1. Grand Rounds Peripheral Exudative Hemorrhagic Chorioretinopathy
Mark Sherman MD
University of Louisville
Department of Ophthalmology and Visual Sciences
08/01/2014

2. Subjective CC: Decreased vision in the right eye for four months
HPI: 70 year old white female presented to the retina clinic with a four month history of painless decreased vision in her right eye. Patient denied any other ocular symptoms. No history of trauma. No recent illness.
POH: None PMH: IDDM, HTN

3. Exam OD OS BCVA: CF @ Face 20/30 Pupils: 53 53 No APD IOP: 14 14
EOM: Full OU

4. Anterior Segment Exam SLE: OD OS L/L WNL WNL Conjunctiva WNL WNL
K WNL WNL
AC WNL WNL
I/L NS 2+ NS
(No NVI OU)

5. DFE OD: Dense vitreous hemorrhage, unable to view disc or fundus
OS: Disc WNL, attenuated vessels, few scattered microaneurysms
(No NVD/NVE)

6. B-Scan OD
Dense vitreous hemorrhage; retina flat

7. Assessment/Differential Diagnosis
Assessment: 70 year old diabetic white female with a dense vitreous hemorrhage OD x ~4 months
DDx: 1) Proliferative Diabetic Retinopathy
2) Retinal Tear/Break
3) Exudate age-related macular degeneration
Plan: Pars Plana Vitrectomy OD

8. Surgical Video

9. 1 Week Follow-Up S: Vision markedly improved, no complaints
O: BCVA: 20/30 OD, Anterior segment: Unchanged
DFE OD: retina flat, ~25% air bubble,
large sub-retinal clot inferior to inferior arcade surrounded by laser,
peripheral laser 360 degrees
A: Peripheral Exudative Hemorrhagic Chorioretinopathy

10. Peripheral Exudative Hemorrhagic Chorioretinopathy
Thought to be a variant of age related macular degeneration
Characterized by blood in the subretinal or sub-retinal pigment epithelial space in the peripheral retina
More common in older (70-80) Caucasians (~90%)
Often confused on presentation for vitreous hemorrhage secondary to retinal detachment or break, choroidal melanoma, or retinal artery macroaneurysm

11. Peripheral Exudative Hemorrhagic Chorioretinopathy
Three characteristic lesion types
Hemorrhagic: subretinal or sub-pigment epithelium blood present in the absence of exudate (60%)
Exudative: subretinal exudates in the absence of clinically detectable blood (10%)
Exudative-Hemorrhagic: both blood and exudates present (30%)
Treatment is usually not required unless secondary complications occur (persistent vitreous hemorrhage, retinal detachment, extension into the macula)

12. Retrospective chart review of 173 eyes (146 patients)
Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal melanoma in 173 eyes
Retrospective chart review of 173 eyes (146 patients)
Mean age: 80
145 (99%) Caucasian
98 (67%) Female
171 (99%) were referred for the diagnosis of choroidal melanoma
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:

13. Common clinical features:
Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal melanoma in 173 eyes
Common clinical features:
Subretinal hemorrhage: 78%
Serous RPE detachment: 28%
Vitreous hemorrhage: 24%
Retinal exudation: 21%
Associate macular changes:
RPE changes: 23%
Drusen: 17%
Choroidal neovascularization: 8%
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:

14. Features found to differentiate from melanoma:
Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal melanoma in 173 eyes
15 months of observation
90% stabilized or regressed
10% progressed
7% of patients developed exudative macular changes
Features found to differentiate from melanoma:
Retinal exudation
Hypofluorescence on FA
Lack of sentinel vessels
Cleft separating clot from from choroid on ultrasound
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:

15. Intravitreal Bevacizumab Injection for Peripheral Exudative Hemorrhagic Chorioretinopathy
Case report of 74 year female referred for suspicion of choroidal melanoma OD
Patient presented with 20/50 vision OD, WNL anterior segment, mild vitreous hemorrhage, and a serous retinal detachment with retinal and subretinal hemorrhages in the inferior periphery
B-Scan:
8mm x 3mm
infero-temporal lesion
Socorro, MA, Sabater N, et al. Intravitreal
Bevacizumab Injection for Peripheral Exudative
Hemorrhagic Chorioretinopathy. Jpn J Ophthalmol. 2011;55(4)425-7

16. Intravitreal Bevacizumab Injection for Peripheral Exudative Hemorrhagic Chorioretinopathy
Patient was given a diagnosis of peripheral exudative hemorrhagic chorioretinopathy and was observed
2 months later the patient returned with decreased vision (20/100) and complaints of metamorphopsia
Exam showed increased vitreous hemorrhage and extension of the serous retinal detachment into the macula
Patient was given an intravitreal injection of bevacizumab
One week follow-up: vision had improved to 20/40, improvement of vitreous heme and complete resolution of serous detachment
Socorro, MA, Sabater N, et al. Intravitreal Bevacizumab Injection for Peripheral Exudative
Hemorrhagic Chorioretinopathy. Jpn J Ophthalmol. 2011;55(4)425-7

17. References
Annesley, WH JR: Peripheral exudative hemorrhagic retinopathy. Trans Am Ophthalmol Soc 78: , 1980
BCSC: Retina and Vitreous. Peripheral Retinal Neovascularization. Pgs:
Mantel I, Uffer S, Zografos. Peripheral Exudative Hemorrhagic Chorioretinopathy: A Clinical, Angiographic, and Histologic Study. Am J Ophthalmol. 2009;148:932-38
Pinarci EY, Kilic, et al. Clinical Characteristics of Peripheral Exudative Chorioretinopathy and its Response to Bevacizumab Therapy. Eye. 2013;27:111-12
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:
Socorro, MA, Sabater N, et al. Intravitreal Bevacizumab Injection for Peripheral Exudative Hemorrhagic Chorioreintopathy. Jpn J Ophthalmol. 2011;55(4)425-7