were significant predictors for visual prognosis.

Hyperbaric oxygen for the treatment of the rare combination of central retinal vein occlusion and cilioretinal artery occlusion

A 43-year-old male presented with sudden onset of painless, blurred vision in his left eye. Dilated fundoscopic examination showed signs consistent with the diagnosis of a combination of central retinal vein occlusion (CRVO) and cilioretinal artery occlusion (CLRAO). He received daily 2-h sessions of hyperbaric oxygen treatment (HBOT), 253 kPa for 14 days. At the end of the HBOT course, the patient's left visual acuity had improved from 20/200 to 20/20. Dilated fundoscopic examination showed that the intra-retinal haemorrhages in the entire retina and the retinal whitening along the course of the CLRA seen at presentation had completely resolved. The combination of CLRAO and CRVO comprises a discrete clinical entity. Even though there are many hypotheses concerning this condition, it is most likely the result of elevated intraluminal pressure in the retinal capillaries due to CRVO that exceeds the pressure in the CLRA. HBOT may be an effective treatment for CRVO-associated CLRAO.

PNEUMATIC DISPLACEMENT AS A TREATMENT OF TRAUMATIC MACULAR HOLE WITH SUBMACULAR HEMORRHAGE

PURPOSE

To report the potential benefit of pneumatic displacement with perfluoropropane in the acute treatment of traumatic macular hole and submacular hemorrhage.

METHODS

This article is a descriptive case report. Intravitreal injection of 0.3 mL of undiluted C3F8 was performed in an outpatient clinic setting, with strict face-down positioning for 7 days thereafter.

PATIENT

An otherwise healthy 22-year-old white man with no past ocular history.

RESULTS AND DISCUSSION

Initial examination and optical coherence tomography documented significant displacement of the submacular hemorrhage, and stabilization of the macular hole 24 hours after pneumatic retinopexy was performed. Best-corrected visual acuity on presentation was counting fingers in the affected eye, which improved to 20/50 with a closed macular hole 6 weeks after his initial injury.

Anti-vascular endothelial growth factor with or without pneumatic displacement for submacular hemorrhage

PURPOSE

To compare the treatment outcomes of a combination of pneumatic displacement and intravitreal anti-vascular endothelial growth factor, and anti-vascular endothelial growth factor monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Forty eyes treated with a combination therapy and 42 eyes treated with monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration with no significant difference in baseline central foveal thickness were compared. Central foveal thickness and best-corrected visual acuity (BCVA) at baseline, 1, 3, and 6 months after initial treatment were measured and compared between the 2 groups after adjustment of baseline central foveal thickness.

RESULTS

Central foveal thickness (P < .0001) and BCVA (combination, P < .0001; monotherapy, P = .022) were improved after both treatments. Combination therapy showed more rapid improvement of central foveal thickness (P = .009) and BCVA (P = .007) within 1 month than monotherapy, but there was no difference at 6 months (P = .385 and P = .303, respectively). In eyes with subretinal hemorrhage thicker than 450 μm, visual outcome at 6 months was better in the combination therapy group than in the monotherapy group (P = .021), whereas BCVA showed no significant difference between groups in eyes with subretinal hemorrhage less than 450 μm (P = .930).

CONCLUSIONS

Both treatments are useful options for submacular hemorrhage resulting from exudative age-related macular degeneration. Combination therapy may yield a better treatment outcome than monotherapy in eyes with thick subretinal hemorrhage. Nevertheless, the potential for adverse events resulting from pneumatic displacement should be considered.

Recurrent ocular involvement in pediatric atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (HUS) is a subtype of thrombotic microangiopathy associated with complement alternative pathway dysregulation. It is clinically characterized by a relapsing course and a poor prognosis. Multiple organ systems are commonly affected by thrombotic microangiopathy in pediatric atypical HUS; however, ocular involvement is rarely reported. The case of an 11-year-old girl diagnosed as having atypical HUS who presented with bilateral central retinal vein occlusions with macular subhyaloid hemorrhage during her initial onset and ophthalmoplegia, diplopia, and optic disc edema during her relapsing episode 1 year later is described. All ocular manifestations occurred in the convalescence phase of atypical HUS. No other extrarenal complications were found and full recovery was achieved following typical treatment for atypical HUS (ie, plasma infusion, steroid, and supportive therapy). This is thought to be the first reported case of recurrent ocular involvement in pediatric atypical HUS.

