FP431 : Submacular Blood Removal with RPE-Choroid Graft Transplantation in Marked Submacular Hematomas

Dr. Boral Subhendu Kumar, B09751, Dr. Santanu Mandal, Dr. Tushar Kanti Sinha, Dr. Das Arnab

Introduction :

Common causes of sub retinal hematomas are i)ARMD, ii) Polypoidal choroidal vasculopathy, iii) Macro aneurysm and iv) trauma. Visual prognosis of sub macular haemorrhage usually poor if left untreated. This is the result of the following factors :

• A barrier effect that prevents metabolic exchange between the retina and choriocapillaris,
• Toxicity of iron and hemosiderin released by the haemoglobin,
• Fibrin infiltration between the inner and outer segments of photoreceptors can result in destructive shearing of the cells
• Shearing of the outer segments of the photoreceptors from contraction of the haemorrhage.
• The prognosis of sub macular haemorrhage is further worsened if the haemorrhage is thick and is associated with age related macular degeneration
• Eventually, without treatment, a sub macular fibrotic scar forms, especially in patients with wet AMD, which permanently limit any hope for visual acquity. Retinal damage can occur as early as 24 hours. There is a period of window of opportunity and that is within first 2 weeks of onset.

There are some pre requisites for sub retinal hematoma drainage, which are as follows:

1. Good photoreceptor – can be assessed by recent drop in vision
2. Recent drop or still good visual acuity

• OCT

1. Duration of loss of reading capacity
2. Central visual field defect

Treatment strategies :

All sub macular haemorrhages can be divided into three categories –

1. If small (1-2DD)- Intra vitreal anti-VEGF or pneumatic displacement and follow up.
2. If medium sized (<5DD) – Intra vitrealtPA (tissue Plasminogen Activator) injection + SF6 gas injection + Anti VEGF injection. If it fails to displace the sub macular blood, then one should go for Vitrectomy + Sub retinal tPA injection.
3.  If large and elevated (>5DD) – then Vitrectomy along with sub retinal blood removal with or without full thickness RPE-Choroid transplant can be performed.

Mac Laren RE et al showed that autologous RPE transplantation can in principle restore vision in neovascular AMD, but surgical complications remain high.¹

Indications for surgical drainage of sub retinal blood are :

• Large markedly elevated sub macular hematoma

• RPE tear

• No response after repeated anti – VEGF Injections

• Haemorrhagic retinal detachment ( post AMD / PCV )

Purpose : To study the results of sub macular blood removal with isolated autologous full thickness RPE-Choroid transplantation in marked sub macular hematoma cases in Indian population.

Materials and Methods:

A prospective, nonrandomised study done in eight consecutive patients of massive sub macular hematomas from east India, where two were diffusely distributed.

Inclusion criteria:

1. Marked sub retinal hematoma ( post age related macular degeneration or polypoidal choroidal vasculopathy)
2. Subretinal hematomas with profound vision loss, not responding to anti VEGF injections
3. c) Haemorrhagic retinal detachment (post AMD/PCV) with or without vitreous haemorrhage.

Exclusion criteria:

1. Absence of presence of light (PL)
2. Cases of sub retinal hematomas selected for vitrectomy with sub retinal tPA (tissue plasminogen activator) injection.

In all, following steps were followed:

A) 23G vitrectomy done followed by induction of retinal detachment with or without

41G cannula

1. B) Temporal 180⁰retinectomy performed
2. C) Sub macular blood removed
3. D) Choroidal neovascular tissue removed.
4. E) PFCL injected subretinally.
5. F) A 3mm/ 2mm (approx) full thickness RPE-Choroid autologous graft taken from

a relatively healthy quadrant at mid periphery

1. G) Graft transfer done under PFCL to sub macular area
2. H) Retinal flap re apposed with PFCL and laser done.
3. I) Silicone oil (5000 cst) used for tamponade.

Post operatively wide-field fundus photographs (Optos), serial OCT, ICG and multifocal ERG done.

Results :

Mean age of presentation 67.88 ± 10.03 years.

All patients presented with profound vision loss.

Mean post-operative BCVA improved to 1.17 ± 0.25 LogMAR.

Follow up varied from 2months to 15 months.

Hemorrhagic retinal detachments were seen in 2/8 cases (probability 0.25).

