Subretinal tissue plasminogen-assisted vitrectomy for posttraumatic full-thickness macular hole with submacular hemorrhage

A young male presented with diminution of vision left eye, attributable to full-thickness macular hole, and submacular hemorrhage, following closed globe injury 2 weeks ago. The patient was managed successfully with 25-gauge vitrectomy, subretinal injection of tissue plasminogen activator and aspiration of liquefied blood through the macular hole, internal limiting membrane peeling, short-acting gas tamponade, and prone positioning. This resulted in good visual improvement, type 1 macular hole closure, and restoration of foveal architecture. The outcome and rationale of treatment in this unique scenario is discussed.

A Case of Choroidal Osteoma with Subretinal Hemorrhage Improved by Intravitreal Bevacizumab and Aflibercept Injections

PURPOSE: To report a case of choroidal osteoma (CO) complicated by extensive subretinal hemorrhage treated with intravitreal bevacizumab and aflibercept injections. CASE SUMMARY: A 42-year-old female patient presented with decreased visual acuity and a temporal visual field defect in the left eye. The patient had a history of retinal hemorrhage in the left eye 3 years prior, which improved without any treatment. The patient's visual acuity had decreased to 0.6 at the initial visit. On fundus examination, orange-colored elevated lesions involving the superior peripapillary area with massive subretinal hemorrhage extending to the macular area were revealed. Optical coherence tomography, fluorescein angiography, and B-scan ultrasonography results indicated CO complicated by choroidal neovascularization (CNV). With multiple intravitreal injections of bevacizumab and aflibercept (bevacizumab ×1, aflibercept ×2), the patient's visual acuity improved and the CNV lesion was kept stable without recurrence as of the 1-year follow-up visit. CONCLUSIONS: Intravitreal bevacizumab and aflibercept injections can be helpful in the treatment of CO complicated by CNV, by improving visual acuity and the retinal anatomy.

Characteristics of Polypoidal Choroidal Vasculopathy Associated with Subretinal Hemorrhage

PURPOSE: To evaluate the clinical features and risk factors of hemorrhagic complications in polypoidal choroidal vasculopathy (PCV) using spectral domain-optical coherence tomography (SD-OCT) and indocyanine green angiography (ICGA). METHODS: We respectively reviewed the data from 43 patients (45 eyes) diagnosed with PCV who received ICGA between January 2010 and October 2013. The patients were divided into 2 groups: 16 patients (17 eyes) with subretinal hemorrhage (subretinal hemorrhagic PCV group) and 27 patients (28 eyes) without subretinal hemorrhage (control group). Based on the ICGA and SD-OCT findings, the number, morphology, location, size of polyps, pigment epithelial detachment (PED), and serous retinal detachment (SRD) were measured and compared between the 2 groups. We also analyzed systemic diseases and history of antithrombotic agents associated with subretinal hemorrhage in PCV. RESULTS: The size of polyps measured by ICGA was significantly different between the 2 groups (p = 0.006). As the size of polyps increased, the size of subretinal hemorrhage, height of PED, base diameter and height of SRD increased (p 0.05). CONCLUSIONS: The patients in the subretinal hemorrhagic PCV group had larger-sized polyps than the patients in the control group. This result suggests that eyes with larger-sized polyps are at risk for hemorrhagic complications and require more careful follow-up and observation in PCV treatment-naive patients.

Characteristics of Polypoidal Choroidal Vasculopathy Associated with Subretinal Hemorrhage

PURPOSE: To evaluate the clinical features and risk factors of hemorrhagic complications in polypoidal choroidal vasculopathy (PCV) using spectral domain-optical coherence tomography (SD-OCT) and indocyanine green angiography (ICGA). METHODS: We respectively reviewed the data from 43 patients (45 eyes) diagnosed with PCV who received ICGA between January 2010 and October 2013. The patients were divided into 2 groups: 16 patients (17 eyes) with subretinal hemorrhage (subretinal hemorrhagic PCV group) and 27 patients (28 eyes) without subretinal hemorrhage (control group). Based on the ICGA and SD-OCT findings, the number, morphology, location, size of polyps, pigment epithelial detachment (PED), and serous retinal detachment (SRD) were measured and compared between the 2 groups. We also analyzed systemic diseases and history of antithrombotic agents associated with subretinal hemorrhage in PCV. RESULTS: The size of polyps measured by ICGA was significantly different between the 2 groups (p = 0.006). As the size of polyps increased, the size of subretinal hemorrhage, height of PED, base diameter and height of SRD increased (p 0.05). CONCLUSIONS: The patients in the subretinal hemorrhagic PCV group had larger-sized polyps than the patients in the control group. This result suggests that eyes with larger-sized polyps are at risk for hemorrhagic complications and require more careful follow-up and observation in PCV treatment-naive patients.

