Single intravitreal etamsylate injection for the treatment of choroidal neovascular membrane formation in neovascular age-related macular degeneration

Submacular haemorrhage (SMH) is an accumulation of blood between the neurosensory retina and retinal pigment epithelium (RPE), arising from the choroidal circulation within the macula. It is considered that it usually occurs in the context of neovascular (wet) age-related macular degeneration (ARMD).1 Owing to iron toxicity, SMH damages the RPE and the photoreceptors, affects the fibrin network contraction and causes a subsequent reduced nutrient flux from choriocapillaris ensued of scarring development.2–4 While SMH is not common, wet ARMD patients with coagulopathies to which anticoagulant medication is administered are, nevertheless, particularly susceptible to developing this disease.5 The visual outcome of wet ARMD patients with SMH is typically poor, particularly in eyes with thick blood clots or involving large areas of the macula, and which develop a choroidal neovascular membrane (CNVM).6 Average time for disappearance of the SMH is 6 months.4 Experimental studies support prompt treatment of SMH, as tissue damage occurs within 24hours. Without treatment the natural history of SMH is poor. Search for a safe and effective treatment for removing the blood beneath the macula to hasten visual recovery and prevent irreversible damage to the outer retina is a medical need. There is no standard treatment for acute SMH. Etamsylate is a newly identified therapeutically relevant molecule that could be used in pathological conditions involving aberrant fibroblast growth factor (FGF) signalling7,8 (NOSOTROS). Immunoreactivity for FGF has been reported in CNVM removed surgically from humans with ARMD, which suggests a role of this growth factor in the origin and progression of the disease.9 Furthermore, damage of RPE as it occurs in ARMD, causes the release of FGF which, in turn, could contribute to formation of CNVM by itself.10 Thus, local inhibition of FGF would sum an adequate strategy for resolving CNVM. We describe here the efficacy of intravitreal etamsylate administration in a patient with SMH and CNVM associated with wet ARMD.