Subretinal hemorrhage after photodynamic therapy for juxtapapillary retinal capillary hemangioma

Abstract

A 75-year-old Japanese woman presented with a juxtapapillary retinal capillary hemangioma (RCH) in her left eye. Twelve months after the initial examination, the size of the hemangioma had increased and the exudation from the RCH involved the macula. Her best-corrected visual acuity (BCVA) had decreased from 0.8 to 0.3. A total of five intravitreal injections of bevacizumab (IVB; 1.25 mg) was given but the RCH did not respond. A photodynamic therapy (PDT) was done using multiple laser spots to avoid damaging the optic nerve head. After the first PDT, the subfoveal fluid was reduced but not completely gone. One week after the second PDT, a massive subretinal hemorrhage developed. The subretinal hemorrhage was successfully displaced by injecting intraocular sulfur hexafluoride (SF(6)) gas. At the 3-year follow-up examination, no subretinal hemorrhage or fluid was observed at the macula and the BCVA remained at 0.05. Our case was resistant to the combination of anti-vascular endothelial growth factor (VEGF) and PDT and had a rare massive subretinal hemorrhage. A further collection of RCH cases treated with anti-VEGF and PDT that would justify this treatment is necessary.

Keywords: Intravitreal bevacizumab; Juxtapapillary retinal capillary hemangioma; Photodynamic therapy; Subretinal hemorrhage.

Figures

Fig. 1

a A juxtapapillary RCH can be seen at the temporal superior border of the optic disc. The patient's visual acuity was 0.8. b Early-phase fluorescein angiogram showing fine network of vessels in the hemangioma. c Late-phase fluorescein angiogram showing dye leakage from the RCH. d One year after the initial presentation, the juxtapapillary RCH has significantly increased in size, and subretinal fluid and exudates are present surrounding the hemangioma. The visual acuity has dropped to 0.3. e Early-phase fluorescein angiogram showing a vascular-rich tumor growing outward from the optic disc. f Tomographic images shown by the scan lines in d. The images show an accumulation of subretinal fluid extending to the macula. The deposition of hard exudates and intraretinal edema can also be seen.

Fig. 2

a Photograph of RCH before the first PDT. The orange-colored lesion with prominent exudation was not reduced by multiple intravitreal bevacizumab and patient's visual acuity was 0.01. b The red circles indicate the area where PDT was applied. To avoid the adverse effects to the optic disc, two laser spots of 2,300 and 3,400 µm were used. c After the first session of PDT, the RCH was still active showing further extension of the vascular lesion. d The red circles indicate the site of the PDT spots applied at the second PDT. Two laser spots of 2,500 and 4,500 µm were used.

Fig. 3

a A massive subretinal hemorrhage including the macula developed 7 days after the second PDT. b After a pneumatic displacement using sulfur hexafluoride gas, the hemorrhage disappeared at the macula. The RCH showed regression and the subretinal fluid decreased. The visual acuity was 0.05 at the final visit.