Management of Thick Submacular Hemorrhage With Subretinal Tissue Plasminogen Activator and Pneumatic Displacement for Age-Related Macular Degeneration

Abstract

To evaluate the outcome of pars plana vitrectomy, subretinal tissue plasminogen activator (t-PA) infusion and intraocular gas tamponade with and without postsurgical antivascular endothelial growth factor (VEGF) injection for thick submacular hemorrhage due to exudative age-related macular degeneration (AMD). Retrospective, comparative, interventional case series. setting: 2 retina referral centers. The patient population included 101 eyes of 101 patients with neovascular AMD and thick submacular hemorrhage who underwent surgical displacement of the hemorrhage with or without postoperative anti-VEGF injections. Main outcome measures included degree of blood displacement, best and final postoperative visual acuity (VA), and adverse events. Snellen acuity was converted to logMAR for statistical analysis. All patients were followed for a minimum of 3 months (mean, 15.3 months, range, 3-70 months). In 83 (82%) of 101 eyes, the procedure resulted in complete hemorrhage displacement from the fovea. Mean preoperative VA was 20/2255 (2.05 logMAR). The acuity significantly improved to 20/893 (1.65 logMAR) at month 1 (P < 0.001) at month 1; 20/678 (1.53 logMAR) at month 3 (P < 0.001), and 20/1150 (1.76 logMAR) at month 12 (P = 0.002). Best postoperative visual acuity improved by at least 1 line in 83 (82%) of 101 eyes, and 19.6% of eyes gained 3 lines or more at month 3. The visual acuity of the group of eyes that received postoperative anti-VEGF injection (n = 39) showed greater visual acuity improvement 6 months postoperatively compared to the group of eyes that did not receive postoperative anti-VEGF. Postoperative complications included vitreous hemorrhage in 2 eyes, rhegmatogenous retinal detachment in 4 eyes, and recurrent thick subretinal hemorrhage in 6 eyes. Vitrectomy with subretinal t-PA injection and gas tamponade was found to be relatively effective for displacement of thick submacular hemorrhage with a significant improvement in visual acuity. There is a loss of acuity over time; the addition of postoperative anti-VEGF therapy may help maintain the visual acuity gains.