Submacular hemorrhage: A study amongst Indian eyes.

Aim: To evaluate the management outcomes amongst various treatment modalities for submacular hemorrhage (SMH) in Indian subjects. Settings and Design: Retrospective, single-center study. Materials and Methods: Patients presenting with SMH between 1999 and 2006 were included. Treatment modalities included: vitrectomy with subretinal recombinant tissue plasminogen activator (r-tPA) assisted SMH evacuation (group 1, n = 14); pneumatic displacement with intravitreal r-tPA and gas (group 2, n = 25); and pneumatic displacement with intraocular gas (group 3, n = 7). Favorable anatomical outcome was defined as complete displacement of SMH from fovea and favorable functional outcome was defined as a gain of >2 Snellen lines from the baseline. Kruskal–Wallis, analysis of variance (ANOVA), and Chi-square tests were used to compare the three groups, while Mann–Whitney and independent t-test were used to evaluate the influence of duration and size of SMH on outcomes. Results: There was no difference amongst groups in terms of favorable anatomical (P = 0.121) or functional outcomes (P = 0.611). Eyes with median duration of SMH less than 7.5 days had a significantly higher probability of achieving favorable anatomical outcome compared to eyes with SMH >14.5 days (P = 0.042). However, duration of SMH did not influence functional outcome (P = 0.595). Similarly, size of SMH did not affect anatomical (P = 0.578) or functional (P = 0.381) outcome. Median follow-up was 31.5, 6.5, and 2.5 months in the three groups, respectively. Conclusions: Co- existing posterior segment conditions and duration of SMH may influence the choice of treatment modality and treatment outcomes. Pneumatic displacement with r-tPA and r-tPA assisted vitrectomy appear to be favorable options for the management of SMH.

The Effect of Triple Therapy on Patients with Subretinal Hemorrhage Accompanied by Choroidal Neovascularization

PURPOSE: To presents the effect of triple therapy including C3F8 gas injection, intravitreal anti-VEGF injection and photodynamic therapy on patients with subretinal hemorrhage accompanied by choroidal neovascularization. METHODS: Twelve eyes of 12 patients suffering from subretinal hemorrhage accompanied by choroidal neovascularization with onset of the symptom within a week prior to three-day prone positioning after C3F8 gas injection were included in the present study. Next, intravitreal anti-VEGF injection and photodynamic therapy was performed. Then, within two months, intravitreal bevacizumab or ranibizumab injection was performed. RESULTS: After stabilization of the submacular hemorrhagic lesion, ten eyes of ten patients showed improved visual acuity, one eye showed no improvement, and decreased visual acuity developed in one patient. LogMAR visual acuity improved after the initial treatment from 1.05 +/- 0.43 to 0.74 +/- 0.58 and 0.53 +/- 0.51 at three and six months, respectively. The improvement was considered to be clinically significant. CONCLUSIONS: An appropriate regimen for treating broad submacular hemorrhage accompanied by choroidal neovascularization has not been established. The authors of the patients had obtained positive results from C3F8 gas injection, intravitreal anti-VEGF injection and photodynamic therapy. In the future, additional studies should be conducted.

Subretinal Hemorrhage After Photodynamic Therapy for Age-Related Macular Degeneration