Ruptured retinal arterial macroaneurysm: diagnosis and management

Retinal arterial macroaneurysm is an acquired, focal dilation of a retinal artery, typically occurring within the first three bifurcations of the central retinal artery. The clinical presentation of a retinal arterial macroaneurysm is highly variable, making initial diagnosis difficult and differentials many. Identification of retinal arterial macroaneurysms is crucial to appropriately co-manage with the primary care physician for hypertension control. Prognosis is generally good and observation is often an adequate treatment. However, in cases of macular threat or involvement, some treatment options are available and referral to a retinal specialist is indicated.

[Unique mechanism in heart-shaped balloon burst resulting in blunt ocular injury]

We have previously shown that heart-shaped balloons have a different explosion mechanism than spherical balloons in which the former splits into two rubber parts still attached to the balloon base with a backward whiplash motion. This backward whiplash motion may cause significant blunt ocular trauma if the balloon is inflated by mouth. In this article, the energy of the blunt ocular trauma is estimated by the high speed camera photos analysis of the balloon burst. Furthermore, we describe the followup of eight patients with ocular trauma following inflation of heart-shaped balloons.

Efficacy and safety of recombinant tissue plasminogen activator and gas versus bevacizumab and gas for subretinal haemorrhage

PURPOSE

To report the 12 months efficacy of initial intravitreal bevacizumab or intravitreal recombinant tissue plasminogen activator (rtPA) combined with expansile gas in patients with subretinal haemorrhage caused by neovascular age-related macular degeneration (AMD).

METHODS

Forty-five eyes of 45 patients with subretinal haemorrhage (1-5 disc diameters) involving the fovea secondary to neovascular AMD were evaluated retrospectively consecutively. Thirty-two eyes underwent treatment with rtPA (50 μg/0.05 ml) combined with intravitreal sulphur hexafluoride (SF6). The other 13 eyes were treated with bevacizumab (1.25 mg/0.05 ml) and SF6. Thereafter, all patients received Vascular Endothelial Growth Factor (anti-VEGF) treatment according to modified PrONTO criteria. Main outcome was change of best-corrected visual acuity (VA) at 12 months as determined by Early Treatment Diabetic Retinopathy (ETDRS).

RESULTS

There was more improvement in patients initially treated with rtPA and gas (14 letters; bevacizumab and gas eight letters) and not suffering from adverse events. The incidence of vitreous haemorrhages was significantly higher in the rtPA group (nine of 32 versus one of 13, p < 0.01). In both groups, an average of 3.5 anti-VEGF injections were performed per patient during 12 months (no difference between both groups).

CONCLUSION

Both initial treatment regimen lead to improved functional results after 1 year. However, patients, not suffering from adverse events, who underwent initial treatment with rtPA and gas showed better results. To maintain VA, controlling neovascular AMD by anti-VEGF treatment regime after initial treatment with rtPA+gas is important for all cases.

Treatment of submacular haemorrhage in patients with neovascular age related macular degeneration

