Subretinal hemorrhage

1. Subretinal Haemorrhage
Sujay Chauhan

2. • Blood between NSR and RPE
• Retinal or choroidal circulation
SUBRETINAL HAEMORRHAGE

3. CHOROIDAL CIRCULATION
• Choroidal Neovascular Membrane (CNVM)
– Age-related Macular Degeneration (AMD)
– Presumed Ocular Histoplasmosis Syndrome (POHS)
• Discontinuity in Bruch’s membrane
– Trauma: ‘Choroidal rupture’
– High myopia: ‘Lacquer cracks’
• Polypoidal Choroidal Vasculopathy (PCV)
SOURCES OF SUBRETINAL HAEMORRHAGE

4. RETINAL CIRCULATION
• Hypertension
• Retinal Artery Macroaneurysm (RAM)
• Microtrauma
• Anticoagulant use
SOURCES OF SUBRETINAL HAEMORRHAGE

5. • Sudden onset of blurred vision
• Scotoma
• Metamorphopsia
SYMPTOMS

6. SIGNS

7. Folds in
overlying
retina
Bright-red to dark-
red
Dehemoglobinised
– Yellow-tan
Irregular
scalloped
margins

8. Can mimic choroidal melanoma

9. Sub-RPE hemorrhage – Smooth, well-defined borders

10. ASSOCIATED FINDINGS
• Drusen
• CNVM
• Disciform scars
• Hypertensive retinopathy
• Retinal artery macroaneurysm
in the same or the fellow eye

11. DIAGNOSTIC STUDIES

12. FUNDUS FLUORESCEIN ANGIOGRAPHY
• Blocked choroidal fluorescence
• Clearly visible overlying retinal vessels

13. Retinal Artery Macroaneurysm

14. CNVM – Patch of irregular choroidal hyperfluorescence

15. INDOCYANINE GREEN ANGIOGRAPHY
Detect CNVM in cases with thick overlying subretinal hemorrhages

17. ULTRASOUND B SCAN
• Non-mobile retinal elevation
• Moderately reflective subretinal opacities

19. PATHOGENESIS OF VISUAL LOSS

20. Glatt and Machemer, 1982
• Chemical toxicity
• Mechanical traction on photoreceptor outer segments
• Diffusion barrier between photoreceptors and RPE

21. TOXIC EFFECT
• Ferritin - destruction of photoreceptor layer and RPE
• Substances mitogenic for RPE cells – stimulate development of CNV
• Chemoattractants for macrophages and fibroblasts – scar formation

22. TRACTION EFFECT
Fibrin – clot retraction – retinal traction

23. BARRIER EFFECT
Choriocapillaries Outer retinaRPE
Nutrients (O2, retinoids)
Metabolites (water, ions)

24. NATURAL HISTORY
Subretinal hemorrhage -
• with CNV and thicker subretinal hemorrhage - poor visual prognosis
• without CNV - good visual prognosis
• Avery et al. Natural history of subfoveal subretinal hemorrhage in age-related macular degeneration.
Retina 1996;16:183-189
• Bennett et al. Factors prognostic of visual outcome in patients with subretinal hemorrhage involving
the fovea. Am J Ophthalmol 109:33-37,1990
• Berrocal et al. Variations in the clinical course of submacular hemorrhage. Am J Ophthalmol 122:486-
493,1996
• Holyaerts et al. Kinetics of the activation of plasminogen by human tissue plasminogen activator. Role
of fibrin. J Biol Chem 257:2912-2919, 1982

25. • Area
• Thickness
• Duration
• Avery et al. Natural history of subfoveal subretinal hemorrhage in age-related macular degeneration.
Retina 1996;16:183-189
• Bennett et al. Factors prognostic of visual outcome in patients with subretinal hemorrhage involving
the fovea. Am J Ophthalmol 109:33-37,1990
1
∝ ----------------
Prognosis

26. SUBMACULAR HAEMORRHAGE
Small, thin
Observe
Medium-sized, thick
(extending under macula &
obscuring RPE)
Good response to treatment
Massive
Poor prognosis
regardless of
intervention
MANAGEMENT
Shultz RW, Bakri SJ. Treatment for submacular hemorrhage associated with neovascular age-related
macular degeneration. Semin Ophthalmol 2011;26(6):361-371.

