Pneumatic Displacement of Submacular Hemorrhage with Subretinal Air and Tissue Plasminogen Activator: Initial United States Experience

Abstract

To present the initial multicenter experience of using subretinal air injection in combination with tissue plasminogen activator (tPA) at the time of pars plana vitrectomy (PPV) to displace submacular hemorrhage (SMH). Retrospective, noncomparative, interventional case series. Patients with SMH resulting from age-related macular degeneration or polypoidal choroidal vasculopathy. Chart review of patients who underwent displacement of SMH with PPV, subretinal injection of air and tPA (125 mg/mL), partial fluid-air exchange with gas tamponade, and preoperative, intraoperative, or postoperative intravitreal injection of anti-vascular endothelial growth factor agent at 5 sites in the United States. None of the surgeons had prior experience with using subretinal air. Frequency and extent of SMH displacement, preoperative and postoperative visual acuities and retinal thickness, and postoperative complications. Twenty-four eyes of 24 patients were included (11 men; mean age, 79.1 years) with a mean follow-up of 12.5 months (range, 3-28 months). At 3 months after surgery, complete displacement of SMH from the foveal center was achieved in 24 eyes (100%), displaced beyond the arcades in 75% and beyond the equator in 20%. Residual subretinal pigment epithelial hemorrhage was seen in 5 eyes (20.8%). Mean preoperative and postoperative visual acuity was 1.95 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/1783) and 0.85 logMAR (Snellen equivalent, 20/141; P < 0.0001), respectively. Visual acuity improved in 23 eyes (95.8%) and was unchanged in 1 eye. Mean central retinal thickness improved from 463.7 μm before surgery to 311.3 μm at the final visit (P= 0.026). This initial experience of injecting subretinal air at the time of tPA injection during PPV showed the technique to be effective, with high consistency to displace SMH away from the fovea and even out to the periphery, and resulted in improved VA and retinal thickness. Some cases of subretinal pigment epithelial hemorrhage also benefit from this technique.