Purpose
Vitreous hemorrhage (VH) is a rare but serious complication of the eyes with exudative age-related macular degeneration (AMD). This retrospective study was designed to evaluate various clinical factors that may affect the visual prognosis of patients with VH secondary to exudative AMD.
Design
Retrospective case study.
Methods
We intensively documented 31 cases of VH secondary to exudative AMD and retrospectively analyzed best-corrected visual acuity (BCVA). All eyes underwent standard pars plana vitrectomy (PPV) for treating VH. Three subgroups were created according to the clinical course and treatment history before the occurrence of VH: (1) gas group (7 eyes), pneumatic displacement with sulfur hexafluoride gas performed to treat massive submacular hemorrhage; (2) photodynamic therapy (PDT) group (9 eyes), PDT performed to treat exudative AMD; (3) untreated group (15 eyes), no treatment performed.
Results
As a whole, BCVA before the occurrence of VH was 1.05 ± 0.59 (logarithm of the minimal angle of resolution). After the occurrence of VH, BCVA before PPV dropped to 2.61 ± 0.82. After the operation, final BCVA improved significantly to 1.25 ± 0.73 ( P < 10 −8 ). In a subgroup analysis, no statistically significant difference was seen among the 3 subgroups at any time point. We found that the eyes whose fellow eye had exudative AMD showed significantly poor final BCVA compared with the unilateral cases (0.92 ± 0.57 and 1.49 ± 0.72; P = .02).
Conclusions
PPV can improve visual acuity in the eyes with VH secondary to AMD, although effectiveness is limited. Medical practitioners should be cautious of the visual prognosis, especially in the cases in which the fellow eye has exudative AMD.
Choroidal neovascularization (CNV) secondary to exudative age-related macular degeneration (AMD) has a poor visual prognosis because of fundus manifestations that include pigment epithelial detachment, retinal detachment, subretinal or macular hemorrhage, hard exudates, macular edema, and subretinal fibrosis. Vitreous hemorrhage (VH) is a rare but serious complication of exudative AMD. VH itself contributes to vision loss in AMD and is considered a sign of AMD progression. Although unstable neovasculature may be related to VH, the precise mechanisms that lead to ocular VH with exudative AMD remain unclear. In some cases, VHs may be absorbed spontaneously over time; however, pars plana vitrectomy (PPV) often is required to remove the hemorrhage. PPV surgery provides a relatively good visual prognosis.
In ocular VH with exudative AMD, submacular hemorrhage often precedes the occurrence of spontaneous VH. VH can occur in cases of massive submacular hemorrhage after treatments such as pneumatic displacement. Photodynamic therapy (PDT) for the treatment of exudative AMD also can cause VH. However, there is little information about how the clinical course of the disease affects visual prognosis in eyes with VH resulting from exudative AMD.
To clarify the factors that affect the prognosis of VH secondary to exudative AMD, we documented the clinical courses of patients with exudative AMD who underwent PPV to remove VH. Clinical factors likely to influence visual prognosis were investigated. We additionally evaluated the efficacy of PPV for treating VH resulting from exudative AMD.
Methods
For this interventional case study, we retrospectively reviewed the medical records of 979 consecutive patients with exudative AMD who were treated at the Macula Service, Department of Ophthalmology, Kyoto University Hospital, from January 2004 through September 2008. Inclusion criteria were as follows: (1) the occurrence of VH during the follow-up in the clinic, (2) a diagnosis of exudative AMD during follow-up, (3) treatment with PPV for VH, and (4) a postoperative follow-up of more than 3 months. Patients were divided into 3 subgroups depending on their clinical course before the occurrence of VH: (1) gas group, pneumatic displacement with SF 6 gas was used to treat massive submacular hemorrhage before the occurrence of VH; (2) PDT group, PDT was used to treat exudative AMD before the occurrence of VH; and (3) untreated group, no treatment was performed before the occurrence of VH. For the purposes of this study, patients with polypoidal choroidal vasculopathy (PCV) and retinal angiomatous proliferation were considered to have exudative AMD and were included in the study. We use the term AMD to mean exudative AMD that could not be diagnosed as PCV or retinal angiomatous proliferation. Patients with other types of CNV, for example, pathologic myopia, angioid streaks, retinal angiomatous proliferation, idiopathic CNV, presumed ocular histoplasmosis syndrome, and other secondary forms of CNV, were excluded from this study. Patients with other retinal or macular abnormalities, for example, retinal macroaneurysm, diabetic retinopathy, retinal vein occlusion, or uveitis, also were excluded from the study.
