Macular hole with retinal pigment epithelium tear after anti-VEGF therapy in an eye with neovascular age-related macular degeneration.

Purpose: To report a case of a full-thickness macular hole (FTMH) associated with a retinal pigment epithelium (RPE) tear after anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nvAMD), which was successfully closed by vitreous surgery. Observations: A 73-year-old man with nvAMD in the right eye received an intravitreal aflibercept injection due to enlarged pigment epithelial detachment. However, 2 days after the third injection, the patient experienced a sudden decline in vision. An FTMH with a tear in the underlying RPE was detected. The FTMH was closed using vitrectomy combined with the inverted internal limiting membrane (ILM) flap technique. Conclusions and Importance: Our case highlights a rare complication of both an FTMH and an RPE tear after anti-VEGF therapy. Vitrectomy, with the inverted ILM flap technique, proved effective in closing the FTMH despite the complexity of the case.

Pathogenesis of Pachyvein Formation in Central Serous Chorioretinopathy: A Hydrodynamic Analysis.

Objectives: To attain an understanding of pachyvein formation seen with central serous chorioretinopathy (CSC) by measuring the choroidal blood flow (CBF) velocity and to apply the findings to existing hydrodynamic theorems. Methods: Nineteen subjects with monocular CSC (mean age 51.8 ± 12.7 years) were included. Laser speckle flowgraphy measured the mean blur rate (MBR) in the foveal and perifoveal regions, and the findings were applied to the Equation of Continuity (Q = AV) and Bernoulli's theorem (1/2V2 + P/ρ = constant). Results: The mean foveal/perifoveal MBRs in the CSC eyes were 6.4 ± 3.2/9.6 ± 3.2 (p < 0.001). The mean MBRs in the non-CSC eyes were 8.3 ± 3.2/7.9 ± 2.4 (p = 0.37). The significant foveal CBF velocity decrease in CSC eyes occurs because of exudation from the hyperpermeable choriocapillaris. The subsequent decrease in blood volume due to the exudation elicits a decrease in the blood flow velocity in the inferior venules in accordance with the Equation of Continuity. The decrease in the blood flow velocity may result in an elevated blood flow pressure in the inferior venules and veins at the exudation site, in accordance with Bernoulli's theorem. Conclusion: A significant decrease in the foveal MBR may result from exudation from the hyperpermeable macular choriocapillaris. This decreased velocity may elicit a blood pressure elevation that can expand the inferior venules and veins at the exudation site, so-called pachyvein and pachychoroid formation. The application of hydrodynamic theorems to the measurement of ocular blood flow can provide new insights into the understanding of the pathogenesis of chorioretinal disease.

Effects of Combination Therapy with Intravitreal Ranibizumab and Tissue Plasminogen Activator for Neovascular Age-Related Macular Degeneration.

Background: Subretinal hyper-reflective material (SHRM) sometimes causes vision loss in spite of anti-vascular endothelial growth factor (VEGF) therapy in eyes with neovascular age-related macular degeneration (nvAMD). We evaluated the impacts of combination therapy with intravitreal ranibizumab (IVR) and tissue plasminogen activator (tPA) in eyes with nvAMD accompanying SHRM. Methods: In total, 25 eyes of 25 patients (16 men and 9 women, 76.7 years old), who underwent IVR/tPA for nvAMD with SHRM and were followed up for at least 12 months, were retrospectively reviewed. In total, 15 eyes were treatment-naïve and 10 eyes had previous treatment for nvAMD. Results: In total, 16 eyes had type 2 macular neovascularization (MNV), 5 eyes type 1 MNV with fibrovascular pigment epithelial detachment and 4 eyes polypoidal choroidal vasculopathy. At month 12, SHRM regressed or reduced in 18 eyes (72%) and the best-corrected visual acuity (BCVA) improved in 6 eyes (24%) and was unchanged in 14 eyes (56%), while the mean BCVA was just stabilized. The mean central retinal thickness, macular volume and SHRM thickness significantly improved from 408 µm to 287 µm, from 11.9 mm3 to 9.6 mm3, from 369 µm to 165 µm, respectively (p < 0.01). Conclusions: The combination therapy with IVR/tPA for nvAMD with SHRM may help preserve vision by prompt regression of SHRM.

