Retina Today - Post-Game Film Review With the Wills Retina Coaches: Submacular Hemorrhage (May/June 2015)

摘要

In a previous installment of this column, we gave readers a glimpse into the inner workings of the monthly surgical conferences held by the senior retina fellows at Wills Eye Hospital (see “Post-Game Film Review With the Wills Retina Coaches: PVR and Retinal Detachment” on page 22 of the January/February 2015 issue of Retina Today). Due to the positive feedback, we decided to continue the post-game film review series. Joining us for this session to discuss the management of submacular hemorrhage are Allen Chiang, MD; Allen Ho, MD; Jason Hsu, MD; Richard Kaiser, MD; Joseph Maguire, MD; and Arunan Sivalingam, MD. Links to the videos are provided for readers to follow along. —S. K. Steve Houston III, MD; Ehsan Rahimy, MD; and David C. Reed, MD SUBMACULAR HEMORRHAGE AND ANTICOAGULANT USE This case involves an 85-year-old man with acute-onset loss of visual acuity in his left eye, down to 20/200 (Figure 1). At the time of the examination, he was taking apixaban (Eliquis, Bristol-Myers Squibb), a relatively new agent in the class of novel anticoagulants (NOACs), for atrial fibrillation. Preoperative Management Joseph Maguire, MD: When I see an extensive bleed such as the one in this case, I think of three potential scenarios: polypoidal choroidal vasculopathy, a retinal angiomatous proliferation (RAP) lesion, a patient on anticoagulation, or some combination of these. One often sees small hemorrhages with age-related macular degeneration (AMD), but large hemorrhages are less common. Ehsan Rahimy, MD: Do you routinely ask about anticoagulant use with your AMD patients? Dr. Maguire: You should look at your review of systems and what medications the patient is taking. Allen Ho, MD: If I see a large hemorrhage such as this in the setting of AMD, I assume there is an underlying tear of the retinal pigment epithelium (RPE), unless the differential diagnosis leads me elsewhere (eg, a macroaneurysm). Optical coherence tomography (OCT) can be helpful in confirming this. Figure 1. Preoperative color fundus (A), fluorescein angiography (B), and spectral-domain OCT (C) imaging of a patient presenting with acute-onset vision loss in the left eye secondary to submacular hemorrhage. Dr. Rahimy: Given the imaging findings, how would you manage this case? Would you consider an in-office pneumatic displacement, or would you go straight to the OR? Arunan Sivalingam, MD: You can tell from the OCT that the hemorrhage is mostly subretinal without much under the RPE, so this patient is a good candidate for surgical evacuation. Dr. Ho: This is an 85-year-old man who might not be a good candidate for surgery because of other systemic comorbidities. I am fine with trying a pneumatic displacement in the office, but for the larger bleeds I would prefer to do a surgical displacement because I feel I can clear the macula of hemorrhage more effectively. In thinner hemorrhages, though, I would advise against surgery and try an anti-VEGF injection. Richard Kaiser, MD: In terms of management, OCT is helpful. First, I like to see if the central retinal thickness has at least doubled when deciding whether or not to operate. This is because a thin hemorrhage may look ominous on examination but not necessarily respond well to surgery. Second, looking at the layers where the hemorrhage is located is useful. If the bleeding is 100% under the RPE, then the odds of actually helping this patient surgically are much lower, whereas, in this particular case, you can clearly see most of the bleeding exists between the retina and the RPE. Dr. Maguire: I often use OCT to estimate where to enter the subretinal space during surgery. The safest place to inject tissue plasminogen activator (tPA) under the retina is usually the area with the thickest blood. You do not want to enter under the RPE. Dr. Rahimy: How soon do you add this case to your operating schedule? Jason Hsu, MD: The sooner the better. If you