A PCV diagnosis was based on an indocyanine green (ICG) angiogram that showed polypoidal structures along the border of the branching vascular network. A polypoidal lesion can appear as a single polyp or as a cluster of polyps. In most PCV cases, reddish-orange subretinal nodules were seen under ophthalmoscopic examination that corresponded to the polypoidal lesions seen by ICG angiography.
All patients underwent comprehensive ophthalmologic examinations, including best-corrected visual acuity (BCVA) measurements, binocular ophthalmoscopy, slit-lamp biomicroscopy with a contact lens, color fundus photography, fluorescein angiography, ICG angiography, and optical coherence tomography (OCT). Fluorescein angiography and ICG angiography were performed simultaneously using a confocal laser scanning system (HRA-2; Heidelberg Engineering, Dossenheim, Germany). Four types of OCT instruments were used: Stratus OCT (Carl Zeiss, Dublin, California, USA), OCT ophthalmoscope (Nidek, Gamagori, Japan), 3D OCT-1000 (Topcon, Tokyo, Japan), and RTVue (Optovue Corp, San Francisco, California, USA). All patients were assessed carefully at baseline and then every 3 months. In addition, patients were advised to visit the clinic if they believed their vision was worsening.
To treat VH, standard 3-port PPV was performed on all patients in the study using a 20-gauge or 23-gauge system. Six experienced surgeons in our macular clinic performed all surgeries. Phacoemulsification and intraocular lens implantation were combined in all phakic eyes because of the expected progressive nuclear sclerosis. Fluid–air exchange and sulfur hexafluoride (SF 6 ) gas tamponade were performed in some cases.
To treat massive submacular hemorrhage, pneumatic displacement was performed using 0.5 mL 100% SF 6 gas injected into the vitreous cavity with a 30-gauge needle. Patients were instructed to maintain a prone position for at least 4 days. PDT with verteporfin to treat exudative AMD was performed according to standard procedures. A 689-nm laser system (Carl Zeiss) was used, and 50-J/mm 2 energy was delivered with an 83-second exposure time.
For statistical analysis, counting fingers (CF), hand movements (HM), and light perception (LP) were considered to indicate decimal visual acuity of 0.005, 0.001, and 0.0005, respectively. The BCVA was determined using the Landolt ring test and was converted into the logarithm of the minimal angle of resolution (logMAR) units. All values are reported as the mean ± standard deviation. Continuous variables between 2 groups were compared using the Student t test (2 tailed). Continuous variables between 3 groups were compared by 1-way analysis of variance. Multivariate linear regression analysis was performed to correlate final visual acuity with other clinical parameters. All analyses were performed using a commercial software program (SPSS software version 13.0; SPSS, Inc, Chicago, Illinois, USA). A difference was considered statistically significant when the P value was less than .05.
Results
This study included 31 patients, each with 1 eye with VH resulting from exudative AMD (3.2% of the 979 age-related exudative AMD patients; Table 1 ). The patients ranged in age from 55 to 86 years (mean ± standard deviation, 73.8 ± 7.7 years). The mean postoperative follow-up was 19.9 ± 14.2 months (range, 5 to 52 months). Of the 31 eyes, 22 (71%) were diagnosed as having PCV by angiographic analysis; the other 9 were diagnosed as having AMD. Patient characteristics are summarized in Table 1 .