Electrical stimulation of the lower eyelid orbicularis oculi muscle improves periocular dark circles.

BACKGROUND: We developed and tested the safety and efficacy of a cosmetic device to improve dark circles using electrical muscle stimulation of the orbicularis oculi muscle. METHODS: Overall, 18 participants (36 eyes) were studied. The following five items were evaluated before and after the intervention:(1) the Clinical Dark Circle Score using clinical findings and photographs, (2) transcutaneous oxygen partial pressure (TcPO2) on the lower eyelid, (3) thermography, (4) two-dimensional laser blood flowmetry, and (5) spectrophotometry. RESULTS: The mean score at baseline was 2.0 ± 0.90 (mean ± standard deviation), and that at the end of the study was 1.2 ± 1.0 (Wilcoxon signed-rank sum test, p < 0.0001), indicating a significant reduction. The spectrophotometer showed a significant decrease in a* and L* values before and after use (Wilcoxon signed-rank sum test, p < 0.0001). There was also a weak negative correlation between the change in score and the change in blood flow and TcPO2 measured using a laser perfusion device (Spearman's rank correlation coefficient, r = -0.32 and -0.39, respectively). Stratified analysis of the baseline score showed a strong negative correlation between the change in score and the change in spectrophotometric a* in the subjects/group with mild periocular dark circles (Spearman's rank correlation coefficient, r = -0.46). Contrastingly, no correlation was observed for any of the measurements in the subjects/group with severe periocular dark circles. After 1 month, no device-related ophthalmic adverse events were observed in any of the participants. CONCLUSION: Electrical muscle stimulation could improve periocular dark circles, especially in the subjects/group with mild periocular dark circles, and was safe.

A Case of Posterior Polar Hemispheric Choroidal Dystrophy Successfully Diagnosed With Ultra-Widefield Fundus Autofluorescence and Optical Coherence Tomography Angiography.

We report a case of a 78-year-old man presenting with uncertain visual field loss, ultimately identified as posterior polar hemispheric choroidal dystrophy (PPHCD) using ultra-widefield fundus autofluorescence (FAF) and optical coherence tomography angiography (OCTA). The patient initially reported blurred vision in the left eye and had a previous diagnosis of suspected bilateral normal tension glaucoma based on optic nerve head excavation and static perimetry measurements. Detailed examination revealed suspicious retinal atrophy. Notably, the patient had a tigroid fundus, which complicated the correlation between visual field defect and chorioretinal atrophy. Ultra-widefield FAF highlighted mosaic/patchy hypofluorescent areas, emphasizing this atrophy. OCTA images confirmed choriocapillaris loss in the hemispheric choroidal atrophy and parafoveal atrophy. The combination of these imaging techniques enabled a definitive diagnosis of PPHCD. Long-term follow-up and continued investigation with these imaging modalities may hold promise for a better understanding of disease progression and management in similar cases.

Revolutionizing Patient Monitoring in Age-Related Macular Degeneration: A Comparative Study on the Necessity and Efficiency of the AMD VIEWER.

(1) Background: Age-related Macular Degeneration (AMD) is a critical condition leading to blindness, necessitating lifelong clinic visits for management, albeit with existing challenges in monitoring its long-term progression. This study introduced and assessed an innovative tool, the AMD long-term Information Viewer (AMD VIEWER), designed to offer a comprehensive display of crucial medical data-including visual acuity, central retinal thickness, macular volume, vitreous injection treatment history, and Optical Coherent Tomography (OCT) images-across an individual eye's entire treatment course. (2) Methods: By analyzing visit frequencies of patients with a history of invasive AMD treatment, a comparative examination between a Dropout group and an Active group underscored the clinical importance of regular visits, particularly highlighting better treatment outcomes and maintained visual acuity in the Active group. (3) Results: The efficiency of AMD VIEWER was proven by comparing it to manual data input by optometrists, showing significantly faster data display with no errors, unlike the time-consuming and error-prone manual entries. Furthermore, an elicited Net Promoter Score (NPS) of 70 from 10 ophthalmologists strongly endorsed AMD VIEWER's practical utility. (4) Conclusions: This study underscores the importance of regular clinic visits for AMD patients. It suggests the AMD VIEWER as an effective tool for improving treatment data management and display.