To evaluate the efficacy of the pneumatic displacement of the submacular haemorrhage combined with the intravitreal injection of the tissue plasminogen activator. We present a retrospective clinical case series of nine eyes of nine patients that were treated with the intravitreal injection of the tissue plasminogen activator and expansile gas for the submacular haemorrhage due to the age related macular degeneration. We evaluated visual acuities and complications. Selected patients were additionally treated with the intravitreal bevacizumab injections after the procedure. Mean postoperative followup was 19 weeks. Four (4/9) eyes (44%) received additional treatment with the intravitreal bevacizumab during the postoperative period. Statistical analysis was performed using the Student's paired t-test. The mean visual acuity was 1.77 logMAR preoperatively and 1.06 logMAR postoperatively. After the surgery, 4 or more Snellen lines were gained in 7/9 eyes (78%). The improvement of the visual acuity postoperatively was statistically significant (p = 0.002). In 2/9 eyes (22%) the visual acuity did not get better after the procedure. We observed no complications during the follow up period. In our case series, pneumatic displacement of the submacular haemorrhage with the use of the intravitreal tissue plasminogen activator (with or without additional bevacizumab treatment in the selected cases) turned out to be an effective and safe method leading to the improvement of the visual acuity in the majority of cases. To maximise the treatment success, prompt referral to the retinal surgeon is imperative.

[Subretinal hemorrhage. Natural course and staging]

Subretinal hemorrhages are a complication of various diseases which arise from the choroidal or retinal circulation. Most commonly the underlying pathology is a choroidal neovascular membrane (CNV) especially in patients with age-related macular degeneration (AMD). Less common ocular diseases are those with non-AMD-related CNV and retinal arterial macroaneurysms (RAM). Case studies have demonstrated a poor prognosis, however, a significant portion have favorable outcomes. Therefore, therapeutic decision-making is difficult. As a major difficulty in comparing different treatment modalities for submacular hemorrhages is the lack of a standardized definition of the extent of the hemorrhage. A classification for AMD-related subretinal hemorrhages including size, thickness and intraretinal location is suggested.

Non-vitrectomizing vitreous surgery and adjuvant intravitreal tissue plasminogen activator for non-recent massive premacular hemorrhage

Massive premacular hemorrhage can cause sudden visual loss. We sought to evaluate the efficacy, safety and visual outcome of nonvitrectomizing vitreous surgery with intravitreal tissue plasminogen activator (t-pa) for long-lasting thick premacular hemorrhage. This retrospective, interventional study examined three consecutive eyes of three patients who received nonvitrectomizing vitreous surgery with intravitreal t-pa for the treatment of non-recent massive premacular hemorrhage. Detailed ophthalmoscopic examinations were performed pre- and postoperatively to evaluate the visual outcome, the resolution of premacular hemorrhage and the changes in lenticular opacity.In all three eyes, the premacular hemorrhage cleared after the procedure. Final best-corrected visual acuities improved from 6/30 to 6/10 in patient 1, 2/60 to 6/4 in patient 2, and 3/60 to 6/6 in patient 3. Operated and fellow eyes did not differ in terms of nuclear sclerosis. No complications from the procedure were noted.In these selected cases, nonvitrectomizing vitreous surgery with intravitreal t-pa was an effective and safe alternative treatment for non-recent massive premacular hemorrhage.

Intravitreal injection of recombinant tissue plasminogen activator and pneumatic displacement of submacular haemorrhage

We report a case of a patient with hypertension and ischaemic heart disease on anti-platelet treatment, who developed uniocular profound visual loss from a submacular haemorrhage secondary to valsalva retinopathy. He was treated with a combination of intravitreal recombinant tissue plasminogen activator (rtPA) and sulphur hexafluoride (SF6) gas followed by strict prone positioning. He demonstrated significant displacement of the haemorrhage and improvement of vision postoperatively.

Retinal hemorrhages as a presenting sign in an adolescent patient with hepatosplenic gamma-delta T-cell lymphoma

Hepatosplenic gamma-delta T-cell lymphoma is a very rare, aggressive form of peripheral lymphoma first recognized in 1990. Patients often present with organomegaly, anemia, adenopathy, and B symptoms. Rarely in the literature is a pediatric patient described with this subtype of peripheral T-cell lymphoma. Also, retinal hemorrhages have never been described as a presenting symptom of hepatosplenic gamma-delta T-cell lymphoma. We describe an adolescent patient with hepatosplenic gamma-delta T-cell lymphoma who presented with retinal hemorrhages, massive splenomegaly, bone marrow involvement, and B symptoms.

Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma

Extensive intraocular hemorrhage in young infants in the setting of acute brain injury and in the absence of a history of severe accidental trauma or underlying medical cause must be considered to be nonaccidental injury until otherwise proven. In the absence of any obvious explanation, the presence of any retinal hemorrhage should raise the possibility of abusive head trauma in the differential diagnosis and perhaps lead to such testing as skeletal radiography and neuroimaging, consultation with a child abuse specialist, as well as workup for other relevant systemic conditions. Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that the proper steps are taken to protect their patients from the potential for further harm. Ascertainment of abusive head trauma is critical to prevent a potentially fatal recurrence.

[Management of subretinal hemorrhage with r-TPA, SF-6 and ranibizumab]

CASE REPORT

We present a case of a patient with subretinal hemorrhage treated with intravitreal r-TPA, SF-6 and ranibizumab.

DISCUSSION

Subretinal hemorrhages secondary to age-related macular degeneration are associated with poor visual outcome. A wide variety of management approaches has been developed, but the prognosis of these patients has not been modified by any of them. The association of an intravitreal anti VEGF drug to r-TPA and gas, may improve its results as we add the treatment of the subjacent etiology to the pneumatic displacement.

[Pars plana vitrectomy, subretinal injection of recombinant tissue plasminogen activator and fluid-gas exchange in the management of massive submacular hemorrhages secondary to age-related macular degeneration]

INTRODUCTION

The natural prognosis of eyes with subretinal hemorrhage resulting from age-related macular degeneration is generally poor. A variety of therapeutic approaches have been developed but no consensus was found. Therefore, we evaluated a technique consisting of pars plana vitrectomy and subretinal rt-PA injection followed by evacuation of the liquid blood using sulfur hexafluoride (SF6).

PATIENTS AND METHODS

This study was a retrospective clinical case series examining 18 eyes of 16 patients with age-related macular degeneration and thick submacular hemorrhage treated with vitrectomy, subretinal injection of rt-PA (0.5mg), and fluid-gas exchange.

RESULTS

The subretinal hemorrhage was displaced in all 18 cases, revealing a choroidal lesion in 17 eyes. A treatable lesion accountable for the bleeding was identified in ten eyes, which all received a secondary treatment (intravitreal injection or photodynamic therapy). After a mean follow-up of 6 months, the final visual acuity improved in ten eyes. Complications consisted of one case of retinal detachment and one case of hyphema.

CONCLUSION

This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. However, further controlled and multicentric studies will be required to assess its efficacy and safety in the management of this difficult clinical problem.

Tissue plasminogen activator-assisted vitrectomy: surgical drainage of submacular hemorrhage

A thick subretinal hemorrhage involving the macula is currently treated with pneumatic displacement or surgical removal. We evaluated the long-term effects of tPA-assisted surgical drainage of a submacular hemorrhage by reviewing the medical records of 12 eyes with submacular hemorrhage followed for a mean follow-up time of 6.9 years. The final best corrected visual acuity (BCVA) improved in 10 eyes (83%), was unchanged in 2 (17%), and was reduced in 0 (0%). The mean preoperative BCVA was 6/200, and the best postoperative BCVA was 20/47, and the final BCVA was 20/143. The late postoperative complications, including recurrent submacular hemorrhage, enlargement of the CNV, and retinal degeneration, reduced the final BCVA. These results indicate that tPA-assisted surgical removal of a subretinal hemorrhage can lead to improved long-term vision. Controlling the choroidal neovascularization may be important for retaining the best postoperative vision.

[Evaluation of the efficacy of intravitreal gas injection for submacular hemorrhages]

PURPOSE

To evaluate the efficacy of intravitreal gas injection for submacular hemorrhages(SMH).

PATIENTS AND METHODS

The records of 29 patients with SMH, who were treated by pneumatic displacement with expansile gas, were reviewed retrospectively.

