Author: Karina Spiess (United Kingdom)
Co-authors: Mostafa Elgohary
To describe management and outcome of surgical treatment of massive haemorrhagic retinal detachment (HRD) in patients with neovascular (wet) age-related macular degeneration (wAMD).
Vitreoretinal Service, The Royal Eye Unit, Kingston Hospital, Kingston-upon-Thames (United Kingdom)
This is a retrospective interventional case series of 4 eyes with massive HRD presenting during 2020. Preoperatively, all patients underwent intravitreal injection of tissue plasminogen activator (tpa), combined with bevacizumab in one patient and gas (C3F8 100%) injection in two. Surgical drainage involved 23g pars-plana vitrectomy, retinotomy and aspiration of subretinal blood located in the macular region, followed by fluid-air exchange and silicone oil tamponade (SO). We examined the baseline characteristics, surgical technique, visual outcome and complications.
All patients were female with median age of 92 years (82-95). All were on antithrombotic medication (2 antiplatelet agents and 2 anticoagulants). The cause for HRD was wAMD in all 4 eyes; 3 were known wAMD patients and only 1 was diagnosed at presentation. Median duration of symptoms was 5 days (1-7) and vision of all eyes was hand movements at presentation. Median visual acuity (VA) of the fellow eye was 30 letters (0-75), and in 3 patients the affected eye was the better seeing eye prior HRD. Median logMAR VA at 2 weeks and 6 weeks after surgery was 2,1 (1,9-2,7) and 2,3 (1,9-2,7) respectively. 2 eyes developed early postoperative hyphaema, vitreous cavity haemorrhage, subretinal rebleed and high intraocular pressure. In 1 patient removal of SO and vitreous cavity washout was performed at 2 weeks and 1 declined further surgery. At final examination, median VA was 2,5 (0,7-3,0) after median follow up of 5 months (1-8). All eyes had SO left in situ and 2 patients continued regular anti-VEGF treatment for wAMD. On final examination, macula OCT could be obtained in 3 patients; 2 eyes showed complete resolution of subretinal haemorrhage and one eye had only partial resolution.
In this small case series, massive HRD was observed in elderly patients with wAMD who are on systemic treatment with antiplatelet or anticoagulation agents. Surgical treatment using a combination of preoperative intravitreal tpa followed by surgical treatment may help recover the vision in at least some patients. Close monitoring and continued treatment with anti-VEGF will be required after surgery to reduce the likelihood of recurrence of submacular bleeding or HRD.
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