Graft edema decreased with follow up and gradually incorporated with surrounding RPE-Choroidal complex.

ICG showed re-vascularization of translocated graft in 2 months.

Postoperatively multifocal ERG (after 6 months) showed some wave form. None of cases developed re-bleed. Only one case showed extensive sub retinal scarring.

Silicone oil removed after 4 to 6 months of primary intervention.

Clinical characteristics :

SL	Preop BCVA	No of intra vitreal anti VEGF Inj	C/F	Surgery done	Postop BCVA (Log MAR)	FU	Additional complications	SOR	ICG	ERG
1	FCCF	3 Inj	VitHge+Sub macular hematoma(AMD)	Vit + Sub retinal blood removal +RPE-Choroid graft	1	15	Rec RD…Re Sx done	Not done	–	Y
2	PL+PR Accurate	5 Inj	-do-	-do-	1	9	–	Yes	Y	Y
3	FC 1ft	14 Inj	Submacular hematoma(AMD)	-do-	0.78	2	–	Yes	Y	–
4	HMCF	3 Inj	IMSC+LargeSubmacular hematoma(AMD)	-do- along with Phaco IOL	1.4	6	Excessive sub retinal scarring	Yes	–	–
5	PL+PR inaccurate	Nil	VitHge +Haemorrhagic RD(PCV)	-do-	1.4	2	–	Yes	Y	Y
6	FCCF	16	Sub macular hematoma(AMD)	-do-	1	3	–	No		–
7	PL+PR inaccurate	Nil	IMSC+VitHge+Haemorrhagic RD(PCV)	-do- along with Phaco IOL	1.4	2	–	No	Y	Y
8	PL+PR Accurate	3	Sub macular hematoma(AMD)	-do-	1.4	1	–	Yes	Y	Y

Discussions :

Beneficial effects of sub macular blood removal :

1. Removal of barrier effect and toxic effects of sub macular collected blood
2. Removal of choroidal neovascular tissue (fleshy/ partially scarred) — nearly completely remove the possibility of re-bleed.

Beneficial effects of autologous RPE Choroid patch graft :

1. Transplantation of healthy autologous RPE cells
2. Revascularization occurs in translocated RPE Choroid graft by new feeder vessels over several weeks (ICG proved).

Cereda et al showed that the creation of an full thickness RPE-Choroid flap through a 180 degrees peripheral retinotomy is feasible and safe.²Maaijwee K et al showed an autologous free RPE-choroid graft may stabilise or improve vision in patients with exudative AMD up to 4 years after surgery.³   In our study also it showed that submacular blood removal and full thickness RPE-choroid graft is a viable option in cases with severe vision loss. 2/8 cases presented with haemorrhagic RD, may be due to late presentation in this setting. As we have not seen any case of recurrent sub retinal haemorrhage in our study, it indirectly reflects that removal of neovascular tissue remove the possibility of rebleed. Maajijwee et al observed perfusion 29/31 patients on ICG, suggesting that anatomical reperfusion do happen in the transplanted graft.⁴  In the present study ICG showed reperfusion after 2 months. In our study, some ERG wave patterns in postoperative period denote a functioning graft.

Conclusion :

Timely drainage of sub macular hematomas decreases further damage. Removal of neovascular tissue almost removed the possibility of re-bleed and thus decreased the cost burden. Autologous full thickness RPE-Choroid transplantation provided healthy RPE cells. ERG and ICG proved both anatomical and functional improvement as well as restoration of ambulatory vision with minimal risk of recurrence.

References :

1. 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;114(3):561-70.
2. Cereda MG, Parolini B, Bellesini E, Pertile G. Surgery for CNV and autologous choroidal RPE patch transplantation: exposing the submacular space. Graefes Arch ClinExpOphthalmol. 2010;248(1):37-47.
3. Maaijwee K, Heimann H, Missotten T, Mulder P, Joussen A, Meurs JV. Retinal pigment epithelium and choroid translocation in patients with exudative age-related macular degeneration: long-term results. Graefe’sArchive for Clinical and Experimental Ophthalmology. 2007;245(11):1681–9.
4. Maaijwee K, Van den B, Pieter R, Missotten T, Van Meurs JC. Angiographic evidence for revascularization of an RPE-Choroid graft in patients with age related macular degeneration. Retina. 2008;28(3):498-503.