Grand Rounds
Peripheral Exudative Hemorrhagic Chorioretinopathy
Mark Sherman MD
University of Louisville
Department of Ophthalmology and Visual Sciences
08/01/2014
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
Exam
BCVA:
OD
CF @ Face
OS
20/30
Pupils:
53
53
No APD
IOP:
EOM:
14
14
Full OU
Anterior Segment Exam
SLE:
L/L
 Conjunctiva
 K
 AC
 I/L

OD
OS
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
2+ NS
2+ NS
(No NVI OU)
DFE
OD: Dense vitreous hemorrhage, unable to
view
disc or fundus
OS: Disc WNL, attenuated vessels, few
scattered microaneurysms
(No NVD/NVE)
B-Scan OD
Dense vitreous hemorrhage; retina flat
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
Surgical Video
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
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
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)
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;116:529-35.
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;116:529-35.
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;116:529-35.
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
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
References

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Annesley, WH JR: Peripheral exudative hemorrhagic retinopathy. Trans Am
Ophthalmol Soc 78:321-364, 1980
BCSC: Retina and Vitreous. Peripheral Retinal Neovascularization. Pgs: 121-22
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;116:529-35.
Socorro, MA, Sabater N, et al. Intravitreal Bevacizumab Injection for
Peripheral Exudative Hemorrhagic Chorioreintopathy. Jpn J Ophthalmol.
2011;55(4)425-7