CASE OF THE MONTH: April 2024

Break Point

Submitted by: James Winebrake, MD; and Kyle Kovacs, MD

7/10/23

  • Healthy 34M presenting day after tennis ball injury to left eye
  • Seen at Mt. Sinai and referred to WCMC retina
  • Complaining of fuzzy, crescent-shaped shadow, gradually worsening
  • ROS otherwise negative











Choroidal Rupture

  • Mechanism
    • Closed globe/blunt trauma
    • Scleral tensile strength + retinal elasticity + Bruch's relative fragility
    • Break in choroid, Bruch's, retinal pigment epithelium (RPE)
  • Appearance
    • White-yellow curvilinear subretinal streak concentric to nerve
    • Superimposed choriocapillaris bleed into sub-RPE/subretinal space
    • DDx: angioid streaks, myopic lacquer cracks, other CNV
  • Management
    • Observation/Amsler
    • CNV → consider anti-VEGF
    • Submacular hemorrhage  consider other intervention1

Submacular Hemorrhage

  • Animal models of damage to overlying neurosensory retina
    • Dislodging/stripping of photoreceptors by fibrin clot contraction
    • Hemoglobin-derived iron → oxidative stress-induced apoptosis
    • Mechanical barrier to metabolic support by RPE/choriocapillaris
  • Early evacuation may improve surgical/visual outcomes2
    • Risk of mechanical trauma, recurrent CNV, scarring, PVR

Submacular Hemorrhage: Interventions

  • Variable outcomes, limited prospective data
    • Worse: ARMD (largest body of literature), +CNV, larger/thicker
    • Minimal relative benefit of submacular surgery for nAMD (Submacular Surgery Trials Group B)3

  • Macular translocation
  • RPE patch graft4
  • Pneumatic displacement, intravitreal tPA5
  • PPV, subretinal tPA6
  • Pneumatic displacement with7 or without8 tPA +/- anti-VEGF
  • Photodynamic therapy9


Traumatic Submacular Hemorrhage

  • Case reports
    • PPV/subretinal tPA for traumatic cases due to choroidal rupture10
    • PPV/subretinal tPA/lavage/aspiration/SF6 for same11
    • Pneumatic/intravitreal TPA for same12
    • All promising but still case-by-case basis

7/10/23

  • Choroidal rupture with submacular hemorrhage, left eye
    • Observe vs. evacuation +/- tPA

  • Traumatic iritis
    • Prednisolone q2h, cyclopentolate BID, polytrim QID

Interval history

  • Choroidal rupture with submacular hemorrhage, left eye
    • Observe vs. evacuation +/- tPA
      • 7/11/23: observed given lack of foveal involvement
      • 7/17/23: increased subretinal hemorrhage  aflibercept
      • Traumatic iritis
    • Prednisolone q2h, cyclopentolate BID, polytrim QID
      • 7/17/23: Resolving anterior inflammation, residual mydriasis and angle recession → gonioscopy
      • Traumatic peripheral hyaloid separation with small horseshoe tear
    • Lasered

    • 7/24/23

    • Returns post-trauma day 15
    • Increasing "blind spot"
    • ROS again otherwise negative








    • Choroidal rupture with subretinal hemorrhage, left eye
      • 7/11/23: observed
      • 7/17/23: increased subretinal hemorrhage → aflibercept
      • 7/24/23: worsening vision despite improving hemorrhage
    • Placoid/annular outer retinal white lesions and disc edema, left eye
    • Traumatic peripheral hyaloid separation with small horseshoe tear
      • Lasered
      • Traumatic iritis
      • Resolved AC inflammation, residual mydriasis and angle recession


    Consider: Infectious


    Posterior Tubercular Uveitis


    Acute syphilitic posterior placoid chorioretinitis (ASPPC)


    Consider: White Dots


    Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE)


    Multiple Evanescent White Dot Syndrome (MEWDS)


    Multifocal Choroiditis (and Panuveitis) (MFC)


    7/24/23


    • Next steps?
      • Labs
        • ESR/CRP, ANA, RPR, Quant Gold, Bartonella, dsDNA
          • All negative/within normal limits
      • Meds
        • Oral prednisone 60 mg/day
        • Omeprazole 20 mg/day
        • Decrease topical prednisolone
        • Cyclopentolate daily as needed
      • Uveitis referral
        • Agreed with current management; long steroid taper
      • Further discussion

