A 75-year-old woman with neovascular AMD undergoes intravitreal anti-VEGF therapy. She develops a sharp decline in vision one week post-injection. Fundoscopy shows a submacular haemorrhage larger than 4 disc areas. The most appropriate management step to improve visual prognosis in this scenario is:

• A Continued monthly anti-VEGF monotherapy
• B Pneumatic displacement of the submacular haemorrhage using expansile gas (C3F8) with or without intravitreal tPA and anti-VEGF ✓
• C Immediate submacular surgery (surgical evacuation via PPV)
• D Observation for 6 months for spontaneous haemorrhage absorption

Explanation

Large acute submacular haemorrhages (>4 disc areas, <14 days duration) from CNV rupture can be managed with pneumatic displacement: intravitreal injection of expansile gas (C3F8 or SF6) combined with intravitreal tPA (tissue plasminogen activator) to liquefy the clot, followed by prone positioning to shift the haemorrhage inferiorly away from the fovea. This is superior to observation (photoreceptor toxicity from iron within 2 weeks) and comparable or superior to surgical evacuation with less risk. Anti-VEGF is also co-administered to treat the underlying CNV.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.