Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage of both eyes after COVID-19 infection: a case report.

BACKGROUND: Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage is commonly observed in myopia with tilted optic disc. It presents with typical features on the fundus and follows a self-limiting course. However, due to its complex etiology, clinicians sometimes lack sufficient understanding of it which can easily lead to misdiagnosis or overtreatment. In this case report, we describe a rare case of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage in both eyes. CASE PRESENTATION: An 18-year-old female who has no past medical history experienced sudden black shadow blocking of her right eye in the right eye for the past 2 days after a 5-day history of COVID-19 infection. The best corrected visual acuity is 0.5 in the right eye and 0.6 in the left eye. Optical coherence tomography (OCT) showed tilted optic discs in both eyes, bulged nasal optic discs, and the presence of strong reflective material under the parafoveal retina of the optic discs. Fundus fluorescein angiography (FFA) showed subretinal fluorescence occlusion above and nasolateral to the optic disc in the right eye, with hypofluorescence below the optic disc; the subretinal below the optic disc was obscured by vitreous hemorrhage; hypofluorescence was seen in the optic disc region of the left eye.COVID-19 antigen was positive. The patient was in the early stage of the third COVID-19 infection when the disease occurred. We speculate that it may be related to it. After 5 months of conservative treatment, the patient's hemorrhage disappeared in both eyes and her best corrected visual acuity returned to normal. CONCLUSIONS: Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage usually occurs in myopia with tilted optic disc. In most patients, the cause of the bleeding is unknown, but it can gradually resolve under clinical observation or conservative treatment.

[Survey on blood thinning therapy in patients with age-related macular degeneration]. / Umfrage zur blutverdünnenden Therapie bei Patienten mit altersabhängiger Makuladegeneration.

BACKGROUND: Patients with age-related macular degeneration (AMD) often receive concomitant systemic blood thinning medications. These are known to increase the risk of severe hemorrhage also in connection with AMD, which can lead to extensive subretinal hemorrhaging. OBJECTIVE: The purpose of this study was to investigate the proportion of patients with AMD and concomitant blood thinning treatment, including the type and reason for blood thinning treatment. METHODS: This survey was prospectively conducted at the University Eye Hospital, Bonn, Germany. Volunteers were recruited during retinal consultations and the consultations for intravitreal injections (IVOM). RESULTS: The questionnaire was completed by 178 patients. The mean age was 81.7 years (58-100) and 101 patients (57.7%) were undergoing blood thinning treatment. The majority of patients were taking antiplatelet agents (n = 59; 58.4%), especially ASA (n = 55; 54.5%). Direct oral anticoagulants (DOAC) were taken by 33 patients (32.7%), including most frequently apixaban (17.8%). Vitamin K antagonists (VKA) was taken by 4 patients (4%). The most common reason for blood thinning treatment was atrial fibrillation (n = 32, 31.7%), followed by stent implantation (n = 20, 19.8%) and stroke (n = 12, 11.9%) but 13 patients (12.9%) did not know why they were undergoing blood thinning treatment. No clear indications for the use of blood thinners were found in 31 patients (30.7%). CONCLUSION: A large proportion of patients with AMD undergo blood thinning treatment; however, not every patient has a clear indication. Due to the increased risk of bleeding, the use of blood thinners should be critically evaluated in close cooperation with primary care physicians and cardiologists.

Full-Thickness Macular Hole Caused by Acute Subretinal Hemorrhage From Wet Age-Related Macular Degeneration.

Purpose: To present a case of full-thickness macular hole (MH) that developed in association with acute subretinal hemorrhage from wet age-related macular degeneration (AMD). Methods: A retrospective observational review of a single case was performed. Results: An 84-year-old man with wet AMD presented with central vision loss and floaters and was noted to have a subretinal hemorrhage and an associated MH, which subsequently progressed to MH-associated macular detachment. The patient had a pars plana vitrectomy with internal limiting membrane peeling, gas tamponade, and prone positioning, resulting in closure of the MH and improvement in visual acuity. Conclusions: A full-thickness MH developed as a result of foveal dehiscence from an acute hemorrhage caused by choroidal neovascularization in wet AMD.

