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Observation may work for macular hemorrhage secondary to retinal arterial macroaneurysms
Study with novel data-gathering method finds that surgery is not always necessary.
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MIAMI — Instead of surgical intervention for macular hemorrhage secondary to retinal arterial macro-aneurysms, practitioners should give serious consideration to observation only. A retrospective study of 41 eyes of 41 patients at multiple centers concluded that observation alone can often lead to favorable visual acuity (VA) outcomes.
“Observation is a reasonable alternative to surgery,” said first author Cathleen M. McCabe, MD, a resident in ophthalmology at the Bascom Palmer Eye Institute, University of Miami School of Medicine. “There have been some recently published articles describing vitrectomy with removal of subretinal blood. That is certainly an option; however, any time surgery is performed, there are possible complications.” In addition, “some patients are simply not good surgical candidates, such as those with multiple medical problems,” she said.
The data for the study, which appeared in Archives of Ophthalmology, were obtained in a novel way. “We created a data form that was faxed to over 40 retina specialists across the country,” Dr. McCabe said. “We asked these clinicians to fill out data on their patients regarding vision, pigmentary alterations, follow-up time and the final visual acuities.” Respondents also forwarded the investigators clinical images that could be correlated with the visual acuities and findings on follow-up. The average follow-up was 15.7 months.
Comparable VA
“If you look at all of the published cases of macular hemorrhage from retinal artery macroaneurysms that were treated surgically — vitrectomy with physical drainage of the subretinal blood, not necessarily combined with tissue-type plasminogen activator [TPA] — and compare them with all the natural history cases, such as ours, you find there is very little difference in visual acuity outcomes,” Dr. McCabe said.
On initial examination, VA was 20/200 or worse in all except four of the 41 patients who were managed by observation alone. Three of the four remaining patients were 20/70 and one was 20/80. At final follow-up, though, VA of 20/40 or better was achieved in 15 eyes (37%), between 20/50 and 20/100 in 12 eyes (29%) and 20/200 or worse in 14 eyes (34%).
“For a long time, people had the notion that if you leave blood underneath the retina — especially in the macular region — it was going to negatively affect visual acuity outcomes,” Dr. McCabe said. “These animal studies showed that there was anatomical damage to the retina. But we now know in selected cases that observation can result in good visual acuity outcomes. It is not always true that damage occurs from subretinal blood in that location.”
Still, the current investigators found that poor VA outcomes were associated with macular pigmentary changes after resorption of blood. “Pigmentary changes that remain after the resorption of the blood negatively affect the visual acuity,” Dr. McCabe said. Macular pigmentary abnormalities were noted after clearance of the hemorrhage in 23 (56%) of the 41 cases. “But we don’t have a perfect causal relationship,” she said. Of those with macular pigmentary changes, a VA of 20/40 or better was achieved in five (22%) of the 23 eyes, between 20/50 and 20/100 in eight eyes (35%) and 20/200 or worse in 10 eyes (43%).
The authors stated that one limitation of their study is that best corrected Snellen VAs were not obtained according to a standardized protocol because of the retrospective nature of the project.
Other treatment options
Harry W. Flynn Jr., MD, a professor of ophthalmology at Bascom Palmer Eye Institute, is a co-author of the study. He said that two additional treatment options for the management of this rare condition have been reported. The first, Nd:YAG laser photodisruption of the anterior surface of the hemorrhage (allowing drainage of the blood into the vitreous), has minimal published data. “I am not optimistic about this treatment because of the potential risk of damaging the retina,” Dr. Flynn said.
The other treatment option is pneumatic displacement of macular hemorrhage, with or without pretreatment with intravitreal TPA. “This treatment does have potential of displacing the blood in a subretinal or subhyaloid location,” Dr. Flynn said. “But there also is very little clinical experience using this technique for macular hemorrhage caused by ruptured arterial macroaneurysms.” Of the two interventions, Dr. Flynn personally favors the displacement approach. “And in my opinion, it doesn’t matter whether a patient has been pretreated with TPA,” he said.
In closing, managing by observation “does not necessarily cause irreversible and severe visual loss,” Dr. Flynn said. Added Dr. McCabe, “The clinician should know that observational management may result in very good outcomes in this particular subgroup of patients.” Furthermore, “this method of obtaining clinical data might be used as a model for studying large numbers of patients with rare diseases,” she said.
For Your Information:Reference:
- Cathleen M. McCabe, MD, can be reached at Bascom Palmer Eye Institute, 900 N.W. 17th St., Miami, FL 33136 U.S.A.; +(1) 305-326-6618; fax: +(1) 305-326-6417; e-mail: drcmccabe@hotmail.com.
- Harry W. Flynn Jr., MD, can be reached at Bascom Palmer Eye Institute, 900 N.W. 17th St., Miami, FL 33136 U.S.A.; +(1) 305-326-6618; fax: +(1) 305-326-6417; e-mail: hflynn@med.miami.edu.
- McCabe CM, Flynn HW Jr, McLean WC, et al. Nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms. Arch Ophthalmol. 2000;118:780-785.