RESULT

In observable cases, SMH had started moving within five days after the procedure. After 6 months visual acuity had been improved 2 or more lines in 23 eyes(79%). The causes of SMH were age-related macular degeneration (17 eyes) and microaneurysm (12 eyes). The larger the size of SMH, had the greater the risk of developing vitreous hemorrhage. Twelve eyes of the 29 eyes required vitrectomy owing to vitreous hemorrhage, insufficient removal of SMH, etc. but this pneumatic procedure often eliminated the need for vitrectomy. The visual acuity of the patients with additional vitrectomy was improved with only pneumatic displacement. None of the patients had serious complications with this pneumatic procedure and the vitrectomy.

CONCLUSION

The first choice for SMH is intravitreal gas injection which saves foveal function, and improves the prognosis for better vision.

[Macroaneurysm of central retinal artery branch]

Authors present review of modern diagnostic and therapeutic methods in dealing with retinal macroaneurysms, illustrated by own case reports. The key diagnostic test for retinal macroaneurysms is fluorescein angiography. Prognosis for preserving vision depends on the character of retinal macroaneurysm complications such as hard exudates and haemorrhages after macroaneurysm rupture and its localization in regard to the macular area. Treatment options are related to severity of subjective symptoms and can be conservative or surgical.

Subhyaloidal and macular haemorrhage: localisation and treatment strategies

Deterioration of visual acuity as a result of haemorrhage

PNEUMATIC DISPLACEMENT OF SUBMACULAR HEMORRHAGE

PURPOSE

To investigate the safety and efficacy of pneumatic displacement of submacular hemorrhage without the use of intravitreal tissue plasminogen activator (tPA).

METHODS

In a prospective, consecutive, single-center, noncomparative, interventional case series, 20 consecutive patients with submacular hemorrhage due to various etiologies (duration, 1-30 days; visual acuity, hand movements to 20/125) were treated with intravitreal perfluoropropane gas injection followed by prone positioning for 5 days to 7 days. Patients were observed 1 day, 7 days, 30 days, 3 months, 6 months, and 1 year after the procedure.

RESULTS

Submacular blood was completely or partially displaced from the fovea in 16 of 20 eyes within 7 days after the injection. Mean best-corrected visual acuity improved from 1.6 to 0.72 logarithm of minimum angle of resolution, which was statistically significant (Wilcoxon signed rank test, P = 0.001). Final visual acuity was 20/63 or better in 10 eyes (50%). The change in proportion of eyes with best-corrected visual acuity of 20/63 or better after treatment was statistically significant (McNemar test, P = 0.002). Four patients developed nonresolving vitreous hemorrhage, which necessitated vitrectomy.

CONCLUSION

The results of pneumatic displacement of submacular hemorrhage using perfluoropropane gas are encouraging, thus questioning the role of tPA in the management of such cases.

ANALYSIS OF FORCES ACTING UPON SUBMACULAR HEMORRHAGE IN PNEUMATIC DISPLACEMENT

PURPOSE

To analyze the forces affecting pneumatic displacement of submacular hemorrhage and determine an efficient postoperative positioning method for patients.

METHOD

Geometric analysis of the forces that act upon submacular hemorrhage in the absence and presence of a gas bubble.

RESULTS

A component of gravity force of the hemorrhage parallel to the subretinal space is responsible for pneumatic displacement. This component is largest when the patient is looking straightforward and is absent when the patient is positioned facedown.

CONCLUSION

Face down positioning is not optimal for pneumatic displacement of submacular hemorrhage and should be avoided.

Complete resorption of retinal hemorrhages in idiopathic thrombocytopenic purpura

PURPOSE

Idiopathic thrombocytopenic purpura (ITP) is characterized by refractory thrombocytopenia, production of autoantibodies, and persistent predisposition to bleeding affecting virtually all mucocutaneous tissues and various organs.

METHODS

A 50-year-old man with chronic ITP and diabetic maculopathy developed massive preretinal, intraretinal, and numerous subretinal hemorrhages accompanied by impaired vision to 20/400. His platelet count was 1100/microL, hemoglobin concentration was 4.6 mg/dL, however his blood clotting and activated partial thromboplastin time (APTT) maintained a normal 26 sec.

