Elsevier

American Journal of Ophthalmology

Volume 149, Issue 2, 1 February 2010, Pages 316-321.e1
American Journal of Ophthalmology

Original article
Subretinal Hemorrhages Associated with Age-Related Macular Degeneration in Patients Receiving Anticoagulation or Antiplatelet Therapy

https://doi.org/10.1016/j.ajo.2009.08.033Get rights and content

Purpose

To evaluate the incidence of and risk factors for subretinal hemorrhages in age-related macular degeneration (AMD) patients on anticoagulation or antiplatelet therapy.

Design

Retrospective, observational case series.

Methods

We retrospectively reviewed the medical and photographic records of 71 consecutive patients who sought treatment at our institution with acute subretinal hemorrhages complicating age-related macular degeneration. The size of the subretinal hemorrhage was measured in standardized Macular Photocoagulation Study disc areas. Data on the use of medications and medical indications for anticoagulation and antiplatelet therapy were obtained.

Results

Overall, patients receiving antithrombotic therapy had a significantly larger subretinal hemorrhage size (mean, 9.71 disc areas) than patients not receiving anticoagulant or antiplatelet therapy (mean, 2.99 disc areas). Subgroup analysis revealed that both antiplatelet (P < .0001) and anticoagulant therapy (P = .003) were associated with a significantly larger bleeding size. Moreover, subgroup analysis among patients with arterial hypertension revealed that individuals receiving antithrombotic therapy had a statistically significantly larger hemorrhage size than hypertensive patients who did not receive anticoagulants or antiplatelet agents (P < .0001).

Conclusions

Our results indicate that anticoagulants and antiplatelet agents are strongly associated with the development of large subretinal hemorrhages in AMD patients. Moreover, arterial hypertension is a strong risk factor for large subretinal hemorrhages in AMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in AMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

Section snippets

Methods

We retrospectively reviewed the medical and photographic records of 71 consecutive patients who sought treatment at our institution with subretinal hemorrhages complicating AMD. All patients had acute hemorrhages (< 1 week old) and reading vision in the affected eye before the onset of hemorrhage. If both eyes of the same patient met the inclusion criteria, only the first affected eye was selected for further analysis to avoid possible bias. Patients were excluded whenever pathologic myopia,

Results

Seventy-one patients (71 eyes; 25 males and 46 females; mean age, 75.8 years; range, 50 to 94 years) were included in the study. The mean size of subretinal hemorrhages was 5.63 disc areas (range, 0.1 to 32 disc areas; median, 1.5 disc areas). The mean hemorrhage size among patients with severe subretinal hemorrhages (≥ 4.5 disc areas) was 14.1 MPS disc areas (range, 5 to 32 MPS disc areas; median, 10.0 disc areas) compared with a mean hemorrhage size of 1.1 MPS disc areas (range, 0.1 to 4.0

Discussion

Severe submacular hemorrhage, particularly in patients with AMD, generally is associated with a poor visual outcome.2, 3 Several potential mechanisms have been proposed to explain the visual acuity loss in eyes with subretinal hemorrhage. Animal studies have shown that photoreceptors degenerate in fewer than 24 hours with pyknosis of the outer nuclear layer.23 Other mechanisms of damage may include clot retraction, iron toxicity, and blockage of nutrient diffusion.24, 25 According to

Claudia Kuhli-Hattenbach, MD, graduated from the Johann Wolfgang Goethe-University in Frankfurt am Main, Germany, and underwent ophthalmology training at the Frankfurt University Eye Hospital. Dr. Kuhli-Hattenbach completed her residency and is currently specializing in pediatric ophthalmology and strabismus. Her main research interests include systemic risk factors and coagulation diasorders in ocular vascular occlusive diseases.

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    Claudia Kuhli-Hattenbach, MD, graduated from the Johann Wolfgang Goethe-University in Frankfurt am Main, Germany, and underwent ophthalmology training at the Frankfurt University Eye Hospital. Dr. Kuhli-Hattenbach completed her residency and is currently specializing in pediatric ophthalmology and strabismus. Her main research interests include systemic risk factors and coagulation diasorders in ocular vascular occlusive diseases.

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