27. INDICATIONS FOR INTERVENTION
1. Affected eye had good (useful) visual acuity before subretinal
hemorrhage occurred
2. Duration of subretinal hemorrhage < 30 days, preferably < 7
days
3. Subretinal hemorrhage is thick, creating clinically evident fovea
elevation of ≥ 500 µ with complete obscuration of underlying
RPE and choroidal detail
4. Underlying RPE and overlying retina are healthy (e.g., non-AMD-
related subretinal hemorrhage)
5. Subretinal hemorrhage is causing significant visual impairment
Hochman et al. Pathophysiology and management of subretinal hemorrhage. Surv Ophthalmol.
1997;42(3):195-213.

28. SURGICAL MANAGEMENT BEFORE 1991
• Creation of a retinotomy and evacuation of haemorrhage using
20-30 G cannula and intraocular forceps to remove the clot
• Disadvantage: Retinal or retinal pigment epithelial damage
• Tennant et al. Management of submacular hemorrhage. Ophthalmol Clin North Am 2002;15:445–
52.
• Scheider et al. Surgical extraction of subfoveal choroidal new vessels and submacular haemorrhage
in age‐related macular degeneration: results of a prospective study. Graefes Arch Clin Exp
Ophthalmol 1999;23:710–15.
• Vander et al. Surgical removal of massive subretinal hemorrhage associated with age‐related
macular degeneration. Ophthalmology 1991;98”23–27.
• Wade et al. Subretinal hemorrhage management by pars plan vitrectomy and internal
drainage. Arch Ophthalmol 1990;108:973–978.

29. TISSUE PLASMINOGEN ACTIVATOR (tPA)
Naturally occurring endogenous serine protease
tPA Fibrin
[tPA-Fibrin]
Plasminogen Plasmin
Fibrin
(insoluble)
Fibrin
degradation products
(soluble)

30. Heriot, 1996
• Physically displacement of SMH out of fovea using expansile gas
• Intravitreal injection of 0.3-0.4 ml SF6 or C3F8 and tPA (25 µg/0.1
ml)
• Face-down head positioning for 1-3 days
• Stretching of retina from subretinal haemorrhage induces
microlesions allowing for diffusion of t‐PA into subretinal space
PNEUMATIC DISPLACEMENT
Heriot W J. Intravitreal gas and tPA: an outpatient procedure for submacular hemorrhage.
Paper presented at the American Academy of Ophthalmology Annual Vitreoretinal
Update; Chicago, IL, 1996

31. Ideal candidates: Thick SMH <3 weeks old involving or inferior to
fovea
Limitations:
• Whether sufficient quantities of t‐PA penetrate retina to cause
dissolution of subretinal clots – questionable
• SMH superior to fovea - hemorrhage may be displaced into
subfoveal space

32. Haupert et al, 2001
• Infusion of 0.4 ml t‐PA (12 µg/0.1 ml) into subretinal space using
32 G rigid cannula
• Fluid‐air exchange
• Postoperative 1 hour face up, and then sitting upright overnight
Haupert et al. Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid‐gas
exchange for displacement of thick submacular hemorrhage in age‐related macular degeneration. Am
J Ophthalmol 2001;131:208–215.

33. • Ensured t‐PA exposure to blood clot
• Minimal manipulation of retina
• High anatomical success rate
• Pneumatic displacement with air (not expansile gas) - fewer
complications such as increased IOP and cataract formation

34. ANTI-VEGF AGENTS
• SMH secondary to AMD
• Poor surgical candidates
• Patients intolerant to prone head positioning
• Patients with subretinal hemorrhage that may be displaced
directly into fovea

35. SURGICAL ADVANCES
• Using an ultramicrosurgical machine to direct a micropipette into
the subretinal space, tPA can be infused and subretinal
hemorrhage aspirated through a retinotomy under 300 µ in
diameter
• Less RPE and retinal damage
• Less damage to photoreceptors during tPA-assisted clot removal
compared to use of forceps
Toth et al. Ultramicrosurgical removal of subretinal hemorrhage in cats. Am J Ophthalmol. 113:175-182,
1992