Severe Macular Ischemia Is Associated with a Poor Visual Prognosis and Serious Complications in Eyes with Central Retinal Vein Occlusion.

PURPOSE: This study aims to investigate the factors influencing post-treatment visual acuity (VA) in patients with central retinal vein occlusion (CRVO) with macular edema (ME). METHODS: The subjects of this study were patients who visited our clinic from May 2013 to July 2019 and who could be followed up with for at least 12 months. Cases with hemi CRVO were excluded from this study. Factors considered in the evaluation of visual prognosis at the 12 months included initial best-corrected VA, central subfoveal thickness, CRVO subtype (nonischemic, ischemic, or converted from nonischemic to ischemic), time taken for the first treatment, number of anti-vascular endothelial growth factor agent injections, structural changes in the inner and outer retinal layers, and the presence of macular ischemia in a multiple regression analysis. RESULTS: There were 41 patients with 41 eyes, 27 males and 14 females. The mean age of the patients was 70.5 ± 12.2 (mean ± standard deviation) years. The mean VA was 0.544 ± 0.576, 0.456 ± 0.568, and 0.586 ± 0.665 at the initial visit, 12 months later, and time of last observation, respectively. There were no significant differences in VAs observed between the baseline, month 12, and final visit. Multiple regression analysis revealed that the external limiting membrane score at month 12 (p = 0.030), the VA at initial visit (p < 0.001), and the presence of severe macular ischemia (p < 0.001) were the key factors associated with VA at month 12. Moreover, severe macular ischemia was identified as the only factor affecting decimal VA less than 20/200 at the last observation (p = 0.0092). CONCLUSIONS: Severe macular ischemia is strongly linked to a poor visual prognosis in patients with ME associated with CRVO.

Quantitative Evaluation of Fundus Autofluorescence in Laser Photocoagulation Scars for Diabetic Retinopathy: Conventional vs. Short-Pulse Laser.

Short-pulse laser is popular for its advantages like less pain. However, its effectiveness is still debated. The aim of this study was to compare fundus autofluorescence (FAF) luminosity changes of laser photocoagulation scars between the conventional laser (0.2 s) and the short-pulse laser (0.02 s) for diabetic retinopathy. Conventional and short-pulse laser photocoagulations were performed in six and seven eyes, respectively. FAF images were captured at 1, 3, 6, 12, and 18 months after the treatments. To evaluate FAF, individual gray-scale values of the laser scars adjacent to the retinal arcade vessels were recorded; then, the mean gray values of the scars were divided by the luminosity of arcade vein. The average luminosity ratio of laser scars at 1, 3, 6, 12, and 18 months were 1.51 ± 0.17, 1.26 ± 0.07, 1.21 ± 0.03, 0.95 ± 0.11, and 0.89 ± 0.05 with conventional laser and 1.91 ± 0.13, 1.50 ± 0.15, 1.26 ± 0.08, 1.18 ± 0.06, and 0.97 ± 0.04 with short-pulse laser, respectively. Findings suggest the short-pulse laser displayed delayed hypoautofluorescence progression. This implies potential postponement in post-irradiation atrophic changes, as well as metabolic amelioration delay in the ischemic retina, when compared to conventional laser treatment.

Long-Term Prognosis of Patients with Polypoidal Choroidal Vasculopathy Treated with Photodynamic Therapy.

