Graefe's Archive for Clinical and Experimental Ophthalmology · 6 authors, 2 centres
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This retrospective study of 115 patients found that 72.2% of those with surgically treated submacular hemorrhage (SMH) due to neovascular AMD were on blood-thinning therapy. Patients on blood thinners had significantly larger SMH (35.92 mm² vs. 21.91 mm², p=0.001) and worse visual outcomes at 1 year (1.68 logMAR vs. 1.30 logMAR, p=0.503). The findings suggest that blood thinners increase the severity of SMH, and their indication should be critically evaluated in AMD patients.
**Background:** Submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD) is a devastating complication with poor visual prognosis. Many elderly AMD patients also take systemic blood-thinning medications (antiplatelet or anticoagulant) for cardiovascular comorbidities. While these drugs are known to increase bleeding risk, their impact on the severity of SMH in AMD patients is not well understood. This study aimed to investigate whether blood thinners affect SMH severity and whether differences exist between drug types.
**Methods:** This retrospective study reviewed medical records of patients presenting with SMH due to neovascular AMD at the Department of Ophthalmology, University of Bonn, Germany, between January 2020 and March 2022. Inclusion criteria were SMH involving the foveal center large enough to require surgical intervention (intravitreal injection of rtPA, bevacizumab, and gas tamponade or pars plana vitrectomy with subretinal rtPA). Data collected included demographics, best-corrected visual acuity (BCVA), SMH size measured via OCT or fundus photography, blood-thinning therapy type and indication, and comorbidities. Statistical analyses used chi-square, t-test, Mann-Whitney U, and Spearman correlation.
**Key Results:** A total of 115 patients (mean age 82.2 years, 60.9% female) were included. 83 patients (72.2%) were on blood-thinning therapy: 46 (40.0%) on antiplatelet agents (40 ASA, 4 clopidogrel, 2 DAPT) and 37 (32.2%) on anticoagulants (32 DOAC, 4 VKA, 1 heparin). Mean SMH size was 32.01 mm². Patients on blood thinners had significantly larger SMH (35.92 mm² vs. 21.91 mm², p=0.001) and worse BCVA at 1 year (1.68 logMAR vs. 1.30 logMAR, p=0.503). Subgroup analysis showed no significant difference in SMH size between antiplatelet and anticoagulant groups (34.49 mm² vs. 37.06 mm², p=0.604). However, patients on VKA had significantly larger SMH than those on DOAC (63.70 mm² vs. 31.75 mm², p=0.005) and worse visual outcomes (BCVA 2.4 logMAR vs. 1.86 logMAR at 1 year, p=0.264).
**Clinical Implications:** This study demonstrates that blood-thinning therapy is associated with larger SMH and worse visual outcomes in AMD patients requiring surgical intervention. The high proportion (72.2%) of patients on blood thinners in this cohort suggests a potential increased risk of severe hemorrhage. The similar impact of antiplatelet and anticoagulant agents highlights the need for careful risk-benefit assessment, especially for antiplatelet therapy where indications may be less stringent. The finding that DOACs may be safer than VKAs warrants further investigation. Close collaboration between ophthalmologists and prescribing physicians is essential to optimize management of these patients.