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.

[Diagnostic and treatment options for retinal arterial macroaneurysms in relation to our cases]. / Retinalis artéria macroaneurysmák diagnosztikai és kezelési lehetoségei eseteink kapcsán.

In our report, we present the history of four patients diagnosed with retinal arterial macroaneurysm associated with complications. Our aim is to present the varied appearance of the disease and to present the various therapeutic options. Retinal artery macroaneurysm is a rare, but potentially vision-threatening ophthalmic condition. Macroaneurysm develops from the arteriosclerotic transformation of the artery caused by high blood pressure. Macroaneurysms can be asymptomatic, or they can be associated with exudative or hemorrhagic complication which causes visual impairment. Depending on the symptoms, they can be treated with laser photocoagulation, intravitreal injections, or with vitrectomy. Our presented cases also illustrate that each case requires individual consideration because a uniform therapeutic recommendation is still yet to be developed. In addition to the ophthalmic treatment, it is extremely important to refer the patient to internal medicine. Orv Hetil. 2023; 164(42): 1673-1677.

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.

Efficacy of Simultaneous Application of Subretinal Tissue Plasminogen Activator and Bevacizumab for Submacular Hemorrhages.

Objectives: The aim of the study was to evaluate the patients who received simultaneous subretinal tissue plasminogen activator (tPA) and bevacizumab for submacular hemorrhages secondary to neovascular age-related macular degeneration. Methods: This retrospective study included patients who underwent pars plana vitrectomy (PPV) with simultaneous subretinal tPA and subretinal bevacizumab with 18% SF6 tamponade. Anatomical and functional results of the patients before surgery and at the 1st, 6th, and 12th months after surgery, additional treatments, and complications after PPV were evaluated. Results: Eight eyes of eight patients were included in the study. The mean age of the patients was 72.38±92.3. The mean time from the onset of symptoms to treatment was 5.13±1.88 days. The patients' mean best-corrected visual acuity (BCVA) was 2.23±0.14 logMAR at baseline. Mean BCVA increased significantly at 1st, 6th, and 12th months to 1.68±0.47 logMAR, 1.58±0.49 logMAR, and 1.51±0.58 logMAR, respectively (p=0.001 at all). The mean central foveal thickness (CFT) in measurable patients was 836.8±627.02 µm at baseline. Mean CFT decreased significantly to 370.13±66.13 µm in the 1st month, 373.38±78.33 µm in the 6th month, and 367.75±116.43 µm in the 12th month (p<0.05). The maximum measurable subretinal hemorrhage height at baseline was 814.2±556.45 µm. The mean number of anti-VEGFs performed for 12 months after surgery was 4.13±2.1. At month 12, the ellipsoid zone could not be detected in 6 (75%) patients. Conclusion: Administration of subretinal bevacizumab and subretinal tPA effectively removes subretinal hemorrhage under the fovea. Intravitreal anti-VEGF treatment must be continued, as choroidal neovascular membrane activity continues after surgery.

Unusual Presentation of Skin Tattoo-Associated Panuveitis.

AIM: We report a case of a young male who developed bilateral panuveitis after extensive tattooing. DESIGN: Case report. METHODS: A 22-year-old male with a history of inflamed tattoos presented with pain in both eyes and blurred vision in the left eye. Clinical examination showed ciliary congestion, flare, vitreous cells in both eyes, and posterior synechiae in the left eye. Optic nerve was swollen in both eyes. OCT scans demonstrated subretinal blood, associated with neurosensory macular detachment in the left eye. The skin tattoo biopsy showed a granulomatous inflammation without evidence of sarcoidosis. Long-term corticosteroid therapy allowed a regression of clinical signs and symptoms with full recovery. CONCLUSION: TAttoo Granulomas with Uveitis (TAGU) is a syndrome with numerous clinical presentations. In our case, optic nerve head oedema and subretinal hemorrhage at the posterior pole were the presentation signs. Ophthalmologists should always consider TAGU as a diagnosis in patients with a history of inflamed tattoos.