We evaluated the long-term prognosis of the eyes of patients with polypoidal choroidal vasculopathy (PCV) treated with photodynamic therapy (PDT). In total, 60 eyes of 57 patients diagnosed with PCV and treated with PDT were reviewed retrospectively in real-world settings. The best-corrected visual acuity (BCVA), central retinal thickness (CRT), anatomical findings (vision-threatening findings), and treatment history were assessed. In total, 38 eyes underwent PDT as the initial treatment (initial PDT group) and 22 eyes underwent PDT as a rescue treatment (rescue PDT group). In the initial PDT group, 11 eyes (29%) did not require additional therapy throughout the observation period and maintained good BCVA. A total of 27 eyes (71%) underwent additional treatments and the mean BCVA was only stabilized for 2 years; thereafter, decreased vision occurred even with additional treatments. In the rescue PDT group, 22 eyes (95%) required additional treatment. Hard exudate, serous pigment epithelial detachment, and the total vision-threatening score were related to worse BCVA. Initial PDT may be effective in about 30% of cases with preservation of good vision and no need for additional treatment. However, patients with received rescue PDT needed additional treatment in most cases and the vision decreased in many cases.

The Role of Laser Photocoagulation in Treating Diabetic Macular Edema in the Era of Intravitreal Drug Administration: A Descriptive Review.

Background and Objectives: This study aimed to elucidate the role of laser photocoagulation therapy in the treatment of diabetic macular edema (DME) as an alternative to, or in conjunction with, the first-line treatment, anti-vascular endothelial growth factor (VEGF). Materials and Methods: A comprehensive literature search to identify studies that evaluated the efficacy of laser photocoagulation therapy in the management of DME was performed. The relevant findings of the efficacy of focal/grid laser therapy from data in randomized, controlled trials were synthesized, and the potential of new laser technologies, such as navigated laser systems, pattern scan lasers, and subthreshold lasers, was explored. The usefulness of multimodal imaging-guided laser therapy was also evaluated, with a focus on the potential contribution to anti-VEGF therapy. Results: Focal laser photocoagulation targeting microaneurysms remains an effective therapeutic approach to chronic refractory edema, despite the widespread use of anti-VEGF therapy. To achieve the best possible treatment outcomes, precise identification of microaneurysms is essential. This requires the use of multimodal imaging-guided, highly accurate, minimally invasive coagulation techniques. Subthreshold laser therapy can also reduce the frequency of anti-VEGF injections and minimize treatment burden. Conclusions: Further studies are needed to determine the optimal timing and settings for laser photocoagulation therapy and the potential of new laser technologies in the management of DME. Nevertheless, laser photocoagulation therapy plays an important role in the management of DME, in conjunction with anti-VEGF therapy.

Central Retinal Vein Occlusion after mRNA COVID-19 Vaccination.

A 47-year-old man presented with visual loss in the right eye 8 h after the first dose of a coronavirus disease 2019 (COVID-19) vaccine developed by Pfizer/BioNTech (BNT162b2). The best corrected visual acuity (BCVA) was 20/200. Fundus examination showed dilated and tortuous retinal veins at the posterior pole, retinal hemorrhages throughout the fundus, and macular edema. Fluorescein angiography showed multiple hypofluorescent spots that appeared to be fluorescent block due to retinal hemorrhages and hyperfluorescent leakage from the retinal veins. The eye was diagnosed with central retinal vein occlusion (CRVO). For the treatment of macular edema, intravitreal injection of aflibercept (IVA) was administered and treated with one plus pro re nata regimen. Five IVAs were performed over a 10-month follow-up period, with resolution of macular edema, and the BCVA recovered to 20/20. The patient was young and had no history of diabetes mellitus, hypertension, or atherosclerotic diseases, and his blood tests showed no abnormal findings. Both antigen test and polymerase chain reaction test for COVID-19 were negative, and the antibody test was positive due to vaccination. The development of CRVO in this patient may have been related to COVID-19 vaccination, and the appropriate IVA treatment resulted in a good visual prognosis.

Anti-VEGF Treatment Strategies for 3 Subtypes of Neovascular Age-Related Macular Degeneration in a Clinical Setting: A Multicenter Cohort Study in Japan.

