Rapid resolution of submacular hemorrhage in neovascular age-related macular degeneration using pneumatic displacement and faricimab

Abstract

Abstract Background Submacular hemorrhage (SMH) is a rare but visually devastating complication of neovascular age-related macular degeneration (nAMD) associated with poor long-term prognosis due to photoreceptor iron toxicity, subretinal fibrosis, and retinal pigment epithelial (RPE) damage. Pneumatic displacement (PD) combined with anti-vascular endothelial growth factor (anti-VEGF) therapy is an established approach for managing acute SMH; however, the role of faricimab, a novel dual inhibitor of VEGF-A and angiopoietin-2 (Ang-2), in this context has not been previously evaluated. Case presentation This study reports the outcomes of PD combined with faricimab injection in a case of a 75-year-old female with acute SMH secondary to nAMD. The patient with dense SMH and a large PED secondary to presumed polypoidal choroidal vasculopathy (PCV) underwent PD with 0.40 mL of sulfur hexafluoride and intravitreal faricimab injection (50 µL, 6 mg) on the same day as presentation, followed by 5 days of face-down positioning with excellent patient compliance confirmed by verbal verification. Two additional faricimab injections were administered at 4 and 8 weeks, followed by treat-and-extend protocol. Conclusions The use of timely PD with appropriate head positioning can effectively manage patients with acute large SMH and improve visual outcomes. While the combined approach with serial faricimab injections showed longer-term benefits, the immediate improvement was likely due to mechanical techniques. The potential added benefit of faricimab’s dual inhibition mechanism over other anti-VEGF therapies in SMH remains to be investigated through larger, comparative trials.

Summary statement This reports shows the successful management of submacular hemorrhage in presumed polypoidal choroidal vasculopathy using pneumatic displacement. The timely displacement of subretinal hemorrhage observed within 24 h was likely because of the mechanical technique with good head positioning, whereas longer-term anatomical stabilization can be attributed to continued anti-VEGF injections with faricimab. Significant SMH displacement was seen within 24 h post-procedure, with visual acuity improving from counting fingers to 20/100. After 3 intravitreal faricimab injections over 3 months, complete resolution of SMH and serous PED was achieved with visual acuity improving to 20/50. A mild self-resolving vitreous hemorrhage was seen after 1 month.