One year of follow-up of massive retinal hemorrhage complicating age-related macular degeneration treated with intravitreal injection of recombinant tissue Plasminogen Activator (rtPA), aflibercept and pneumatic displacement.

Author: Juan Marín Nieto (Spain)

Co-authors: Juan Yanguas Lucena, Victoria Segura Fernández-Noguera

Purpose

Massive retinal hemorrhage is a rare complication in age-related macular degeneration (AMD) and it usually implies a poor visual outcome due to the devastating damage the blood provokes in the photoreceptors layers within just a few days. There is a lack of knowledge about which is the best treatment for this as massive hemorrhages have usually been a reason for exclusion from studies about anti-Vascular Endothelial Growth Factor (antiVEGF) efficacy. There are many approaches to manage this complication but two of them stand out from others: performing pars plana vitrectomy and placing recombinant tissue Plasminogen Activator (rtPA) in the subretinal space through a hole practiced in the retina as well as provoking pneumatic displacement with injection of air also in the subretinal space followed by an intravitreal injection of antiVEGF (the manipulation of the retina during this procedure increases the risk of latter complications). The other approach is more conservative: it does not imply performing any vitrectomy but putting an intravitreal injection of rtPA followed by an intravitreal injection of aflibercept (Eylea ® ) and air to allow pneumatic displacement. Here we present a case treated with the latter approach as well as the outcome after a year of follow-up.

Setting/Venue

Tertiary level hospital. Retina department.

Methods

A case report. A 70-year-old Caucasian woman attended the Emergency Room of Ophthalmology due to loss of vision in her left eye (LE); this symptom appeared suddenly two days ago. The best corrected visual acuity in that eye was hand movements (logMAR > 1) whereas it was 20/20 (logMAR = 0) in the right eye (RE). No pathological signs were observed in the anterior segment in either of the two eyes. The intraocular pressure (IOP) was 15mmHg. The LE fundus examination revealed the presence of a massive intraretinal hemorrhage (sub-retinal pigment epithelium [sub-RPE] and sub-retinal bleeding) that spreads from the superior temporal artery branch to the inferior one; the central macular thickness (CMT) was 534 μm. In the fundus examination, the RE showed drusen of medium size and some areas of hypopigmentation. A treatment based on intravitreal injection of 0.1 mL rtPA, 0.05mL of aflibercept and air was started. Following this, the patient has to stay in complete rest and sit down for 48 hours to enable the pneumatic displacement of the blood downwards. 500mg of acetazolamide were given to the patient 30 minutes before the procedure. Once the injections were applied, the patient followed a regime of treat-and-extend.

Results

A week after the treatment was applied, there was a displacement of the hemorrhage to the inferior retina but the fovea was still affected by sub-RPE and sub-retinal residual blood (CMT= 405 μm). IOP=19mmHg. The visual acuity in the LE was 1/10 (LogMAR=1). Three weeks latter, the blood decreased notably (CMT=324μm). The vision was still 1/10 (LogMAR = 1). Following a regime of Treat and Extend, another injection of aflibercept (Eylea ® ) was given. No complication was found. In the second and third month, most of the blood has been displaced to the inferior part of the retina. A minimum rest of hemorrhage is found still in the macula (CMT= 300μm). The vision acuity has improved to 3/10 (LogMAR = 0.5). In the sixth month, most of the blood has disappeared, but there are still changes in the sub-RPE space (CMT=254μm). Visual acuity was 5/10 (LogMAR = 0.3). A year after the patient attended the Emergency Room an alteration in the external layers of the retina was found (CMT=218μm), the visual acuity was still 5/10, the patient was attending intravitreal injections every 8 weeks at that moment and there were not any new complications or bleeding reported.

Conlusions

With this conservative management, an improvement in the visual acuity is reached within a few months. The main advantage of this type of treatment is that there is no need to perform a vitrectomy, it can be applied on the same day the patient attends the emergency room as there is no need of an available operating room and the complications are few and rare and can be avoided by giving a prophylactic acetazolamide.

Financial Disclosure

Neither of the authors have financial relations.