PRESENTING AUTHOR

The purpose of the video  is to report a case of peripheral exudative hemorrhagic chorioretinopathy (PEHCR), managed surgically with favorable visual outcome.

A 66‑year‑old female with a history of type 2 diabetes mellitus and systemic hypertension presented with sudden painless visual decrease in the right eye. She had no history of intraocular surgery, injections, or laser photocoagulation. Visual acuity in the right eye was hand motion. Slit lamp examination was unremarkable with no iris neovascularization and mild nuclear sclerosis. Fundus examination in the right eye was not possible due to dense vitreous hemorrhage. B scan ultrasound was performed in the right eye and reported vitreous hemorrhage and an exudative retinal detachment inferotemporally extending from the far periphery into the macula with dense subretinal opacities. A 23‑gauge three‑port pars plana vitrectomy (PPV) was performed with careful examination of the peripheral retina and shaving of the vitreous base. Significant subretinal hemorrhage was found involving the temporal and inferotemporal retina extending from the periphery into the macula until the perifoveal area. 0.3 ml of 25 μg/0.1 ml of TPA was injected into the subretinal space with a 41‑gauge needle in an area of attached retina superior to the subretinal hemorrhage, and eventually, this bleb joined and diluted with the subretinal hemorrhage. Air–fluid exchange was performed, and sulfur hexafluoride 20% was injected into the eye. Postoperative visual acuity in the right eye improved to 20/100 in the early stages. Follow‑up visits have shown cystoid macular edema (CME) in the right eye that is being managed with intravitreal anti‑vascular endothelial growth factor agents

PEHCR is a degenerative condition of the peripheral retina with a difficult diagnosis. Most cases are diagnosed during routine eye examinations as incidental findings in the peripheral retina in patients who have good visual acuity. A large percentage of patients are referred as choroidal masses, making it one of the largest members of the pseudomelanomas. Management is usually directed to the associated retinal pathology. In some cases, the natural course of this entity is self‑limited. Shields et al and Cebeci et al found spontaneous regression in 89% and 76%, respectively. Reduction in visual acuity appears when the peripheral subretinal exudation, fluid, or hemorrhage approaches the macula or choroidal neovascular membranes and CME appears. Several case series have described the use of intravitreal bevacizumab and ranibizumab for successful management of these conditions.  In some rare cases, significant visual loss can be attributed to dense vitreous or massive subretinal hemorrhage. PPV has been reported in one such case with bilateral involvement. However, that case ended up with phthisis. In our case report, PPV with subretinal TPA injection was successfully performed with satisfactory anatomic and visual outcomes. The patient underwent a second procedure to washout the vitreous cavity and to treat the affected areas in the periphery with endolaser, as we were unable to treat them during the first vitrectomy due to the massive hemorrhage. This combination could provide to be a useful alternative when sight‑threatening vitreous hemorrhage, retinal detachment and subretinal hemorrhage are present. The use of subretinal TPA with pneumatic displacement for submacular hemorrhage has been reported since 2011 by Haupert et al. In our case, we elected to use it because the subretinal hemorrhage was massive, and although it started in the periphery, it was approaching the fovea.

In conclusion, PEHCR can present with severe visual loss due to a posterior extension of subretinal hemorrhage or dense vitreous hemorrhage. Surgical management with PPV and subretinal TPA injection might result in favorable anatomical and visual outcomes.