PURPOSE: Neovascular age-related macular degeneration (nAMD) is classified into typical AMD (tAMD), polypoidal choroidal vasculopathy (PCV), and retinal angiomatous proliferation (RAP). This study investigated clinical features of the 3 subtypes and visual outcome associated with treatment regimens in a large cohort of patients with nAMD in a clinical setting. DESIGN: Retrospective multicenter cohort study. PARTICIPANTS: Five hundred patients with treatment-naive nAMD (268 tAMD, 200 PCV, and 32 RAP) initiated with anti-VEGF agents and followed for 1 year. METHODS: Medical records were reviewed to extract demographic data, best-corrected visual acuity at baseline and 1 year after treatment initiation, spectral-domain OCT findings, baseline fellow eye condition, systemic factors, treatment strategies, and number of intravitreal injections in the first year. MAIN OUTCOME MEASURES: Primary outcome measures were anti-VEGF treatment strategy (ranibizumab or aflibercept, anti-VEGF regimen, concomitant photodynamic therapy, drug switch), best-corrected visual acuity at 1 year, and factors associated with visual acuity. RESULTS: Patients with RAP were significantly older, were more commonly women, and had more macular lesions in fellow eye than patients with tAMD and PCV. Smoking history and diabetes prevalence were not different among the 3 subtypes. Frequencies of subretinal fluid were higher and intraretinal fluid were lower in tAMD and PCV than in RAP, whereas serous pigment epithelial detachment and subretinal hemorrhage were higher in PCV than in tAMD and RAP. Choice of anti-VEGF agents and treatment regimens did not differ among 3 subtypes. The aflibercept-to-ranibizumab ratio was approximately 7:3. The mean number of injections in 1 year was 5.3 ± 2.4 in nAMD overall, which was significantly less in pro re nata (PRN) than in treat and extend (TAE) regardless of the anti-VEGF agent. Best-corrected visual acuity improved in all 3 subtypes, although it was not significant in patients with RAP. CONCLUSIONS: This clinical study demonstrates that treatment regimens were similar in 3 subtypes and aflibercept was used in 70% of all patients. Approximately 5 injections were given in the first year regardless of the anti-VEGF agent, which was significantly less in PRN regimen than in TAE. Visual acuity improvement was observed after 1-year anti-VEGF therapy in all 3 subtypes, but was not significant in RAP. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Retinal Microvascular Changes after Intravitreal Triamcinolone Acetonide in Diabetic Macular Edema.

Intravitreal injection of triamcinolone acetonide (TA) is essential for clinical treatment in patients who insufficiently respond to vascular endothelial factor inhibitors for diabetic macular edema (DME). The aim of this study was to investigate microvascular changes treated with TA using optical coherence tomography angiography (OCTA). After TA in twelve eyes of eleven patients with central retinal thickness (CRT), there was a 20% or more reduction observed. Visual acuity, the number of microaneurysms, vessel density, and the foveal avascular zone (FAZ) area were compared before and at 2 months after TA. At baseline, the number of microaneurysms was 2.1 ± 1.1 in the superficial capillary plexuses (SCP) and 2.0 ± 1.1 in the deep capillary plexuses (DCP), with a significant decrease post-treatment to 1.0 ± 1.0 for SCP and 0.8 ± 0.8 for DCP (SCP; p = 0.018, DCP; p = 0.008). There was significant enlargement of the FAZ area from 0.28 ± 0.11 mm2 to 0.32 ± 0.14 mm2 (p = 0.041). There was no significant difference in the visual acuity and vessel density of SCP and DCP. Results indicated that OCTA was useful for the evaluation of qualitative and morphological retinal microcirculation and that intravitreal TA may decrease microaneurysms.

Subtype prevalence and baseline visual acuity by age in Japanese patients with neovascular age-related macular degeneration.

