|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 7 | Page : 833-834
Massive submacular hemorrhage resulting in acute angle closure
Wei Kiong Ngo1, Kai Xiong Cheong1, Colin SH Tan2
1 National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
2 National Healthcare Group Eye Institute, Tan Tock Seng Hospital; Fundus Image Reading Center, National Healthcare Group Eye Institute, Singapore
|Date of Web Publication||13-Aug-2014|
Colin SH Tan
National Healthcare Group Eye Institute, Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng -308433
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ngo WK, Cheong KX, Tan CS. Massive submacular hemorrhage resulting in acute angle closure. Indian J Ophthalmol 2014;62:833-4
|How to cite this URL:|
Ngo WK, Cheong KX, Tan CS. Massive submacular hemorrhage resulting in acute angle closure. Indian J Ophthalmol [serial online] 2014 [cited 2020 Apr 9];62:833-4. Available from: http://www.ijo.in/text.asp?2014/62/7/833/138176
We read with interest the article by Williams et al. describing a case of macular hemorrhage causing angle closure glaucoma.  The fundus photo shows pigment epithelial detachments and massive sub-macular hemorrhage, which is one of the common presenting features of polypoidal choroidal vasculopathy (PCV). , We are curious to know if fluorescein angiography or indocyanine green angiography was performed and, if so, whether these investigations revealed lesions consistent with neovascular age-related macular degeneration (AMD) or PCV. Although PCV is not as common in Caucasian populations compared to Asians, this is still an important differential diagnosis because the clinical course and treatment options for PCV differ from AMD.  In contrast to neovascular AMD, which typically responds well to monotherapy with intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, the EVEREST study showed that in patients with symptomatic macular PCV, combination therapy with verteporfin photodynamic therapy (PDT) and intravitreal ranibizumab was superior to PDT or intravitreal ranibizumab monotherapy in achieving polyp closure. 
Williams et al. described that their patient had an abnormally severe episode of cough, which might have caused the neovascular membrane to bleed and thereby precipitating the sub-retinal hemorrhage.  It has also been previously suggested that factors such as age, hypertension, and arteriosclerosis increase the fragility of blood vessels and hence their susceptibility to shearing forces such as coughing.  A paper by Tan et al. described a case of PCV causing massive sub-retinal and suprachoroidal hemorrhage resulting in secondary angle closure glaucoma,  and we were intrigued by the similarities between the presentations of these two patients. In the case described by Tan et al.,  the patient did not have any risk factors for suprachoroidal bleed such as anticoagulation use, coughing, or straining. This case illustrates that sub-retinal and suprachoroidal hemorrhages may occur spontaneously, without the need for precipitating factors.
In conclusion, we congratulate the authors on their timely intervention and on achieving a good clinical outcome. This case serves to remind us to consider massive sub-retinal and suprachoroidal hemorrhages as causes of secondary angle closure glaucoma, especially in patients with known AMD and PCV.
| References|| |
Williams GS, Anderson L, Eddyshaw D. Macular hemorrhage as a cause of acute angle closure. Indian J Ophthalmol 2013;61:683-4.
Lim TH, Laude A, Tan CS. Polypoidal choroidal vasculopathy: An angiographic discussion. Eye (Lond) 2010;24:483-90.
Tan CS, Wong HT, Lim BA, Hee OK, Lim TH. Polypoidal choroidal vasculopathy causing massive suprachoroidal haemorrhage. Eye (Lond) 2007;21:132-3.
Tan CS, Ngo WK, Lim LW, Cheong KX, Lim TH. Outcomes of polypoidal choroidal vasculopathy treated with ranibizumab monotherapy. Br J Ophthalmol 2013;97:1357-8.
Koh A, Lee WK, Chen LJ, Chen SJ, Hashad Y, Kim H, et al
. Everest study: Efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with symptomatic macular polypoidal choroidal vasculopathy. Retina 2012;32:1453-64.