Background / Aims:

Acute and massive hematoma involving the macula is a devastating complication; age-related macular degeneration (ARMD) is the main cause. Undertreating choroidal neovascularization may explain it in some cases but it also may follow intravitreal anti-VEGF injection especially in previously treated eyes. Other underlying causes include retinal arterial macroaneurysms. In both cases, volume and time to evacuation have strong prognostic factors for visual outcome. A variety of therapeutic approaches have been developed without consensus. Therefore, we evaluated a novel approach of pars plana vitrectomy in the treatment of these patients.

Patients, Material & Methods:

6 consecutive patients with massive and recent (< 7 days) subretinal hemorrhages were enrolled: 4 with ARMD (one with related intravitreal hemorrhage) and 2 posterior pole arterial macroaneurysms ruptures with pre and retro macular hemorrhages. All patients underwent complete two or three port pars plana vitrectomy (general or peribulbar anesthesia), direct cannulation of the subretinal space (De Juan subretinal canula 41Ga tip) with injection of 50 µg of t-PA (0.1 ml) and 2 mg of aflibercept (0.05 ml), and fluid-gaz exchange (SF6 20%). After 1 hour face up supine positioning postoperatively, the patient had to vary “face down” position and upright positioning for 3 days. Before sub-retinal injections, the two patients with retinal arterial macroaneurysm rupture (RAMAR) were treated by peeling of the vitreous cortex, removing of the ILM over the hematoma, dissection, drainage and/or vitreous cutter removal, dissection of the fibrinous aneurysmal body, endophotocoagulatio n. Acuities, SD-OCT, color fundus photographs (CFP), fundus autofluorescence (FAF), infra-red (IR) images +/- fluorescein/ICG angiograms (FA) were obtained for all evaluations.

Results:

One patient (severe RAMAR) needed a treatment in 2 steps because of the formation of a secondary macular hole (MH) due to the first vitrectomy (preretinal and intralamellar hemorrhage removal, subretinal injections through the MH, gas tamponade). A second vitrectomy was performed few weeks later with closure of the MH (“massage” of the edges, C2F6 20%, “face down” position 3 days). The two patients with RAMAR had total clearing of the macular hemorrhage contrary to partial clearing for ARMD patients Anatomical and functional results were however satisfactory for each of them: all of the 6 patients experienced an improvement of their visual acuity.

Conclusion / Discussion:

Thanks to this short series with good results, we can propose an alternative way to classic surgery which seems to be useful in displacing thick submacular hemorrhage. Mixing drugs together for a single injection may be safer than two separate injections with same efficacy and without adverse effects. Early access to surgery is essential to avoid severe effects of subretinal fibrosis, and in case of RAMAR, to permit good photocoagulation which probably decreases risk of recurrent hemorrhage. Geographic atrophy remains a problem in the management of this retinal disease. Further controlled and multicentric studies will be required to assess efficacy and long term safety.

Contact Details:

Email: emiliemerce@hotmail.com
Cell Phone: +33648115209