Sir,

Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is characterized by subretinal or sub-pigment epithelial hemorrhage and exudation localized outside the macular region.1 PEHCR is thought to be a variant of age-related macular degeneration (ARMD),2 but its neovascular origin is still controversial.

Case report

In this study, our aim was to evaluate the clinical features, prognosis, and response to intravitreal bevacizumab of PEHCR.

Twenty-three eyes of 15 patients with a diagnosis of PEHCR were included. The mean age of patients was 82.4±5.8 years (range 75–95). Nine (60%) of the patients were female. PEHCR lesions were often detected in the temporal quadrants (91.3%). Most eyes (78.2%) had a subretinal or sub-RPE (retinal pigment epithelium) hemorrhage followed by subretinal fluid. The bilateral involvement ratio was 37%. After 32.6±4.8 months of follow-up, PEHCR lesions were found to be stable and/or regressed, leading to RPE atrophy or a subretinal scar formation in 11 eyes (47.8%). In nine eyes (39.1%), after two or three consecutive intravitreal injections of bevacizumab, PEHCR lesions significantly regressed, leading to atrophy, fibrosis or a subretinal scar formation (Figure 1 a–h). In three eyes (13.04%), lesions extended into the macula, despite consecutive injections, and the BCVA was decreased. The patients’ characteristics are seen in Table 1.

Figure 1
figure 1

An 85-year-old woman with 0.4 LogMAR visual acuity in her left eye. (a) Color fundus photograph with geographic atrophy and drusen. (b) Fluorescein angiogram with corresponding window defect. (c) Two years later, visual acuity was 0.4 LogMAR. Color fundus photograph with increased geographic atrophy and a large mass of subretinal blood temporal in the macula (d) Fluorescein angiogram with corresponding window defect and blockage defect. (e) A large mass of subretinal blood and exudates. (f) Fluorescein angiogram with a corresponding blockage defect and leakage along the edge of the lesion. (g) Three months after intravitreal bevacizumab, the mass-like lesion and exudates had regressed on the peripheric retina; visual acuity stayed the same. (h) Fluorescein angiogram with corresponding blockage and decreased leakage along the edge of the lesion that were detected.

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Table 1 Patients’ characteristics including age, sex, eye, number of bevacizumab injection, BCVA at first and last visits are shown
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Comment

PEHCR is thought to be a variant of ARMD, and both share common risk factors, including age, female gender, hypertension, and cardiovascular disease.3 Although there are several case reports supporting the efficacy of anti-VEGF (Vascular endothelial growth factor) agents in PEHCR, investigations of a large series are required.2, 4 In most cases, there is a self limiting condition, but it may be vision threating because of the subretinal hemorrhage and fluid extention into the macula. In progressive cases, intravitreal bevacizumab may be an effective treatment option, but further studies are needed to prove its efficacy in PEHCR.