Long-Term Success of Bevacizumab-Pneumatic Displacement Combination for Subfoveal Hemorrhage Treatment

Can Combined Therapy Revolutionize Retinal Treatment?

Bevacizumab combined with pneumatic displacement demonstrates significant long-term benefits for subfoveal hemorrhage, according to a decade-long study from India. The retrospective analysis of 54 patients showed substantial vision improvement over a 24-month follow-up period, though researchers noted that less than half of patients achieved best-corrected visual acuity (BCVA) of logMAR ≥0.3.

The study, conducted at a tertiary care ophthalmic hospital in southern India between 2012 and 2021, addressed a critical gap in understanding the long-term efficacy of pneumatic displacement (PD) with intravitreal bevacizumab (IVB) for subfoveal hemorrhage (SFH) secondary to polypoidal choroidal vasculopathy (PCV) or neovascular age-related macular degeneration (n-AMD). Patients underwent a minimally invasive procedure combining 0.05 ml of 1.25 mg IVB with 0.3 ml of 100% SF₆ gas, followed by a face-down positioning regimen for seven days. The average follow-up period was 29.33 months, significantly longer than most previous studies on this technique.

Key Clinical Findings: A 10-year study of 54 patients demonstrated that combining intravitreal bevacizumab (0.05 ml of 1.25 mg) with pneumatic displacement (0.3 ml of 100% SF₆ gas) achieved complete anatomical resolution of subfoveal hemorrhage in 100% of cases. Vision improved significantly from 1.07 to 0.74 logMAR over an average 29.33-month follow-up period, with 74.07% of patients gaining at least 2 lines on Snellen's chart. The procedure required a 7-day face-down positioning protocol and showed excellent safety, with only one case of secondary glaucoma reported.

What Do the Clinical Results Tell Us About Treatment Efficacy?

Results showed complete anatomical resolution of SFH in all cases over the follow-up period, with final BCVA improving from 1.07 ± 0.46 to 0.74 ± 0.62 logMAR (p < 0.001). However, only 44.44% of patients achieved BCVA ≥0.3 logMAR. Notably, 74.07% of patients showed at least a 2-line improvement on Snellen's chart, comparable to results from Chen et al.'s larger dataset on SMH management. The procedure demonstrated a favorable safety profile, with only one patient developing secondary glaucoma requiring medication. Approximately 30.96% of PCV patients showed complete resolution of polyps, consistent with previous findings by Kitahashi et al.

Subgroup analyses investigating the impact of hemorrhage size and treatment timing revealed trends toward better outcomes in patients with SFH ≤2 disc diameter area and those treated within seven days of symptom onset, though these differences did not reach statistical significance. OCT evaluations identified ellipsoid zone/external limiting membrane disruption in 51.85% of patients and retinal pigment epithelium degeneration in 20.37%, likely contributing to the modest final visual outcomes in many cases.

Clinical Considerations: While the combination therapy showed promising results, clinicians should note:

Only 44.44% of patients achieved best-corrected visual acuity of logMAR ≥0.3
OCT findings revealed ellipsoid zone/external limiting membrane disruption in 51.85% of patients, likely limiting final visual outcomes
Trends suggested better results with smaller hemorrhages (≤2 disc diameter area) and treatment within 7 days of symptom onset
This minimally invasive approach offers a cost-effective alternative to surgical evacuation with potentially fewer complications

How Will These Insights Shape Future Retinal Care?

The study's primary limitations include its retrospective design, lack of a control group, and potential dimensional errors in measuring hemorrhage size. Nevertheless, as the second-largest dataset with long-term follow-up on this topic, it provides valuable insights into the durability of treatment effect. The findings position PD with IVB as a viable, minimally invasive alternative to surgical evacuation for SFH management, with potentially fewer complications.

For pharmaceutical stakeholders, these results highlight the continued relevance of off-label bevacizumab in retinal care despite the availability of newer anti-VEGF agents. The study also underscores the importance of combination approaches in managing complex retinal conditions, suggesting potential opportunities for developing optimized protocols that combine pharmacological and physical interventions. As the global burden of AMD increases with aging populations, such cost-effective approaches may become increasingly important in healthcare systems worldwide.

Summary

A decade-long retrospective study from India demonstrates that the combination of bevacizumab with pneumatic displacement offers significant long-term benefits for treating subfoveal hemorrhage secondary to polypoidal choroidal vasculopathy or neovascular age-related macular degeneration. The analysis of 54 patients over an average follow-up period of 29.33 months revealed complete anatomical resolution of subfoveal hemorrhage in all cases, with statistically significant improvement in best-corrected visual acuity from 1.07 to 0.74 logMAR. The minimally invasive procedure, which combined intravitreal bevacizumab with SF₆ gas and a seven-day face-down positioning protocol, showed a favorable safety profile with only one case of secondary glaucoma. While 74.07% of patients achieved at least a 2-line vision improvement, only 44.44% reached BCVA of logMAR ≥0.3 or better. Subgroup analyses suggested trends toward better outcomes in patients with smaller hemorrhages and earlier treatment, though these differences were not statistically significant. The study positions this combination therapy as a viable, cost-effective alternative to surgical evacuation for subfoveal hemorrhage management, with potentially fewer complications, highlighting the continued relevance of bevacizumab in retinal care and the importance of combination approaches in managing complex retinal conditions.