Visual acuity outcome in patients with subretinal hemorrhage - office procedure vs. surgical treatment.

PURPOSE: To evaluate the effects of intravitreal injection of tissue plasminogen activator (tPA) and gas vs. pars plana vitrectomy (PPV) surgery as first-line treatment for subretinal hemorrhage. METHODS: Retrospective study of 107 adults treated for subretinal hemorrhage at a tertiary hospital during 2008-2019; 51 received injection of tPA and gas and 56 underwent PPV. RESULTS: No between-group differences were found in age and sex, medical history, use of anticoagulants or antiplatelets, history of ocular surgeries, and previous use of intravitreal anti-VEGF. Overall follow-up time was longer in the PPV group (median 4.9 vs 3.28 years, p = 0.005). The hemorrhage was displaced in a similar percentage of patients in the tPA-and-gas group (n = 40, 78.4%) and the PPV group (n = 45, 80.4%) (p = 0.816). Approximately 80% of patients in the tPA-and-gas group were able to forgo PPV surgery. Visual acuity (in LogMAR) was similar in the two groups prior to the diagnosis of subretinal hemorrhage but better in the tPA-and-gas group at the end of follow-up (p < 0.001). CONCLUSION: Injection of gas and tPA can be done immediately following diagnosis of subretinal hemorrhage as an office procedure. Visual acuity outcome is good, with a high rate of blood displacement. About 20% of patients might require additional PPV as secondary intervention.

Características clínicas de la coriorretinopatía exudativa hemorrágica periférica en un centro de referencia en España / Clinical characteristics of peripheral exudative hemorrhagic chorioretinopathy in a referral center in Spain

Objetivo: Publicar las características clínicas de la coriorretinopatía exudativa hemorrágica periférica (CEHP) en la población española. Métodos: Estudio retrospectivo y análisis de los resultados en pacientes con diagnóstico de CEHP. Fueron recogidas las características clínicas, por OCT, el tratamiento utilizado y la evolución posterior al tratamiento. Resultados: Se evaluaron 39 ojos de 23 pacientes con CEHP. La edad promedio al diagnóstico fue de 79 años (66-94 años). El síntoma ocular principal fue la disminución de visión en 26 ojos (66,6%), siendo 11 ojos (28,2%) asintomáticos. El diagnóstico de referencia más frecuente fue sangrado/exudación en 24 ojos (61,5%), le siguió melanoma coroideo con 9 (23,1%). Las hemorragias intra o subretinianas fueron el tipo de lesión periférica más frecuentemente encontrado, en 24 ojos (61,5%). Veinticinco ojos (58,9%) recibieron algún tipo de tratamiento: A 15 ojos (60%) se les realizó inyección intravítrea (IIV) de antioangiogénicos (anti-VEGF); se realizó fotocoagulación con láser en 2 casos (8%), terapia fotodinámica en 2 casos (8%) y 6 casos (18,2%) precisaron vitrectomía vía pars plana (VPP) por hemorragia vítrea. No hubo cambios en la agudeza visual (AV) en los pacientes seguidos con observación entre el inicio 0,66±0,80 (0,04-2,82) y el fin de seguimiento 0,75±0,96 (0,00-2,82) (p=0,352), ni para los que recibieron algún tipo de tratamiento entre inicio 0,78±0,79 (0,04-2,30) y fin 1,22±1,01 (0,04-2,82) (p=0,157), posiblemente debido al gran componente de degeneración macular asociada con la edad (DMAE) atrófica o exudativa presente en ambos grupos (29 ojos presentaron DMAE atrófica o exudativa). Conclusiones: La CEHP es una enfermedad poco frecuente, asociada frecuentemente con DMAE, que se presenta típicamente como una masa periférica que se confunde frecuentemente con melanoma...(AU)