RESULTS

After a splenectomy the patient was placed on high-dose oral corticosteroids (40 mg/day), immunoglobulin, and CellCept. The platelet count was restored to 25,000/microL within months. Four months later the unaffected retina received a panretinal photocoagulation and intravitreal triamcinolone injection (25 mg). Two years after the thrombolytic event the hemorrhages resolved completely and the patient's vision recovered to 20/100.

CONCLUSIONS

Repetitive treatments with immunoglobulins and high-dose corticosteroids may increase the platelet count, inducing a complete resorption of the retinal hemorrhages and visual recovery during a long-term follow-up.

Pneumatic displacement of submacular hemorrhage due to age-related macular degeneration

PURPOSE

Subretinal hemorrhage is one of the most serious complications of exudative age-related macular degeneration (AMD). Treatment with vitreous surgery with or without plasminogen activator, fluid-gas exchange, or perfluorocarbon yields only a small improvement in visual acuity.

PATIENTS AND METHODS

The files of 24 patients with submacular hemorrhage secondary to AMD who were treated by injection of perfluoropropane gas (C(3)F(8)) (11 patients) or sulfur hexafluoride (SF(6)) (13 patients) were reviewed for visual acuity before and after the procedure and time of treatment from onset of symptoms.

RESULTS

For the whole sample, pneumatic displacement led to a statistically significant improvement in mean visual acuity (p = 0.015). A significant difference between pre- and postoperative visual acuity was found for the patients treated with SF(6) (p = 0.034), but not for the patients treated with C(3)F(8) (p = 0.245).

CONCLUSION

The use of gas injection to displace submacular hemorrhage can significantly improve visual acuity.

Application of transpupillary thermotherapy in a patient with asteroid hyalosis and premacular hemorrhage

A 70-year-old woman with long-term poor vision was found to have unilateral massive premacular hemorrhage and asteroid hyalosis. Transpupillary thermotherapy (TTT) was applied sequentially to the vitreous in four separate spots, covering the area of the asteroid hyalosis and hemorrhage. Outcome measures included visual acuity, biomicroscopic appearance, ultrasonography, and fluorescein angiography. Significant resolution of the hemorrhage was observed 3 months after TTT, with visual acuity improvement from counting fingers at 25 cm to 20/60. There were no complications noted during the procedure or during follow-up. The long-term safety measures and visual prognosis following TTT for resolution of the vitreous impurities remain to be evaluated, but the procedure may be effective for treating premacular hemorrhage and asteroid hyalosis.

Massive hemorrhagic retinal detachment during radial optic neurotomy

BACKGROUND

We encountered obvious arterial bleeding from the incision site during radial optic neurotomy (RON) in a 55-year-old woman with central retinal vein occlusion (CRVO) and report the findings herein.

CASE REPORT

The patient initially demonstrated a retinal hemorrhage and macular edema due to a left CRVO. Her corrected visual acuity was 0.5 OS. Since her symptoms did not improve and were aggravated, even though she received an oral anticoagulant drug orally, RON was performed 2 months after the onset of symptoms. During surgery, obvious arterial bleeding started from the RON incision site and it was not arrested although the infusion bottle was fully elevated. However, a subsequent infusion of liquid perfluoro-carbon successfully stopped the bleeding by direct pressure. Hemorrhagic retinal detachment occurred in the nasal quadrant and postoperative vitreous hemorrhage was treated surgically. The hemorrhagic retinal detachment was gradually absorbed and replaced by fibrous scar tissue. Two years after the surgery, no expansion of retinal detachment has been observed and corrected visual acuity is being maintained at 0.2 OS.

CONCLUSION

We conclude that RON for CRVO carries a risk of arterial bleeding and that infusion of liquid perfluoro-carbon seems to be effective to arrest arterial bleeding from the RON site.