Preventing hemorrhage in end-stage NVAMD

[Dusn]

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Blue Sclera posted recently about trying to make this msg board more clinical and given that it seems like we have some very knowledgable retina specialists here, I'll present a case that comes up often and I'd like to see they'd do:

Suppose you have an elderly patient with end-stage wet AMD in one eye. He has had several years of 20/400 or counting fingers vision in one eye with a fibrotic macular scar and overlying loss of the ellipsoid zone. At the edge of the scar you see a new >1DD sub-retinal hemorrhage in a pretty extra-foveal location. What would you advise the patient?

On one hand this patient has no prospect of central vision improvement. On the other hand his central scotoma might enlarge if he hemorrhages more or he may get a vitreous hemorrhage blocking out his peripheral vision.

Would you offer monthly anti-VEGF injections until the heme clears? PDT? Thermal laser? Or rec: observation?

If you chose injections -- What if the patient does not want monthly injections if they have poor vision and no prospect of vision improvement, as many patients don't? Would you do PDT or thermal? Do you think one mode of laser treatment is much better than the other in this scenario?

What if the patient is on a strong blood thinner: coumadin, pradaxa, eliquist, xarelto, etc.. would that change your recommendation?

Thanks for the posts!

 

[speyeder]

Blue Sclera posted recently about trying to make this msg board more clinical and given that it seems like we have some very knowledgable retina specialists here, I'll present a case that comes up often and I'd like to see they'd do:

Suppose you have an elderly patient with end-stage wet AMD in one eye. He has had several years of 20/400 or counting fingers vision in one eye with a fibrotic macular scar and overlying loss of the ellipsoid zone. At the edge of the scar you see a new >1DD sub-retinal hemorrhage in a pretty extra-foveal location. What would you advise the patient?

On one hand this patient has no prospect of central vision improvement. On the other hand his central scotoma might enlarge if he hemorrhages more or he may get a vitreous hemorrhage blocking out his peripheral vision.

Would you offer monthly anti-VEGF injections until the heme clears? PDT? Thermal laser? Or rec: observation?

If you chose injections -- What if the patient does not want monthly injections if they have poor vision and no prospect of vision improvement, as many patients don't? Would you do PDT or thermal? Do you think one mode of laser treatment is much better than the other in this scenario?

What if the patient is on a strong blood thinner: coumadin, pradaxa, eliquist, xarelto, etc.. would that change your recommendation?

Thanks for the posts!

I usually try several injections to see if the heme resolves. If it doesn't then I recommend observation. As you pointed out, there is no hope for central VA with a large scar and loss of the photoreceptors. Treating with injections would minimize the risk of a large subretinal bleed and loss of peripheral VA but it would also subject the patient to the risks of endophthalmitis.

If the fellow eye had similarly poor or worse VA, then I may be more aggressive in treating.

Patients on anticoagulation therapy present more of a challenge, as I've seen massive subretinal bleeds involving almost the entire macula in the setting of wet AMD. In those patients I may consider injecting q 6-8 weeks to prevent a catastrophic bleed.

I personally don't perform PDT or laser for CNV but it's an interesting thought.

 

[MstaKing10]

I always start the discussion with these patients that if we chose to treat, it is not to improve vision, rather, our goal is to preserve the vision that is present and limit the size of the central scar that is causing their central scotoma. I really try to clarify that to make sure there is no false hope or misunderstanding.

It all depends on the patient. If this is their worst eye and the fellow eye is dry with decent vision, I would observe monthly then treat if there is any worsening. If the fellow eye is in the same shape or worse, I may treat monthly until the heme clears then prn. If they do not want to come in monthly or have transportation issues etc. I may treat simply to prevent a bleed and minimize the exam burden. If there is a history of a massive bleed in the past I would also be more inclined to treat.

I've seen catastrophic bleeds in anti-coagulated and non-anti-coagulated patients, however, I think I might be more inclined to treat in those patients, especially if they have a history of bleeds in the past which many do.

If the lesion on angiogram/ICG is completely extrafoveal and predominantly classic I think PDT or thermal laser would be a good thought. This is rarely the case however. Most patients with this degree of disease usually have diffuse leakage and occult lesions. I'm not sure PDT would prevent bleeding in this scenario and thermal laser would not be the best option. Injections are so effective they are really the best option in most circumstances.

 

[MullerCell]

If they have a disciform scar involving the central macula, I am very unlikely to recommend an injection. Would consider treating if the fellow eye is even worse off or the have noted a drop in vision that is somehow impacting their level of functioning (this is almost never the case). Other than likely reducing the small risk of a massive hemorrhage, I'm not really sure what you are hoping to achieve by treating them?

 

[Visionary]

In my experience, most of this edge activity on disciform scars tends to resolve spontaneously. I therefore only offer treatment if the patient is symptomatic. In some instances, the area of activity is actually the area of fixation. If this is their better eye, they may be very symptomatic. As to the anticoagulation issue, I have seen some bad hemorrhages, but that does not change my approach.

 

[Dusn]

Thanks for the opinions. It seems that most are leaning towards observation which I may be more inclined to do.