Objective: To publish the clinical characteristics of peripheral exudative hemorrhagic chorioretinopathy (PHEC) in the Spanish population. Methods: Retrospective study and analysis of results in patients diagnosed with PHEC. The clinical characteristics, by OCT, the treatment used and the evolution after treatment were collected. Results: 39 eyes of 23 patients with PHEC were evaluated. The average age at diagnosis was 79 years (66-94 years). The main ocular symptom was low vision in 26 eyes (66.6%); only 11 eyes (28.2%) were asymptomatic. The most frequent referred diagnosis was bleeding/exudation in 24 eyes (61.5%), followed by choroidal melanoma in 9 (23.1%). Intra or subretinal hemorrhages were the type of peripheral lesion most frequently found, in 24 eyes (61.5%). Twenty-five eyes (58.9%) received some type of treatment: 15 eyes (60%) underwent intravitreal injection (IIV) of antiangiogenic agents (anti-VEGF); Laser photocoagulation was performed in 2 cases (8%), Photodynamic therapy in 2 cases (8%) and 6 cases (18.2%) required pars plana vitrectomy (PPV) due to vitreous hemorrhage. There were no changes in visual acuity (VA) in patients followed with observation between baseline 0.66±0.80 (0.04-2.82) and end of follow-up 0.75±0.96 (0.00-2.82) (P=.352), nor for those who received some type of treatment between the beginning 0.78±0.79 (0.04-2.30) and the end 1.22±1.01 (0.04-2.82) (P=.157), possibly due to the large component of atrophic or exudative age-related macular degeneration (AMD) presented in both groups. (29 eyes presented atrophic or exudative AMD). Conclusions: PHEC is a rare pathology, frequently associated with AMD, which typically presents as a peripheral mass that is frequently confused with choroidal melanoma and other intraocular tumors and hence the importance of learning to identify it, making the correct differential diagnosis and avoid unnecessary treatments. Antiangiogenic therapy is effective in most patients with...(AU)

[PEHCR-Peripheral exudative hemorrhagic chorioretinopathy: Diagnosis and treatment]. / PEHCR ­ periphere exsudative hämorrhagische Chorioretinopathie: Erkennen und behandeln.

Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare degenerative chorioretinal disease with subretinal or subepithelial hemorrhage and exudation in the fundus periphery in older patients. Even though it is the second most common entity among pseudomelanomas and its characteristic features simplify diagnosis, PEHCR is often not recognized and therefore misdiagnosed. In most cases stabilization or regression spontaneously occur. Therefore, treatment for PEHCR should be cautiously selected when function is good and surgical intervention should be preferably considered when visual loss is imminent.

Vitrectomy with subretinal tissue plasminogen activator (r-TPA) and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) for submacular hemorrhages treatment: Retrospective analysis of 22 cases.

BACKGROUND: Macular hemorrhages are a severe complication of other retinal pathologies, such as age-related macular degeneration (AMD) or macroaneurysms. Their therapeutic approach is not standardized, and can vary from observation to surgical treatment. MATERIAL AND METHODS: Retrospective analysis of 22 cases of macular hemorrhage, treated with vitrectomy associated to subretinal rTPA and intravitreal anti-VEGF over a period of 5 years. RESULTS: 22 eyes of 22 patients were included, of which 12 (52%) were women. The mean age at diagnosis was 84.4 years. 13 patients were pseudophakic (54.1%) and 19 (86.36%) had previous ophthalmological comorbidities. The etiology of the macular hemorrhage was AMD in 19 patients (86.36%). The mean of best VA corrected at diagnosis was 24.55 (Early Treatment Diabetic Retinopathy Study score -ETDRS), with a statistically significant improvement to 36.78 3 months after surgery (p = 0.011). With an average of 23.5 months of follow-up, no differences in prognosis associated with the etiology or size of the hemorrhage were observed. CONCLUSION: The treatment of macular hemorrhages by vitrectomy, subretinal rTPA and antiVEGF improves the visual prognosis of affected patients.

