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  • Submacular Hemorrhage and Timing of Anti-VEGF Therapy

    By Jean Shaw
    Selected By: Andrew P. Schachat, MD

    Journal Highlights

    Ophthalmology Retina, April 2021

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    More retina physicians are employing a treat-and-extend anti-VEGF regimen for their patients with age-related mac-ular degeneration (AMD)—but do prolonged dosing intervals raise the risk of large submacular hemorrhages (SMHs)? Matsunaga et al. set out to characterize the timing of large SMHs in patients with wet AMD. They found that treat-and-extend regimens do not seem to be associated with large SMHs in these patients, and they suggest that a mechanism other than loss of effec­tive VEGF inhibition may play a role.

    For this retrospective case series, the researchers included 42 patients (42 eyes) who had a large SMH resulting from wet AMD and were selected to undergo pars plana vitrectomy with subretinal tissue plasminogen activator. Mean age was 82 ± 9.9 years, and 60% of the patients were taking anticoagula­tion or antiplatelet medications. All patients received intravitreal injections of one or more of three anti-VEGF drugs (aflibercept, bevacizumab, and ranibizumab) in a treat-and-extend fashion. The main outcome measures included the timing of SMH in relation to the last anti-VEGF injection and treatment status at the time of SMH.

    When their SMH occurred, 19 (45%) of the patients were stable, 15 (36%) were treatment-naive, five (12%) were on a recently extended anti-VEGF dosing regimen, and three (7%) were on a shortened anti-VEGF regimen. The average treatment interval at the time the hemorrhage occurred was 6.8 weeks, with an average of 13.2 total in­jections (median, 7; range, 1-37) before SMH. The average time between last injection and SMH was 29 days (range, 5-62 days), and SMH was more likely to occur within 30 days of an anti-VEGF injection than after 30 days (p < .001).

    The authors noted that this study’s limitations include its selection for patients who had large SMHs and underwent surgical intervention. Thus, the findings may not apply to smaller subretinal hemorrhages or to those not affecting the fovea. They noted that large, controlled studies are needed to further assess the risks of SMH in AMD and to shed light on its underlying mechanisms.

    The original article can be found here.