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Hemorrhagic PED

Hemorrhagic PED results from blood leak via Bruch’s membrane to space between Bruch’s and RPE, causing an increase in hydrostatic pressure separating RPE from Bruch’s membrane.


Fundus image


On clinical exam, a smooth, well-defined border of RPE elevation and deep red color. PED is associated can be associated with subretinal fluid or intraretinal hemorrhage.


Fundus image showing hemorrhagic PED with subretinal hemorrhage
Fundus image showing hemorrhagic PED with subretinal hemorrhage 


Optical coherence tomography


PED features smooth or irregular RPE elevation, which contains blood, and features hyperreflectivity beneath the RPE, followed by Hyporeflectivity below due to OCT signal block from the blood. PED may feature sub / intraretinal fluids and hemorrhage accompanied by ellipsoid zone disruption and, in some cases, intraretinal fluids.

OCT cross-section shows hemorrhagic PED with subretinal fluids
OCT cross-section shows hemorrhagic PED with subretinal fluids 



Fluorescein fundus angiography


On FFA, hemorrhagic PED shows hypofluorescence due to blood blocking the fluorescein dye along with subretinal fluid dye pooling, and sometimes associated choroidal neovascularization may exhibit leak.

Fundus image showing hemorrhagic PED with subretinal hemorrhage and exudation
Fundus image showing hemorrhagic PED with subretinal hemorrhage and exudation 

Early FFA showing blocked fluorescence with hyperfluorescence from CNV
Early phase FFA showing bl ocked fluorescence from subretinal hemorrhage with hyperfluorescence from CNV  

Mid phase FFA showing blocked fluorescence with hyperfluorescence from CNV and subretinal fluids
Mid phase FFA showing bloc ked fluorescence from subretinal hemorrhage with increased hyperfluorescence from CNV and subretinal fluids 

Late phase FFA showing blocked fluorescence from subretinal hemorrhage with leakage from CNV and pooling from subretinal fluids
Late phase FFA showing blocked fluorescence from subretinal hemorrhage with leakage from CNV and pooling from subretinal fluids 


Management

 
Treating hemorrhagic PED is a clinical challenge with poor prognosis; however, better treatment response to VEGF trap (Aflibercept or Conbercept) in contrast to Anti VEGF (Bevacizumab or Ranibizumab),
If PED presented without any other retinal features such as active CNVm does not warrant treatment as regressing PED alone



won’t improve vision or prognosis.


Please check Clinical guidelines for ARMD and course of clinical changes in RPE

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