Clinical characteristics of peripheral exudative hemorrhagic chorioretinopathy in a referral center in Spain.

OBJECTIVE: To publish the clinical characteristics of peripheral exudative hemorrhagic chorioretinopathy (PHEC) in the Spanish population. METHODS: Retrospective study and analysis of results in patients diagnosed with PHEC. The clinical characteristics, by OCT, the treatment used and the evolution after treatment were collected. RESULTS: 39 eyes of 23 patients with PHEC were evaluated. The average age at diagnosis was 79 years (66-94 years). The main ocular symptom was low vision in 26 eyes (66.6%); only 11 eyes (28.2%) were asymptomatic. The most frequent referred diagnosis was bleeding/exudation in 24 eyes (61.5%), followed by choroidal melanoma in 9 (23.1%). Intra or subretinal hemorrhages were the type of peripheral lesion most frequently found, in 24 eyes (61.5%). Twenty-five eyes (58.9%) received some type of treatment: 15 eyes (60%) underwent intravitreal injection (IIV) of antiangiogenic agents (anti-VEGF); Laser photocoagulation was performed in 2 cases (8%), Photodynamic therapy in 2 cases (8%) and 6 cases (18.2%) required pars plana vitrectomy (PPV) due to vitreous hemorrhage. There were no changes in visual acuity (VA) in patients followed with observation between baseline 0.66±0.80 (0.04-2.82) and end of follow-up 0.75±0.96 (0.00-2.82) (P=.352), nor for those who received some type of treatment between the beginning 0.78±0.79 (0.04-2.30) and the end 1.22±1.01 (0.04-2.82) (P=.157), possibly due to the large component of atrophic or exudative age-related macular degeneration (AMD) presented in both groups. (29 eyes presented atrophic or exudative AMD) CONCLUSIONS: PHEC is a rare pathology, frequently associated with AMD, which typically presents as a peripheral mass that is frequently confused with choroidal melanoma and other intraocular tumors and hence the importance of learning to identify it, making the correct differential diagnosis and avoid unnecessary treatments. Antiangiogenic therapy is effective in most patients with an active phase (exudative/hemorrhagic) into leading to fibrosis of peripheral hemorrhagic areas.

Vitrectomía asociada a activador tisular del plasminógeno (rTPA) subretiniano e inyección intravítrea de anti-VEGF como tratamiento de hemorragias submaculares: análisis retrospectivo de 22 casos / Vitrectomy with subretinal tissue plasminogen activator (r-TPA) and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) for submacular hemorrhages treatment: Retrospective analysis of 22 cases

Introducción: Las hemorragias maculares suponen una complicación severa de otras patologías retinianas, como la degeneración macular asociada a la edad (DMAE) o los macroaneurismas. El abordaje terapéutico de las mismas no se encuentra estandarizado, pudiendo variar desde la observación hasta el tratamiento quirúrgico.Material y métodosAnálisis retrospectivo de 22 casos de hemorragia macular, tratados mediante vitrectomías asociada a rTPA subretiniano y antiVEGF intravítreo durante un período de cinco años.ResultadosSe incluyeron 22 ojos de 22 pacientes, de los que 12 (52%) eran mujeres. La edad media al diagnóstico fue de 84,4 años. Del total de pacientes, 13 eran pseudofáquicos (54,1%) y 19 (86,36%) presentaban comorbilidades oftalmológicas previas. La etiología de las hemorragias maculares fue DMAE en 19 pacientes (86,36%). La media de mejor agudeza visual (AV) corregida al diagnóstico fue de 24,55 (puntuación Early Treatment Diabetic Retinopathy Study - ETDRS), con una mejoría estadísticamente significativa a 36,78 a los tres meses de la cirugía (p=0,011). Con un promedio de 23,5 meses de seguimiento, no se observaron diferencias en el pronóstico asociadas a etiología o tamaño de la hemorragia.ConclusiónEl tratamiento de las hemorragias maculares mediante vitrectomía, rTPA subretiniano y antiVEGF mejora el pronóstico visual de los pacientes afectos. (AU)