PURPOSE: To evaluate the clinical features of subretinal hemorrhage after photodynamic therapy in eyes with exudative age-related macular degeneration. METHODS: We retrospectively reviewed data for 267 eyes of 243 patients who had undergone PDT for the treatment of ARMD between January 2005 and December 2006. Best corrected visual acuity, fundus photography, fluorescein angiography, and ICG angiography were performed before and after treatment. We followed up the patients at 1 week, 1 month, and 3 months after treatment and at 3-month intervals thereafter. RESULTS: Postoperative subretinal hemorrhage was seen in 36 (13.4%) of 267 eyes. The pretreatment and post-treatment mean visual acuities were logMAR 0.80 and logMAR 1.05 respectively, representing a decrease of 2.05 lines. On FAG, two eyes were predominantly classic, four eyes were minimally classic, and 30 eyes were occult. The laser irradiation spot size was under 3,000 micrometer in one case and from 3,000 micrometer to 5,000 micrometer in 19 cases and over 5,000 micrometer in 16 eyes. CONCLUSIONS: Subretinal hemorrhage after PDT for ARMD can be a common complication in patients who have been treated for larger irradiation spot sizes and for pigment epithelial detachment (PED), so doctors should be aware of the risk of serious hemorrhagic complications in such situations.

Two Cases of Intrapapillary Hemorrhage with Adjacent Peripapillary Subretinal Hemorrhage

PURPOSE: To report two cases of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH). METHODS: A 15-year-old boy and a 13-year-old girl who had sudden the sensation of floaters underwent ophthalmic examination including fundus examination, fundus photographs, fluorescein angiography, Goldmann visual field test, B-scan ultrasonography, and optical coherence tomography. RESULTS: Initial corrected visual acuities were 20/20 and 20/25. Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage was found upon fundus examination. Blocked fluorescence due to peripapillary subretinal hemorrhage was found by fluorescein angiography. Intrapapillary and peripapillary subretinal hemorrhage was spontaneously resolved without treatment in eight weeks later. CONCLUSIONS: Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH) is a benign and self limiting disease. It is important to diagnose and differentiate IHAPSH from the other diseases.

A Case of Recurrent Valsalva Retinopathy Associated with Exercising a Barbell

PURPOSE: To report one case of recurrent Valsalva retinopathy presented as subretinal hemorrhage associated with exercising a barbell in a healthy man. METHODS: A 47-year-old healthy man visited our hospital complaining of a pericentral blind-spot in the right visual field. At first visit, visual acuity was 20/20 without correction. Anterior segment examination was unremarkable and dilated fundus examination revealed a subretinal hemorrhage in the inferior area of the macula. We followed up the visual acuity, anterior segment exam, fundus examination, and fluorescein angiography for several weeks. RESULTS: Three weeks after the first visit, the size of subretinal hemorrhage decreased, but recurrent subretinal hemorrhage presented after exercising a barbell at the existing hemorrhagic part and its inferior area. Six weeks after the recurrent hemorrhage, the hemorrhage was resolved completely and the pericentral blind-spot was recovered. CONCLUSIONS: Valsalva hemorrhagic retinopathy is characterised by retinal hemorrhage occurring in healthy individuals due to a rapid rise in intrathoracic or intra-abdominal pressure. In this case, there was recurrent subretinal hemorrhage after repeatedly exercising a barbell. So, it is very important to educate patients about the restriction of excessive Valsalva maneuver to prevent recurrent Valsalva retinopathy.

Unilateral Idiopathic Maculopathy

This is a report of five patients who experienced slow, severe, unilateral central vision loss without a history of any other systemic illness. All patients were female and the age of the patients ranged from 21 to 33 years, with a mean age of 27 years. The follow-up period was 1 to 3 years. Each patient had a small yellowish spot in the fovea, which was associated with subretinal or retinal hemorrhage. No inflammatory cells were found in the vitreous or anterior chamber. Most patients presented with a visual acuity of 0.3 to 0.6. In one patient, the presenting visual acuity was 1. 0. Each patient described a central scotoma which was confirmed by Amsler`s grid test. The presenting manifestations of the disorder did not progress or recur in any of these patients during the period of follow-up. Visual acuity recovered to the visual acuity of the initial visit in three of five patients. The fluorescein angiogram revealed the early hyperfluorescence in the spot of the fovea which remained the same through the late phase. Three of five patients demonstrated a neurosensory detachment of the macula usually with irregular margins. The spot of the fovea showed hypofluorescence on the indocyanine green angiography. No hyperfluorescence in the center of the macula was found on the ICG-A. To the best of our knowledge, this unique clinical entity does not seem to be consistent with any previously described maculopathies in its clinical, angiographic features, and its natural course.

