Subretinal hemorrhage in macular neovascularization secondary to age-related macular degeneration managed with intravitreal faricimab monotherapy

Subretinal hemorrhage (SRH) is a vision-threatening complication of age-related macular degeneration (AMD).[1] SRH can be displaced using either expansile gas injection, pars plana vitrectomy (PPV) with adjunctive agents such as tissue plasminogen activator (tPA), and/or antivascular endothelial growth factor (anti-VEGF) injections.[2-4] Faricimab, a recently approved agent, combines anti-VEGF action with inhibition of angiopoietin-2 (ang2). Thus far, there are no reports of intravitreal faricimab monotherapy for SRH. Case Presentation A 57-year-old Emirati male presented with sudden acute vision loss in his right eye (OD) for 1 day. His best-corrected Snellen visual acuity (BCVA) was counting fingers close to face in OD and 20/20 in OS. OD showed an approximately 4-disc diameter center-involving SRH. Optical coherence tomography (OCT) revealed a tall pigment epithelial detachment (PED), SRH, and fluid (SRF) [Fig. 1]. The patient was treated with intravitreal faricimab 6 mg/0.05 mL (Vabysmo®, Roche, Basel, Switzerland). Within a week, his BCVA improved to 20/200 with reduction of SRH [Fig. 1]. SRH resolved completely in 6 weeks [Fig. 2]. Due to active MNV with recurrent SRF, he received three serial faricimab injections every 4 weeks with an improvement of BCVA to 20/80. OCT did not show subretinal fibrosis [Fig. 2]. After six additional injections, the BCVA improved to 20/30 (partial) in OD with a near-complete resolution of PED. OCT taken 18 months from baseline showed minimal subretinal fibrosis or scar formation [Fig. 3]. The patient was on a treat-and-extend regimen with a follow-up scheduled every 16 weeks.Figure 1: Fundus photograph and optical coherence tomography (OCT) of the patient at the initial visit (a and b) and at 1-week follow-up (c and d). The patient presented with central subretinal hemorrhage (SRH) with a tall pigment epithelial detachment (PED) (yellow asterisk) on OCT. There was significant SRH. The patient received intravitreal faricimab, and the fundus photograph taken 1 week after the injection (c) reveals mild reduction in the SRH. The OCT shows a reduction in the PED height (yellow asterisk) and the overall retinal thicknessFigure 2: Serial optical coherence tomography (OCT) imaging of the patient (a–c) taken up to 24 weeks after the initial presentation. The fluorescein angiography (FA) and indocyanine green angiography (ICGA) was performed at 9 weeks after the initial presentation. OCT imaging shows resolution of the subretinal hemorrhage at 6 weeks, with only a streak of fibrin (black arrow) at week 6 and week 9 (a and b). At week 24, there was mild subretinal fluid (white arrow) due to the persistent macular neovascularization (MNV) activity. FA and ICGA at week 9 (d and e) show an active MNV but no polyps (yellow arrowhead)Figure 3: Optical coherence tomography (OCT) imaging of the patient performed at 12 and 18 months from the initial presentation. At both visits, there is minimal subretinal fibrosis or scarring (white arrowheads) on the infrared imaging. Due to active macular neovascularization (MNV), there was recurrent subretinal fluid (yellow arrow) (a). The patient was treated with intravitreal faricimab every 16 weeks with a good response and resolution of the subretinal fluid (b)Discussion In this report, we demonstrated the outcomes of SRH in neovascular AMD with faricimab monotherapy that has been previously unreported.[4,5] Faricimab may offer particular advantages: (1) the possibility to extend the treatment to 16 weeks, and (2) reduced fibrosis/scarring. The ang2 inhibitory action may have an anti-fibrotic effect, which needs further exploration in clinical settings. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.