PURPOSE: To investigate age-specific prevalence of disease subtypes and baseline best-corrected visual acuity (BCVA) in Japanese patients with treatment-naïve neovascular age-related macular degeneration (nAMD). STUDY DESIGN: Retrospective multicenter case series. METHODS: We reviewed the records of patients with treatment-naïve nAMD who underwent initial treatment in 14 institutions in Japan sometime during the period from 2006 to 2015. In patients in whom both eyes were treated, only the eye treated first was included for analysis. The patients were stratified by age for the analysis. RESULTS: In total, 3096 eyes were included. The overall prevalence of subtypes was as follows: typical AMD, 52.6%; polypoidal choroidal vasculopathy (PCV), 42.8%; retinal angiomatous proliferation (RAP), 4.6%. The number of eyes in each age group was as follows: younger than 60 years, 199; 60s, 747; 70s, 1308; 80s, 784; 90 years or older, 58. The prevalence of typical AMD in each age group was 51.8%, 48.1%, 52.1%, 57.7%, and 55.2%, respectively. The prevalence of PCV was 46.7%, 49.1%, 44.7%, 34.4%, and 19.0%, respectively. The prevalence of RAP was 1.5%, 2.8%, 3.2%, 7.9%, and 25.9%, respectively. The prevalence of PCV decreased with age, whilst that of RAP increased. The prevalence of RAP was higher than that of PCV in patients aged 90 years or older. The mean baseline BCVA (logMAR) was 0.53. In each age group, the mean baseline BCVA was 0.35, 0.45, 0.54, 0.62, and 0.88, respectively. The mean logMAR BCVA at baseline significantly worsened with age (P < 0.001). CONCLUSION: The prevalence of nAMD subtypes differed according to age in Japanese patients. The baseline BCVA worsened with age.

AUTOLOGOUS POSTERIOR CAPSULE FLAP TRANSPLANTATION IN THE MANAGEMENT OF REFRACTORY MACULAR HOLE IN A PSEUDOPHAKIC EYE.

PURPOSE: To report a case of refractory macular hole (MH) in pseudophakic eye treated with autologous posterior capsule flaps transplantation. METHODS: Case report. RESULTS: A 48-year-old man visited our hospital with visual loss in the right eye because of unclosed MH. The patient had undergone two previous surgeries in another hospital, that is, the first included a cataract surgery, vitrectomy, and internal limiting membrane peeling with sulfur hexafluoride (SF 6 ) gas tamponade, and the second included an ineffective autologous internal limiting membrane flap technique and massaging the edges of the MH with a soft-tipped flute needle followed by the same gas, but the MH remained open. In our hospital, posterior capsule flaps were acquired from the same eye, inserted into the MH, and the same gas tamponade was performed, which was about four months after the disease onset (3 months after the prior second surgery). The patient kept face-down position for a week after the surgery and the MH was closed, which remained for over 12 months. The visual acuity improved from 20/250 to 20/60, and the retinal sensitivities around the MH gradually improved. CONCLUSION: An autologous posterior capsule flaps transplantation was effective in the management of refractory MH to not only close the MH but also improve the visual outcomes.

Genome-Wide Association Study of Age-Related Macular Degeneration Reveals 2 New Loci Implying Shared Genetic Components with Central Serous Chorioretinopathy.

