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Dominik T. Uram, Anna M. Blonska, Stanley Chang, William M. Schiff, R T. Smith, Reza Iranmanesh, Lucian V. Del Priore; Oct-guided Detection Of Risk Factors For Macular Hemorrhage During Anti-vegf Therapy For Neovascular Age Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2011;52(14):4887.
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Massive subretinal hemorrhage is a devastating complication in patients with wet age-related macular degeneration (AMD), and there is concern that decreasing the frequency of anti-VEGF injections may increase the risk of this event. Herein we determine whether pre-bleeding optical coherence tomography (OCT) can be used to identify patients who are at risk for this complication.
We retrospectively reviewed 10 patients who developed new massive submacular hemorrhage while on anti-VEGF therapy. We examined the last OCT obtained before the hemorrhage for the presence of intraretinal fluid, subretinal fluid, or pigment epithelium detachment (PED). We determined the time from last intravitreal anti-VEGF injection to hemorrhage, a history of preceding small hemorrhage in the study eye, the pattern of injection and whether there was a history of hypertension and anticoagulant/antiplatelet therapy.
The last OCT was acquired in average 33 days before hemorrhage (range: 6 days to 10.2 weeks), and it revealed the presence of intra- or subretinal fluid in 80 % of patients; PED was present prior to bleeding in all 10 patients; and 6 patients had a history of small amount (less than ½ disc area) of extrafoveal blood prior to submacular hemorrhage. 8 patients previously had choroidal neovascularization in the other eye, with active submacular hemorrhage in 3 of the 8 fellow eyes. The time from last injection to bleeding was short (mean of 11.02 weeks; range: 5 to 403 days) with 60% of patients experiencing macular hemorrhages < 5 weeks since the last injection. Four patients were receiving anticoagulants but this did not affect the size of hemorrhage. There was no correlation between whether bevacizumab or ranibizumab was used and either the time from last injection to hemorrhage, nor the size of the hemorrhage.
Massive subretinal hemorrhage can occur in patients during active treatment for neovascular AMD, with 60 % of the hemorrhages occurring within 5 weeks of the last injection; most hemorrhages occurred in the second eyes of patients with active disease in the first eye. All patients who experienced massive hemorrhages had an anatomic abnormality on OCT prior to the bleeding (PED, subretinal fluid, intraretinal fluid or blood). It is not known if more frequent anti-VEGF injections will reduce the incidence of large hemorrhages.
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