FLORetina 2025: Antithrombotic use examined in wet AMD submacular hemorrhage

Submacular hemorrhage in wet age-related macular degeneration (AMD) poses significant risk to vision, making it important to understand how antithrombotic agents may influence presentation and outcomes. Sharon Fekrat, MD, FACS, FASRS, presented a retrospective analysis exploring the impact of antithrombotic agents on submacular hemorrhage in eyes with AMD at the FLORetina 2025–International Congress on OCT and OCT angiography (ICOOR), held from 4 to 7 December in Florence, Italy.¹ Fekrat is with Duke University School of Medicine in Durham, North Carolina, USA, where she is professor of ophthalmology; vice chair for faculty affairs; professor in neurology; and associate professor in the Department of Surgery.

“This study came from our desire to figure out what effect antithrombotic agents have in eyes with wet AMD who develop a submacular hemorrhage,” Fekrat explained. Clinically, she noted that patients on antiplatelet agents, anticoagulants, or combination therapy “appear to be the ones developing submacular hemorrhage due to wet AMD in the era of anti-VEGF therapy.”

The study showed no significant difference in the size or thickness of submacular hemorrhage at presentation across antithrombotic groups. “We found that interesting,” Fekrat said. The team reviewed photographs, optical coherence tomography, ultrasound, and fluorescein angiography, yet “found no significant difference in size or thickness.”

Fekrat emphasized the importance of communication with cardiology and primary care colleagues, especially after a hemorrhage that “gets our attention.” Retina specialists, she noted, can inquire about thrombotic risk scores and discuss whether “it is absolutely necessary that the patient be on that antithrombotic agent, or is there another option that may decrease their bleeding risk a little bit?” Still, she underscored that discontinuation decisions rest with the prescribing physician: “We can make a recommendation, and that is really about it.”

The study confirmed that larger hemorrhages—defined as four disc diameters or more—were associated with worse visual outcomes. Yet after controlling for numerous factors (age, sex, time to presentation, initial VA, treatment variation, cataract surgery, follow-up duration), a counterintuitive result emerged: patients taking oral anticoagulants or antiplatelet agents showed greater visual acuity improvement at final follow-up than those not taking antithrombotics. “This was somewhat surprising,” Fekrat said. To explain it, she pointed to fibrin mechanics: anticoagulants reduce thrombin-mediated fibrin mesh contraction, resulting in “less photoreceptor shearing, and then better visual acuity outcomes.” Antiplatelet agents have a weaker effect but still showed significant findings.

Antithrombotic use did not worsen anti-VEGF responsiveness; instead, the data suggested a possible mitigating effect via fibrin inhibition. Fekrat called the results “really really eye-opening,” while cautioning about retrospective limitations and the need for a prospective multicenter study collecting detailed drug, comorbidity, and hemorrhage-metric data to clarify causality. For now, the findings are “very hypothesis-generating,” but not practice-changing—highlighting the need for further evidence-based guidance.

Sharon Fekrat, MD, FACS, FASRS
E: [email protected]
Fekrat is with Duke University School of Medicine in Durham, North Carolina, USA, where she is professor of ophthalmology; vice chair for faculty affairs; professor in neurology; and associate professor in the Department of Surgery.

REFERENCE

1. Fekrat S. Oral antithrombotics in eyes with submacular hemorrhage from wet AMD. Presented at: FLORetina 2025–International Congress on OCT and OCT Angiography (ICOOR); December 4-7, 2025; Florence, Italy.