Pneumatic displacement and intravitreal bevacizumab for management of submacular hemorrhage in choroidal neovascular membrane

We would like to share our experience of a 52-year-old male patient who presented with blurring of vision in the right eye for the last one month and a sudden drop of vision with a central black spot of two days duration. The best corrected visual acuity (BCVA) was counting fi ngers close to face in the right eye and counting fi ngers at 4 meters in the left eye. Intraocular pressure and slit-lamp examination were within normal limits. Fundus examination of the right eye showed submacular hemorrhage with breakthrough vitreous hemorrhage [Fig. 1] and the left eye was normal. He was diagnosed to have anisometropic amblyopia in the left eye. Fundus fl uorescein angiography (FFA) of the right eye showed blocked fl uorescence corresponding to submacular hemorrhage. He underwent gas injection with tissue plasminogen activator (TPA) (50 ug/0.05 ml)[2] under topical anesthesia and aseptic precautions. This was followed by prone positioning of the patient.


Pneumatic displacement and intravitreal bevacizumab for management of submacular hemorrhage in choroidal neovascular membrane
Dear Editor, We read with great interest the article titled "Pneumatic displacement and intravitreal bevacizumab: A new approach for management of submacular hemorrhage in choroidal neovascular membrane" by Chawla S et al. [1] We would like to share our experience of a 52-year-old male patient who presented with blurring of vision in the right eye for the last one month and a sudden drop of vision with a central black spot of two days duration. The best corrected visual acuity (BCVA) was counting fi ngers close to face in the right eye and counting fi ngers at 4 meters in the left eye. Intraocular pressure and slit-lamp examination were within normal limits. Fundus examination of the right eye showed submacular hemorrhage with breakthrough vitreous hemorrhage [ Fig. 1] and the left eye was normal. He was diagnosed to have anisometropic amblyopia in the left eye. Fundus fl uorescein angiography (FFA) of the right eye showed blocked fl uorescence corresponding to submacular hemorrhage. He underwent gas injection with tissue plasminogen activator (TPA) (50 ug/0.05 ml) [2] under topical anesthesia and aseptic precautions. This was followed by prone positioning of the patient. At nine months follow-up the BCVA in the right eye was 20/120P, N36. Fundus examination showed old sub-retinal hemorrhage displaced to the lower macular area. FFA of the right eye showed a scarred CNVM with blocked fl uorescence in the inferior macular area corresponding to the persistent old hemorrhage. Optical coherence tomography of the right eye showed a normal foveal contour and the scarred extrafoveal CNVM.
Management of the cases with submacular hemorrhage secondary to CNVM are oft en challenging. Various treatment options are available for the submacular hemorrhage such as pneumatic displacement with or without TPA or vitrectomy with evacuation of the blood. Chawla et al., [1] in their case series experienced a good visual recovery in all the four cases. However the visual recovery in our case was not good even aft er a good displacement of the submacular hemorrhage.
As mentioned in the literature, the visual prognosis in cases with submacular hemorrhage depends on a number of factors such as location of the CNVM (extrafoveal, subfoveal or juxtafoveal), duration of the submacular hemorrhage -longer the duration worse is the prognosis due to photoreceptor damage, level of the hemorrhage -sub-retinal or sub-retinal pigment epithelial (RPE), the size and the thickness of the hemorrhage and lastly the underlying disease process. [2] The combination of gas tamponade with an anti-vascular endothelial growth factor (VEGF) such as bevacizumab without using TPA does provide an inexpensive treatment option to our patients, however, the visual recovery may not always be predictable.

Gains beyond cosmesis: Recovery of fusion and stereopsis in adults with longstanding strabismus following successful surgical realignment
Dear Editor, I read with interest the article by Fatima et al., [1] It's well established that surgical alignment of the eyes in adults can result in recovery of binocular vision, even in cases with tropia and/or amblyopia. [2] Not all tropias similar in size, direction and duration, have a similar postoperative course.
The patients included in the present study had good vision in both eyes indicating that the strabismus manifested aft er the completion of the critical period of binocular development. The actual age of the patient, at the time of onset of strabismus is not mentioned. The authors considered the children (six of them) in the age group of 12-16 as adults! This invalidates the conclusion of this study as, aft er strabismus surgery, the adults and children respond diff erently.
One must understand that, for recovery of binocularity, postoperatively, the age of the patient at the time of onset of strabismus as well as the total duration of strabismus are important. For example, a nine-month-old child with strabismus of just a few weeks' duration may have significant loss of binocularity, whereas a child with onset of strabismus at the age of four years may not have any loss of binocularity in a few months.
Adults with cataract may have sensory exotropia, due to disruption of the fusion. The cataract surgery with intraocular implant will restore binocularity and correct strabismus. In these patients preoperative evaluation may reveal no binocularity. Postoperatively many of these patients recover good binocular function and straight eyes.
What matt ers for recovery of binocular vision, is the age at which the strabismus started, rather than just the duration of the strabismus. The younger the age at onset of strabismus, the more disrupted will be the binocularity. In the current study, most patients have had exotropia (12) and few esotropia. Esotropias starting at an early age tend to disrupt binocular vision much more than exotropias with an onset at the same age. Tropia not reducing the vision in either of the eyes is unlikely to signifi cantly aff ect the cortical binocular circuitry. Hence it is not unusual for these patients to have regained good binocularity postoperatively. Therefore, strabismus surgery for adults should not be denied on the wrong assumption of "poor postoperative functional recovery", in longstanding strabismus.
The author's conclusion that adults do recover good binocularity aft er surgical correction of squint is true, but the approach route is incorrect! They have included children in the study and drawn conclusions for adults. Most patients in the study have a greater chance of recovery of binocularity postoperatively, due to age or the type of strabismus.