Background: Macular hemorrhages are a severe complication of other retinal pathologies, such as age-related macular degeneration (AMD) or macroaneurysms. Their therapeutic approach is not standardized, and can vary from observation to surgical treatment.Material and methodsRetrospective analysis of 22 cases of macular hemorrhage, treated with vitrectomy associated to subretinal rTPA and intravitreal anti-VEGF over a period of 5 years.Results22 eyes of 22 patients were included, of which 12 (52%) were women. The mean age at diagnosis was 84.4 years. 13 patients were pseudophakic (54.1%) and 19 (86.36%) had previous ophthalmological comorbidities. The etiology of the macular hemorrhage was AMD in 19 patients (86.36%). The mean of best VA corrected at diagnosis was 24.55 (Early Treatment Diabetic Retinopathy Study score -ETDRS), with a statistically significant improvement to 36.78 3 months after surgery (p = 0.011). With an average of 23.5 months of follow-up, no differences in prognosis associated with the etiology or size of the hemorrhage were observed.ConclusionThe treatment of macular hemorrhages by vitrectomy, subretinal rTPA and antiVEGF improves the visual prognosis of affected patients. (AU)

Analysis of optic disc tilt angle in intrapapillary hemorrhage adjacent to peripapillary subretinal hemorrhage using swept-source optical coherence tomography.

Purpose: To report findings on the tilt angle of optic nerve heads (ONHs) that developed intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH) using swept-source optical coherence tomography (SS-OCT). Observations: Five consecutive patients who presented with IHAPSH were reviewed retrospectively. We reviewed five consecutive eyes from the five patients, analyzed the optic tilt angle obtained from SS-OCT B-scans, and compared the results and other clinical characteristics. All patients had larger optic disc tilt angles in the eyes with IHAPSH than in the contralateral, unaffected eye. The mean ratio of the tilt angle in the eyes with IHAPSH to that in the contralateral eye was 1.37 (95% confidence interval 1.15-1.58). Conclusions and Importance: The ONH of IHAPSH was evaluated quantitatively with SS-OCT for the first time in this study. Larger angle tilted discs in IHAPSH-affected eyes are anatomically and histologically more vulnerable and may explain why IHAPSH develops monocularly.

Development of subretinal hemorrhage after treatment discontinuation for neovascular age-related macular degeneration and polypoidal choroidal vasculopathy.

PURPOSE: To investigate the incidence, risk factors, and their influence on visual outcomes of subretinal hemorrhage (SRH) in patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy(PCV) who discontinue treatment. METHODS: This retrospective study included 148 patients with nAMD and PCV who discontinued treatment. The development of a 3-disc area or greater extent of SRH after treatment discontinuation was identified. Visual acuity at the final visit was compared between patients with and those without SRH. Factors associated with SRH were then analyzed. RESULTS: During the mean 56.8 ± 18.2 months of follow-up, treatment was discontinued at a mean 24.1 ± 16.3 months after diagnosis. SRH developed in 24 (16.2%) patients at a mean 21.5 ± 17.6 months after treatment discontinuation. The visual acuity at the final follow-up was significantly worse in patients with SRH than in those without SRH (P < 0.001). There was a significant difference in the incidence of SRH among the different types of macular neovascularization (MNV) (P = 0.024). In particular, the incidence of type 3 MNV was relatively high (36.0%). CONCLUSIONS: The development of SRH may lead to very poor visual prognosis in patients who discontinue treatment. The high risk of SRH in type 3 MNV suggests the need for caution when choosing treatment discontinuation in cases of type 3 MNV.