PURPOSE: To investigate the genetic architecture of age-related macular degeneration (AMD) in a Japanese population. DESIGN: Genome-wide association study (GWAS). PARTICIPANTS: Three thousand seven hundred seventy-two patients with AMD and 16 770 control participants from the Japanese population were enrolled in the association analyses. METHODS: We conducted a meta-analysis of 2 independent GWASs that included a total of 2663 patients with AMD and 9471 control participants using the imputation reference panel for genotype imputation specified for the Japanese population (n = 3541). A replication study was performed using an independent set of 1109 patients with AMD and 7299 control participants. MAIN OUTCOME MEASURES: Associations of genetic variants with AMD. RESULTS: A meta-analysis of the 2 GWASs identified 6 loci significantly associated with AMD (P < 5.0 × 10-8). Of these loci, 4 were known to be associated with AMD (CFH, C2/FB, TNFRSF10A, and ARMS2), and 2 were novel (rs4147157 near WBP1L and rs76228488 near GATA5). The newly identified associations were confirmed in a replication study (P < 0.01). After the meta-analysis of all datasets, we observed strong associations in these loci (P = 1.88 × 10-12 and P = 1.35 × 10-9 for meta-analysis for rs4147157 and rs76228488, respectively). When we looked up the associations in the reported central serous chorioretinopathy (CSC) GWAS conducted in the Japanese population, both loci were associated significantly with CSC (P = 4.86 × 10-3 and P = 4.28 × 10-3 for rs4147157 and rs76228488, respectively). We performed a genetic colocalization analysis for these loci and estimated that the posterior probabilities of shared causal variants between AMD and CSC were 0.39 and 0.60 for WBP1L and GATA5, respectively. Genetic correlation analysis focusing on the epidemiologically suggested clinical risk factors implicated shared polygenic architecture between AMD and smoking cessation (rg [the measure of genetic correlation] = -0.33; P = 0.01; false discovery rate, 0.099). CONCLUSIONS: Our findings imply shared genetic components conferring the risk of both AMD and CSC. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Hydrodynamic Analysis of the Clinical Findings in Pachychoroid-Spectrum Diseases.

We wish to demonstrate that theorems of fluid dynamics may be employed to hydrodynamically analyze the clinical presentations seen within the pachychoroid-spectrum diseases (PSD). Methods: We employed both the Equation of Continuity Q = A · V in which Q represents blood flow volume, A the sectional area of a vessel, and V blood flow velocity as well as Bernoulli's Principle 1/2 V2 + P/ρ = constant where V represents blood flow velocity, P static blood pressure and ρ blood density. The Equation of Continuity states that a decrease in flow volume occurs simultaneously with a decrease in the flow velocity and/or sectional area, and vice versa. Bernoulli's Principle states that a decrease in the velocity of a fluid occurs simultaneously with an increase in static pressure, and vice versa. Results: Hyperpermeability of the choriocapillaris, as visualized on fluorescein angiography and indocyanine green angiography (ICGA), causes a fluid exudation and, therefore, a decrease in the blood flow volume Q which elicits a simultaneous decrease in the blood flow velocity V clinically observable in filling delay into the choriocapillaris on ICGA. An increase in the static blood pressure P will simultaneously occur in venules in accord with Bernoulli's Principle. Conclusions: A decrease in the blood flow velocity in the choriocapillaris due to its hyperpermeability will hydrodynamically elicit an increase in the blood pressure in venules. This blood pressure rise may expand Sattler and Haller veins, forming pachyveins. The primary lesion of PSD can be in pigment epithelium and choriocapillaris.

Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group.

PURPOSE: To evaluate the clinical characteristics, treatment trends, and visual prognosis of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) and retinal arterial macroaneurysm (RAM). METHODS: This retrospective study enrolled 187 Japanese patients with SMH at 10 institutions from 2015 to 2018. Medical records including SMH etiology, best-corrected visual acuity (BCVA), fundus photographs, optical coherence tomography images, and selected treatments were analyzed. RESULTS: Major causes of SMH were typical nAMD (tnAMD) (18%), polypoidal choroidal vasculopathy (PCV) (50%) and RAM (29%). Age, male/female ratio, baseline BCVA, central retinal thickness, and involved retinal layers were significantly different between etiologies (all P<0.0001). Treatment with anti-vascular endothelial growth factor drugs with and without intravitreal gas injection was chosen for half of eyes in the tnAMD and PCV groups, whereas vitrectomy was performed in 83.7% of eyes with RAM. The final BCVA improved significantly from baseline in the PCV and RAM groups (P = 0.0009, P<0.0001) and final BCVA was significantly better in the PCV group at a level similar to the other groups (P = 0.0007, P = 0.0008). BCVA improvement from baseline was significantly greater in the RAM group compared with the tnAMD (P = 0.0152) and PCV (P = 0.017) groups. Multivariate analysis revealed better final BCVA was significantly associated with younger age (P = 0.0054), better baseline BCVA (P = 0.0021), RAM subtype (P = 0.0446), and no tnAMD (P = 0.001). CONCLUSIONS: The characteristics of, and treatment strategy for, SMH were different between the underlying diseases. Anti-vascular endothelial growth factor treatment with or without expansile gas was mainly chosen for SMH in tnAMD and PCV, whereas vitrectomy with gas was the most common treatment for RAM, and the higher rate for vitrectomy might result in the greater BCVA improvement in the RAM group than in the other groups. Final BCVA was better in PCV, RAM, and tnAMD, in that order, because patients with PCV were younger and had better baseline BCVA.

