First Author: A.Rajendran INDIA
Co Author(s): C. Mishra A. Kamble
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Massive submacular haemorrhages (SMH), secondary to neovascular age-related macular degeneration (AMD) and Polypoidal Choroidal Vasculopathy (PCV) are one of the most formidable of acquired maculopathies to treat. The rapid rate of photoreceptor debilitation coupled with the usual intrinsic and incessant macular haemorrhaging mandates early intervention and evacuation of the submacular bleed. Although pneumoretinopexy and tissue plasminogen activator (tPA) may be attempted in mild cases, large submacular bleeds invariably need the more challenging procedure of surgical clearance of the bleed. The video helps highlight the steps and demystify the complex procedure of surgical removal of a large submacular haemorrhage secondary to PCV.
The patient was treated at the Retina Service of a large tertiary eye care hospital in South India. A 58 year old male presented with reduced vision in the right eye 5 days earlier. The best corrected vision (BCV) was 1/60 OD and 6/9 OS
Fundus evaluation revealed large fresh SMH extending beyond arcades. OCT highlighted large SMH, tall PEDs. Fluorescein Angiography (FA) and Indocyanine green angiography (ICG) confirmed PCV. Intravitreal Ranibizumab (0.5mg) was administered. A week later, vitreous haemorrhage was noted. 3-port 23 G Pars plana vitrectomy was performed. Temporal to the arcades, utilising a 40 G pipette attached to syringe infusion, multiple localised retinal detachments were created. A curvilear retinectomy in the equatorial retina with vitrectomy probe, (post-diathermy) was done. Large submacular clots were evacuated with cutter and soft silicone tip aspirator. Laser photocoagulation, Fluid-air exchange were followed by Silicone oil infusion.
The immediate postoperative period was uneventful with the retina being well attached, submacular area having minimal bleed. 2 weeks postoperatively, the patient had 6/60 BCV and had a well attached retina, with negligible staining of a flat macula. Intraocular pressure was 16mm Hg. 3 months later BCV had improved to 6/18; the macula flat with clearance of bleed. OCT showed a mound shaped elevation of the Retinal pigment epithelium (RPE). 6 months later, BCV remained 6/18 with clear, flat macula; attached retina. OCT showed reduced elevation of the RPE and ICG/FFA showed inactivity of the pathology.
Mild submacular bleeds may be managed by intravitreal anti-vascular endothelial growth factor (VEGF) injections, pneumoretinopexy and tPA injections. However, massive SMHs, as in our case, mandate a surgical solution. The key steps here are – a) Use of the 40G pipette infusion allowing atraumatic, controlled retinal detachments. b) A neat curvilinear retinectomy ensures good apposition, minimising scar tissue. c) The 23G vitrectomy probe, along with silicone tip aspirator, is adequate to detach the leathery blood clots. The video would demonstrate the nuances and help demystify a radical procedure, that may yield very gratifying results as in our case.