AMD Subretinal Hyperreflective Material (SHRM)

This 82YO male presented with recent vision loss in his right eye. Vision was 20/200.

Color photography shows a poor foveal reflex with superotemporal geographic atrophy. OCT scanning shows subretinal hyperreflective material (SHRM) with overlying retinal fluid. A possible bacillary layer detachment is also noted. About 6 weeks following a single intravitreal anti-VEGF injection, vision improved to 20/50. A new RPE tear is noted, with the bed of the tear inferonasal to the retracted hyperpigmented RPE. Despite persistent flow signals on OCT angiography, there is no fluid on structural OCT. The SHRM has completely resolved. A treat-and-extend anti-VEGF regimen was begun.

Learning Points:
A tear in the RPE is a fairly common finding in RPE detachment (PED) associated with type 1 macular neovascularization (MNV) located below the RPE. The neovascularization can spontaneously contract or involute following treatment. It then puts traction on the overlying RPE, which can then rip at the opposite edge of the PED. Like a cheap window blind, the torn RPE retracts and scrolls towards the MNV. This leaves a depigmented region where the RPE was and is now absent, along with a pigmented, relatively straight subretinal lesion from the scrolled RPE edge.

SHRM is an OCT finding that is invisible clinically. This material, located between the neurosensory retina and RPE, is thought to consist of fluid, fibrin, blood, and other fibrovascular tissues. SHRM is a biomarker of active disease that decreases with successful anti-VEGF therapy (Willoughby et al, Ophthalmology 2015;122:1846-1853). Persistent SHRM is associated with an increased incidence of scar formation and worse vision.

It is impossible to determine whether the anti-VEGF injection alone or in combination with the RPE tear caused such a rapid resolution of the SHRM. Fortunately, our patient’s vision remained quite good since the RPE tear just spared the foveal center.

This 80YO female presented with counting-fingers vision in her left eye from treatment-naive neovascular AMD (nAMD).

Triton color photography shows a few retinal hemorrhages and more peripheral large drusen. Swept-source OCT shows a shallow irregular RPE detachment with underlying type 1 macular neovascularization (MNV). A hyporeflective prechoroidal cleft is noted below the MNV and subretinal hyperreflective material (SRHM) above. There is shallow outer retinal fluid above the SRHM. Subretinal fluid is seen on either side of the MNV. Intravitreal Avastin therapy was begun.

Learning Points:
Our patient’s OCT includes numerous findings of active MNV, including SRHM, prechoroidal cleft, and subretinal and intraretinal fluid.

SHRM is an OCT finding that is invisible clinically. This material, located between the neurosensory retina and retinal pigment epithelium (RPE), is thought to consist of fluid, fibrin, blood, and other fibrovascular tissues. SHRM is a biomarker of active disease that decreases with successful anti-VEGF therapy (Willoughby et al, Ophthalmology 2015;122:1846-1853). Persistent SHRM is associated with an increased incidence of scar formation and worse vision.

A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane. It is seen in up to 20% of treated eyes with nAMD, particularly with type 3 neovascularization (intraretinal MNV) and polypoidal choroidal vasculopathy. They are usually associated with worse visual acuity due to potential complications, including RPE tears and subretinal hemorrhages (Kim et al, Retina 2017;37:2047-2055).

This 78YO female originally presented on 2/2/21 with decreased vision in her right eye from a treatment-naive macular neovascularization (MNV) with subretinal fluid on OCT.

The lesion became completely inactive after several monthly anti-VEGF injections (5/25/21).

She was then lost to follow-up due to other health issues and returned on 11/23/21 with an active lesion with overlying subretinal hyperreflective material (SHRM).

After several additional monthly injections, all exudation resolved with the disappearance of the SHRM (2/15/22).

Learning Points:

SHRM is an OCT finding that is invisible clinically. This material, located between the neurosensory retina and retinal pigment epithelium (RPE), is thought to consist of fluid, fibrin, blood, and other fibrovascular tissues.

SHRM is a biomarker of active disease that decreases with successful anti-VEGF therapy (see Willoughby et al., Ophthalmology 2015;122:1846-1853).

Persistent SHRM is associated with an increased incidence of scar formation and worse VA.