Age Related Macular Degeneration – additional opinion
62-year-old male complained of decreased visual acuity in his right eye for 1 week. His past ocular history was relevant for an episode of central serous choroidopathy. Upon examination there was a large subretinal hemorrhage in the macular area , with a visible choroidal neovascularization. Intravitreal Bevacizumab (Avastin) was injected. One week following treatment, there was still macular bleeding and no improvement in visual acuity. Therefore, a vitrectomy was performed. There was impressive resolution of the subretinal hemorrhage but still some intraretinal fluids.
The patient asks about the diagnosis, the recommended treatment options and about centers of excellence.
The above 62 year old patient was first examined in the out patient clinic on November 2007, complaining of decreased visual acuity in his right eye for 1 week. His past ocular history was relevant for an episode of central serous choroidopathy in 1991. Upon examination in November his visual acuity was 0.32 (20/60) in the right eye, and 1.0 (20/20) in the left. The anterior segments were normal in both eyes, and in the right eye there was a large subretinal hemorrhage in the macular area, with a visible choroidal neovascularization, as seen on fluoresceing angiography, Indocyanine green Angiography, and OCT. Intravitreal Bevacizumab (Avastin) was injected in the right eye. One week following treatment, there was still macular bleeding and no improvement in visual acuity. Therefore, three weeks following injection, a vitrectomy was performed. The details of the surgery are not given in the notes, but probably removal of subretinal blood was performed. At follow up about 1 month after surgery the visual acuity in that eye was 0.20 (20/100), with increased intraocular pressure to 34 mmHg, which was treated medically. On March 2008, 3 months following surgery, the visual acuity was 0.3 (20/80), the intraocular pressure 20 mmHg, there was impressive resolution of the subretinal hemorrhage but still some intraretinal fluids on OCT. Follow up examination was scheduled at 6 weeks.
Impression and recommendation:
The above referenced patient suffered from a subretinal hemrrohage which resolved nicely following a vitrectomy. In the last OCT, performed on March 2008, there is still some retinal fluid. The underlying diagnosis causing the choroidal neovascularization and the hemorrhage is not clear to me, since I cannot see in the notes or in the images the existence of drusen (the hallmark of age- related macular degeneration), but this maybe due to the quality of the scanned pictures. In any event, he does have choroidal noevascularization and should be treated accordingly.
At his next scheduled visit (which I believe was scheduled at 6 weeks following the last reported one) he should have a repeat OCT. Should the OCT still show the existence of fluids in or under the retina, a repeat injection of bevacizumab (Avastin) can be considered.
I would be happy to see this patient in my practice if he wishes to travel to the Israel, however, it seems to me that he is getting the most appropriate treatment in China.