Smaller Lesions, Better Baseline Visual Acuity Bode Well for Submacular Hemorrhage

Smaller submacular hemorrhages (SMHs) secondary to exudative age-related macular degeneration among patients with good baseline visual acuity (VA) have a better chance of improving and resulting in a better final VA, according to a small retrospective study from Israel.

In this cohort of 43 patients, prognostic factors for final VA better than 20/200 included better VA at baseline (1.25 vs 1.90 logMAR, P<0.001), a smaller area of SMH in the infra-red image (19.47 mm² vs 38.45 mm², P=0.024), and lower height of SMH as measured by optical coherence tomography (713.5 µm vs 962.5 µm, P=0.03), reported Edward Barayev, MD, of Tel Aviv University, and colleagues.

In addition, these patients may respond better to less invasive treatment with pneumatic displacement (PD) and intravitreal tissue plasminogen activator (tPA) and gas rather than surgery, they suggested in the European Journal of Ophthalmology.

Overall, patients undergoing PD with tPA were more likely to improve their VA by at least two lines, and to reach a final VA better than 20/200 compared with those undergoing surgical treatment.

Commenting on the study, Allen Chiang, MD, of Mid Atlantic Retina at Wills Eye Hospital in Philadelphia, said the study may bring some renewed attention to the option of PD and intravitreal tPA, but the small numbers and the study’s retrospective nature are significant limitations.

“The data should generate some discussion amongst colleagues and trainees in journal clubs and rounds, for example, but I don’t see it leading to a sea change in how surgeons approach SMH because in the absence of prospective comparative studies, people tend to stick with what they’ve been comfortable and successful with in the past,” he told MedPage Today.

Chiang noted that treatment and outcomes for this condition have traditionally been controversial. “This can be attributed to the heterogeneity that exists in terms of presenting anatomic characteristics, which often colors not only the prognosis but the type of intervention a surgeon ultimately recommends,” he said, noting that this heterogeneity explains the existing lack of standardization and quantification of SMH, which limits the ability to compare different treatment approaches.

“Furthermore, the success of anti-VEGF therapy has suppressed the incidence of SMH, which might explain why studies like this one are often relatively small, despite a study period that spans several years,” Chiang added.

The current study’s findings align with other retrospective research suggesting some advantage with PD over pars plana vitrectomy (PPV).

In addition, a recent French study found that PPV with tPA was not superior to PD with tPA for treating SMH, suggesting that the less invasive PD approach should be considered, absent parameters indicating otherwise.

Among unanswered questions, Chiang said, is whether PD is a better choice than PPV for those on anticoagulation therapy. “Anticoagulation was an exclusion criterion in this study, yet is not uncommon in this patient population. We also don’t know how essential intravitreal tPA really is to the success of this less invasive procedure,” he noted.

While this small retrospective study provides additional data to suggest that PD with tPA is viable as a less invasive option in select cases, Chiang continued, it had key limitations, including the risk of allocation and selection bias, with those undergoing PD faring better simply because they had smaller disease to begin with.

“Conversely, those with larger SMH may have worse outcomes, not because of the PPV necessarily, but because of the initial severity of the SMH, which may have led the surgeon to select the more invasive approach,” he added.

Barayev and colleagues also pointed out that the study’s retrospective design and cohort size were limitations, and allocation bias could have influenced the results. “However, as our data represent real-world data, we believe that our results are important for clinical decision making,” they wrote.

For this study, the researchers included 43 patients (23 women, mean age 86.7) who presented to a tertiary ophthalmology department from 2012 to 2019 with SMH and were treated by PPV or injection of tPA with pneumatic displacement. Mean baseline best-corrected visual acuity (BCVA) before presenting with SMH was 0.33±0.31 logMAR, which improved to 1.05±0.65 logMAR at the last follow-up.

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