Displacement of submacular hemorrhage with intravitreal tissue plasminogen activator following 27 gauge transvitreal fine needle aspiration biopsy for choroidal melanoma.

PURPOSE: To describe the management of submacular hemorrhage (SMH), a vision threatening complication following transvitreal choroidal biopsy, with intravitreal tissue plasminogen activator (tPA) and pure perfluoropropane (C3F8) gas bubble injection. OBSERVATIONS: A 53 year old female with choroidal melanoma of the left eye underwent iodine-125 plaque brachytherapy placement and 27 gauge transvitreal fine needle aspiration choroidal biopsy for gene expression profiling. On postoperative day 2, large SMH was identified on dilated fundus examination. At the time of plaque brachytherapy removal, intravitreal tPA and pure C3F8 gas bubble injection with post operative positioning was also performed to attempt displacement of SMH. At postoperative month 1 following tPA and gas bubble displacement, the SMH was completely displaced inferotemporally outside of the macula and visual acuity improved from 20/70 at postoperative week 1 to 20/25 at postoperative month 1. CONCLUSIONS AND IMPORTANCE: Subretinal hemorrhage can be a complication of transvitreal choroidal tumor biopsy but early detection and prompt treatment can result in good visual outcomes.

Rescue photodynamic therapy for age-related macular degeneration refractory to anti-vascular endothelial growth factor monotherapy.

BACKGROUND: To evaluate the 3-year outcome in eyes with neovascular age-related macular degeneration (nAMD) treated with intravitreal anti-vascular endothelial growth factor monotherapy or rescue therapy using standard verteporfin photodynamic therapy (PDT), and corroborate efficacy of rescue PDT. METHODS: Patients were administered aflibercept injections once a month for 3 months followed by once every 2 months in the first year. After year 1, treatment with aflibercept monotherapy as indicated or in combination with PDT at the retinal specialist's discretion. Only cases completing the three-year follow-up were included. Regression analysis with visual acuity and macular atrophy at year 3 was performed for the dependent variable. RESULTS: Of the 292 eyes, 15 eyes underwent rescue PDT following year 1. The best-corrected visual acuity (logarithm of minimal angle of resolution, mean/Snellen equivalent ± SD) was 0.35 (20/45) ± 0.38, 0.23 (20/30) ± 0.36, 0.26 (20/35) ± 0.38, and 0.31 (20/40) ± 0.42 at baseline, year 1, year 2, and year 3, respectively. Multiple regression analysis revealed that the rescue PDT was significantly associated with macular atrophy and poor visual outcome at year 3 (odds ratio = 1.2, p < 0.001; ß = 0.23, p = 0.0029, respectively). CONCLUSIONS: The visual outcome in eyes with nAMD retained baseline levels at year 3; however, patients treated with rescue PDT developed macular atrophy more frequently and poor visual outcomes.

Subretinal Hemorrhage Complicating Retinal Angiomatous Proliferation in Tubercular Retinal Vasculitis.

PURPOSE: To report a patient with submacular hemorrhage due to retinal angiomatous proliferation (RAP) in tubercular retinal vasculitis (TRV). METHODS: Case report. RESULTS: We report a 33-year-old Asian Indian patient of TRV presenting with capillary non-perfusion areas, submacular hemorrhage and venous loops. The patient presented with sudden onset decrease in vision in the right eye. Multimodal imaging revealed presence of retinal vascular anastomosis and stage 2 RAP. Systemic examination was within normal limits. Laboratory evaluation revealed positive Mantoux and interferon gamma release assay. He underwent right eye intravitreal injection of recombinant tissue plasminogen activator (12.5µg/0.1ml) with 100% sulphur hexafluoride (SF6) tamponade. The patient had successful displacement of the submacular hemorrhage with some improvement in visual acuity. CONCLUSION: This case highlights that rare vascular alterations such as RAP can develop in subjects with ocular tuberculosis.