Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group

Abstract

Purpose To evaluate the clinical characteristics, treatment trends, and visual prognosis of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) and retinal arterial macroaneurysm (RAM). Methods This retrospective study enrolled 187 Japanese patients with SMH at 10 institutions from 2015 to 2018. Medical records including SMH etiology, best-corrected visual acuity (BCVA), fundus photographs, optical coherence tomography images, and selected treatments were analyzed. Results Major causes of SMH were typical nAMD (tnAMD) (18%), polypoidal choroidal vasculopathy (PCV) (50%) and RAM (29%). Age, male/female ratio, baseline BCVA, central retinal thickness, and involved retinal layers were significantly different between etiologies (all P<0.0001). Treatment with anti-vascular endothelial growth factor drugs with and without intravitreal gas injection was chosen for half of eyes in the tnAMD and PCV groups, whereas vitrectomy was performed in 83.7% of eyes with RAM. The final BCVA improved significantly from baseline in the PCV and RAM groups (P = 0.0009, P<0.0001) and final BCVA was significantly better in the PCV group at a level similar to the other groups (P = 0.0007, P = 0.0008). BCVA improvement from baseline was significantly greater in the RAM group compared with the tnAMD (P = 0.0152) and PCV (P = 0.017) groups. Multivariate analysis revealed better final BCVA was significantly associated with younger age (P = 0.0054), better baseline BCVA (P = 0.0021), RAM subtype (P = 0.0446), and no tnAMD (P = 0.001). Conclusions The characteristics of, and treatment strategy for, SMH were different between the underlying diseases. Anti-vascular endothelial growth factor treatment with or without expansile gas was mainly chosen for SMH in tnAMD and PCV, whereas vitrectomy with gas was the most common treatment for RAM, and the higher rate for vitrectomy might result in the greater BCVA improvement in the RAM group than in the other groups. Final BCVA was better in PCV, RAM, and tnAMD, in that order, because patients with PCV were younger and had better baseline BCVA.

Predictors of 3-month and 1-year visual outcomes after vitrectomy with subretinal tissue plasminogen activator injection for submacular hemorrhage

“…First, adequate control of the cause could prevent recurrence. For polypoidal choroidal neovascularization, the most common cause of SMH, 1 regression of polypoidal lesions is desirable, because cluster type polypoidal choroidal neovascularization (many polypoidal lesions) poses a high risk of SMH (hazard ratio, 3.4). 17 The EVEREST II study compared 24-month treatment outcomes between anti-VEGF monotherapy and vPDT combined with anti-VEGF therapy; the combination therapy was superior to monotherapy in complete polypoidal lesion regression (56.6% vs. 26.7%, P < 0.001).…”

“…It mainly occurs in cases of neovascular age-related macular degeneration (nAMD), including its subtype of polypoidal choroidal neovascularization, and retinal macroaneurysm (RMA). 1 Subretinal hemorrhage is toxic to the photoreceptors and causes irreversible retinal destruction within 24 hours after onset in rabbit eyes. 2 In humans, a 24-month observation study showed that the best-corrected visual acuity (BCVA) worsened in 80% of the eyes with SMH, with a mean final BCVA of 20/1250 (range: 20/100 to light perception), indicating an extremely poor prognosis.…”

Visual Recovery and Prognosis in the Treatment of Submacular Hemorrhage due to Polypoidal Choroidal Vasculopathy and Retinal Arterial Macroaneurysm: A Retrospective Study

“…The least invasive of the treatment regimens involves the intravitreous injection of anti-VEGF agents, tPA, and/or expandable gas aimed at treating potential choroidal neovascularization and/or displacing submacular blood [ 22 ]. Furthermore, studies have shown that PPV + tPA and air tamponade result in moderate visual recovery in patients with SMH, PCV [ 23 , 24 ], and RAM [ 25 ]. Therefore, none of the patients in this study received any relevant ocular treatment prior to surgery, nor did they receive intravitreal injections of anti-VEGF drugs during the subsequent observation period.…”