    7/31/23



    Post-Traumatic White Dots








    9/25/23



    Figures/Images:

    • https://eyewiki.aao.org/w/images/1/6/67/Choroidalrupture.jpg
    • https://core4.bmctoday.net/storage/images/priya-fig-4_1658425715.png
    • https://www.hindawi.com/journals/joph/2020/4701820/fig1/
    • https://www.aao.org/image.axd?id=00cbb295-3a34-4c2f-b389-ae30979af854&t=637442512578132340
    • https://doctorlib.info/ophthalmology/principles/principles.files/image399.jpg
    • https://doctorlib.info/ophthalmology/principles/principles.files/image395.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/APMPPE/APMPPE-1-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/APMPPE/APMPPE-3-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/APMPPE/APMPPE-4-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/APMPPE/APMPPE-2-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/MEWDS/MEWDS-fundus-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/MEWDS/MEWDS-FA-early-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/MEWDS/MEWDS-FA-late-LRG.jpg
    • https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/MCP/MFC-OD-lrg.jpg
    • https://media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs12348-021-00278-8/MediaObjects/12348_2021_278_Fig5_HTML.png

    References:

    1. Lupidi M, Muzi A, Castellucci G, et al. The choroidal rupture: current concepts and insights. Surv Ophthalmol. 2021;66:761-770. https://pubmed.ncbi.nlm.nih.gov/33545177/
    2. Tsuyama T, Hirose H, Hattori T. Intravitreal tPA Injection and Pneumatic Displacement for Submacolar Hemorrhage in a 10-Year-Old Child. Case Rep Ophthalmol Med. 2016;2016:9809583. doi:10.1155/2016/9809583
    3. Hawkins BS, Bressler NM, Miskala PH, et al. Surgery for subfoveal choroidal neovascolarization in age-related macular degeneration: ophthalmic findings: SST report no. 11. Ophthalmology. 2004;111(11):1967-1980. doi:10.1016/j.ophtha.2004.07.021
    4. MacLaren RE, Uppal GS, Balaggan KS, Tufail A, Munro PM, Milliken AB, Ali RR, Rubin GS, Aylward GW, da Cruz L. Autologous transplantation of the retinal pigment epithelium and choroid in the treatment of neovascular age-related macular degeneration. Ophthalmology. 2007 Mar;114(3):561-70.
    5. Heriot WJ. Intravitreal gas and TPA: an outpatient procedure for submacular hemorrhage. Paper presented at: American Academy of Ophthalmology Annual Vitreoretinal Update; Chicago, IL; October 1996.
    6. Fine HF, Iranmanesh R, Del Priore LV, et al. Surgical outcomes after massive subretinal hemorrhage secondary to age-related macular degeneration. Retina. 2010;30(10):1588-1594. doi:10.1097/IAE.0b013e3181e2263c
    7. Chang W, Garg SJ, Maturi R, et al. Management of thick submacular hemorrhage with subretinal tissue plasminogen activator and pneumatic displacement for age-related macular degeneration. Am J Ophthalmol. 2014;157(6):1250-1257. doi:10.1016/j.ajo.2014.02.007
    8. Kitahashi M, Baba T, Sakurai M, et al. Pneumatic displacement with intravitreal bevacizumab for massive submacular hemorrhage due to polypoidal choroidal vasculopathy. Clin Ophthalmol. 2014;8:485-492. Published 2014 Mar 3. doi:10.2147/OPTH.S55413
    9. Rouvas AA, Papakostas TD, Ntouraki A, Douvali M, Vergados I, Ladas ID. Photodynamic therapy, ranibizumab, and ranibizumab with photodynamic therapy for the treatment of polypoidal choroidal vasculopathy. Retina. 2011;31(3):464-474. doi:10.1097/IAE.0b013e3181f274ec
    10. Laatikainen L, Mattila J. Tissue plasminogen activator (tPA) to facilitate removal of post-traumatic submacular haemorrhage. Acta Ophthalmol Scand. 1995 Aug;73(4):361-2.
    11. Steinhorst UH, Theischen M, Winter R. Subretinal lavage: a technique of continuous subretinal irrigation for removal of traumatic submacular hemorrhage. Ophthalmologica. 1997;211(6):399-401.
    12. Holland D, Wiechens B. Intravitreal r-TPA and gas injection in traumatic submacular hemorrhage. Ophthalmologica. 2004 Jan-Feb;218(1):64-9.