Macroaneurysms of Retinal Arteries

Two patients with spontaneous intraretinal or subretinal hemorrhages were found, on evaluation by fluorescein angiography, to have macroaneurysms involving the major retinal arteries. Both patients were male in their seventies. One patient had a history of systemic hypertension. In the other patient, hypertension was discovered at the time of consultation. With absorption of the hemorrhage and the macular star, two patients experienced appreciable improvement in vision. Laser thrapy was not applied to both patients. The aneurysms diminished in size after 6 to 8 months as a result of fibrous changes within the arterial walls.

Subretinal Hemorrhages in High Myopia

Ocular changes such as crescents, posterior staphyloma, retinochoroidal degeneration, lacquer cracks and subretinal or choroidal hemorrhage are common In myopia. We examined 13 patients(13 eyes) who had refractive errors of -6.0 Diopter or more and subretinal hemorrhages at initial visit. According to fluorescein angiographic finding, subretinal hemorrhages in high myopia were divided into two groups: 6 eyes without choroidal neovascularization(CNV) and 7 eyes with choroidal neovascularization. Subretinal hemorrhage without choroidal neovascularization was frequent in patients aged 15-32 years(mean, 23.7 years) and choroidal neovascularization was common in patients aged 34-60 years(mean 47.6 years). In the eyes without choroidal neovascularization, the subretinal hemorrhage disappeared spontaneously after a few months and the visual acuity of these patients was variable at the initial visit(range, 5/200-20/30), and was unchanged or improved during the follow-up period. In the eyes with choroidal neovascularization, the visual acuity was less than 0.1 at the initial visit, except 2 cases, and was unchanged or worsened during the follow-up peroid. It will be helpful to divide the high myopia with subretinal hemorrhage into with or without choroidal neovasculrization according to the flourescein angiography to assess the prognosis.

The Surgical Removal of Macular Subretinal Hemorrhage

Subretinal hemorrhage affecting the macula may occur secondary to a variety of etiologies and often results in significant visual loss. Recently, we removed five subretinal hemorrhage affecting the macula by means of vitrectomy combined with the use of tissue plasminogen activator(20-40ug) to facilitate clot removal throught a small retinotomy. Mean follow up period was 7 months. The significant visual improvement(defined as 2 lines) was achieved in 4 of 5 eyes. The postoperative complications were retinal detachment(1 eye), macular fold(1 eye) and recurrent retinal membrane(1 eye). These results suggested that subretinal hemorrhage affecting the macula can be surgically removed with improvement of central vision.

Tissue Plasminogen Activator for Treatment of Subretinal Hemorrhage

We report removing a large subretinal hemorrhage by means of vitrectomy combined with the use of tissue plasminogen activator(tPA) to facilitate clot removal. A 25-year-old man had a 4 days history of visual loss in the right eye after blunt trauma. The right fundus had a large subretinal hemorrhage involving macula. Surgery was performed the following day. A small retinotomy was made, through which tPA was injected into the subretinal space and through which the dissolved clot was removed. The use of tPA minimizes surgical manipulation of the retina and greatly reduces the size of the retinotomy reguired for evacuation of subretinal bood. Although the long-term prognosis is guarded, this case does suggest that tPA may be a useful adjunct in managing of subretinal hemorrhage.

The Effects of Surgical Intrvention on Experimental Subretinal Hemorrhage in the Rabbit

In order to simulate the hemorrhagic detachment stage of disciform macular degeneration, fresh blood was injected into the subretinal space of albino rabbits. In control group, the natural course of subretinal hemorrhage was studied with the ophthalmoscope and by electron microscopy. In experimental group, to study the effect of surgical intervention of the subretinal hemorrhage, a retinotomy was performed at the edge of the detached retina and the subretinal blood was removed by aspiration. And then the histopathologic change of the retina was exam ined by electron microscopy in both groups preceded by the ophthalmoscopic examination. In control group, between 12 hours and 4 days, there was partial damage of the photoreceptor cells characterized by destruction of the outer segment and swelling of mitochondria of the inner segment. In seven days after injection, irreversible retinal destruction was observed. In experimental group, two days after removal of subretinal hemorrhage in two hours following subretinal injection of blood, the outer segment was lost and destructed. Two days after removal of subretinal hemorrhage in five days following subretinal injection of blood, hydropic swelling and vacuolization of visual cells were characteristic. However there was no significant difference in the histopathologic change of retina between two groups.