| Case No. | Age (yrs) | Gender | HT | DM | Anticoagulant Medication | History of Smoking | Laterality of CNV | Diagnosis | Submacular Hemorrhage before VH | Treatment before VH (days) a | Contents of Surgery | VA before VH | VA before PPV | VA Final | Postoperative Follow-up (mos) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 71 | M | No | No | Yes | No | Unilateral | PCV | Yes | Gas (7) | PPV+PEA+IOL | 0.3 | N/A | 0.1 | 29 |
| 2 | 71 | M | No | No | No | Yes | Bilateral | PCV | Yes | Gas (10) | PPV+PEA+IOL | 0.2 | 0.1 | 0.1 | 6 |
| 3 | 78 | M | No | No | No | Yes | Unilateral | PCV | Yes | Gas (19) | PPV+PEA+IOL | 0.1 | HM | 0.04 | 5 |
| 4 | 70 | M | No | No | No | Yes | Bilateral | AMD | Yes | Gas (7) | PPV+PEA+IOL | 0.08 | CF | 0.3 | 24 |
| 5 | 68 | M | No | No | No | No | Unilateral | AMD | Yes | Gas (300) | PPV+PEA+IOL | 0.06 | HM | 0.02 | 52 |
| 6 | 68 | M | Yes | Yes | Yes | No | Bilateral | AMD | Yes | Gas (10) | PPV+PEA+IOL | 0.15 | HM | 0.2 | 48 |
| 7 | 71 | M | Yes | No | No | No | Unilateral | PCV | Yes | Gas (6) | PPV+PEA+IOL | 0.4 | N/A | 1.0 | 13 |
| 8 | 81 | M | Yes | No | No | No | Bilateral | AMD | No | PDT (360) | PPV | 0.04 | CF | 0.07 | 15 |
| 9 | 73 | M | Yes | No | No | Yes | Bilateral | PCV | No | PDT (45) | PPV+PEA+IOL | 0.1 | LP | HM | 13 |
| 10 | 78 | M | Yes | No | No | Yes | Bilateral | PCV | No | PDT (180) | PPV | 0.15 | 0.07 | 0.06 | 37 |
| 11 | 81 | M | No | No | No | Yes | Bilateral | PCV | Yes | PDT (15) | PPV | 0.07 | 0.07 | 0.05 | 8 |
| 12 | 70 | M | No | No | No | No | Unilateral | PCV | No | PDT (930) | PPV+PEA+IOL | 0.3 | 0.01 | 0.5 | 12 |
| 13 | 76 | M | No | No | No | Yes | Unilateral | PCV | No | PDT (810) | PPV+PEA+IOL | 0.1 | HM | 0.07 | 11 |
| 14 | 85 | M | Yes | No | Yes | No | Bilateral | PCV | No | PDT (870) | PPV+PEA+IOL | 0.07 | LP | 0.08 | 8 |
| 15 | 68 | M | No | No | No | Yes | Bilateral | PCV | No | PDT (420) | PPV+PEA+IOL | 0.2 | LP | 0.02 | 10 |
| 16 | 55 | F | No | No | No | No | Unilateral | PCV | No | PDT (60) | PPV+PEA+IOL | 0.1 | LP | 0.06 | 23 |
| 17 | 80 | M | Yes | No | No | Yes | Unilateral | PCV | Unknown | Untreated | PPV+PEA+IOL | N/A | HM | 0.2 | 25 |
| 18 | 77 | F | Yes | No | No | No | Unilateral | PCV | Yes | Untreated | PPV+PEA+IOL | 0.3 | HM | 1.0 | 29 |
| 19 | 58 | M | Yes | No | No | Yes | Unilateral | PCV | Yes | Untreated | PPV+PEA+IOL | 0.06 | HM | 0.02 | 20 |
| 20 | 78 | M | No | No | No | Yes | Bilateral | PCV | Yes | Untreated | PPV+PEA+IOL | 0.04 | LP | 0.03 | 11 |
| 21 | 65 | M | Yes | No | No | Yes | Unilateral | PCV | Unknown | Untreated | PPV+PEA+IOL | N/A | CF | 0.4 | 12 |
| 22 | 58 | M | No | No | No | Yes | Unilateral | PCV | Unknown | Untreated | PPV+PEA+IOL | N/A | 0.09 | 0.2 | 8 |
| 23 | 80 | M | Yes | Yes | Yes | No | Bilateral | PCV | Unknown | Untreated | PPV | N/A | LP | HM | 6 |
| 24 | 75 | F | Yes | No | No | No | Unilateral | PCV | Unknown | Untreated | PPV+PEA+IOL | N/A | CF | 0.08 | 8 |
| 25 | 82 | M | No | No | Yes | Yes | Bilateral | PCV | No | Untreated | PPV | 0.02 | LP | CF | 17 |
| 26 | 74 | M | Yes | No | No | Yes | Bilateral | AMD | Yes | Untreated | PPV+PEA+IOL | 0.08 | HM | 0.09 | 52 |
| 27 | 73 | F | No | No | No | Yes | Unilateral | AMD | Yes | Untreated | PPV | 0.2 | HM | 0.1 | 7 |
| 28 | 77 | M | Yes | No | No | Yes | Bilateral | AMD | Yes | Untreated | PPV+PEA+IOL | 0.01 | LP | 0.01 | 34 |
| 29 | 86 | F | Yes | No | No | Yes | Unilateral | AMD | Unknown | Untreated | PPV+PEA+IOL | HM | HM | 0.02 | 8 |
| 30 | 79 | M | Yes | Yes | No | No | Bilateral | PCV | Unknown | Untreated | PPV+PEA+IOL | N/A | 0.15 | 0.1 | 43 |
| 31 | 81 | M | No | No | No | No | Bilateral | AMD | No | Untreated | PPV+PEA+IOL | 1.0 | HM | 0.01 | 22 |
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