Visual prognosis of submacular hemorrhage secondary to age-related macular degeneration: A retrospective multicenter survey.

PURPOSE: To investigate the clinical features, treatment options, and visual outcomes of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD). DESIGN: A retrospective, observational case series. METHODS: Setting: Multicenter institutional setting. Patient Population: A total of 127 patients (127 eyes; 88 men, 39 women; (mean age, 74.2 years)) diagnosed with AMD-associated SMHs exceeding 2 disc diameters involving the fovea. Observation: The AMD types, previous treatments, treatment options, anatomic findings, and best-corrected visual acuity (BCVA) were assessed. Main Outcome Measures: Clinical features, treatment options, and visual outcomes of SMHs secondary to nAMD. RESULTS: Thirty-two eyes had typical AMD, 94 eyes polypoidal choroidal vasculopathy (PCV), and one eye retinal angiomatous proliferation. Eighty-five eyes were treatment-naïve; 42 eyes were treated previously: anti-vascular endothelial growth factor (VEGF) therapy (n = 26), photodynamic therapy (n = 3), and combined therapy (n = 13). Treatment of SMHs included vitrectomy (36 eyes), pneumatic displacement (49 eyes), and anti-VEGF monotherapy (42 eyes). The final BCVA improved significantly in treatment-naïve cases from 0.86 to 0.62 logarithm of the minimal angle of resolution (logMAR) unit (Snellen equivalent from 20/145 to 20/83) and from 0.80 to 0.56 (Snellen equivalent from 20/126 to 20/73) in PCV cases. Meanwhile, the BCVA logMAR values improved from 1.15 to 0.75 (Snellen equivalent from 20/283 to 20/112) and from 0.87 to 0.63 (Snellen equivalent from 20/148 to 20/85) in eyes that underwent vitrectomy or pneumatic displacement, respectively. In eyes with BCVAs between 20/133 to 20/40 at SMH onset, the final VA in the pneumatic displacement group was better than in the anti-VEGF monotherapy group. One eye had a retinal detachment and 1 eye had a macular hole in the vitrectomy group, and 5 eyes had a vitreous hemorrhage in the pneumatic displacement group. CONCLUSIONS: The recommended treatment for SMHs secondary to nAMD exceeding 2 disc area and with BCVA below 20/40 is vitrectomy or pneumatic displacement for visual improvement.

Multimodal Imaging of Subfoveal Pachydrusen Containing a Blood Flow Signal.

Individuals with pachydrusen, larger than 125 µm, have a significantly thicker choroid than do those with soft drusen or reticular pseudodrusen. Little is known about cases of abnormal blood flow within pachydrusen. The purpose of this report was to demonstrate a blood flow signal within pachydrusen using optical coherence tomography (OCT) angiography. A 76-year-old Japanese woman presented with innumerable drusen/pachydrusen in both posterior poles. Her visual acuity was good. OCT showed subfoveal pachydrusen in the left eye, but no exudative changes. The subfoveal choroidal thickness was increased to 274 µm in the left eye. OCT angiography revealed a blood flow signal within the pachydrusen. However, fluorescein and indocyanine green angiographies indicated no abnormal hyperfluorescent lesion in the macula of the left eye. During the 13-month follow-up, the blood flow signal in OCT angiography did not change in diameter, and no exudative change was observed. The blood flow signal may have properties of capillary blood vessels derived from the choriocapillaris, rather than angiogenic vessels from choroidal neovascularization or polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization.