Management Of Submacular Hemorrhage Research Articles

Management of Submacular Hemorrhage

Management of Submacular Hemorrhage

Vitrectomy, subretinal Tissue plasminogen activator and Intravitreal Gas for submacular haemorrhage secondary to Exudative Age-Related macular degeneration (TIGER): study protocol for a phase 3, pan-European, two-group, non-commercial, active-control, observer-masked, superiority, randomised controlled surgical trial

BackgroundNeovascular (wet) age-related macular degeneration (AMD) can be associated with large submacular haemorrhage (SMH). The natural history of SMH is very poor, with typically marked and permanent loss of central vision in the affected eye. Practice surveys indicate varied management approaches including observation, intravitreal anti-vascular endothelial growth factor therapy, intravitreal gas to pneumatically displace SMH, intravitreal alteplase (tissue plasminogen activator, TPA) to dissolve the clot, subretinal TPA via vitrectomy, and varying combinations thereof. No large, published, randomised controlled trials have compared these management options.MethodsTIGER is a phase 3, pan-European, two-group, active-control, observer-masked, superiority, randomised controlled surgical trial. Eligible participants have large, fovea-involving SMH of no more than 15 days duration due to treatment-naïve or previously treated neovascular AMD, including idiopathic polypoidal choroidal vasculopathy and retinal angiomatous proliferation. A total of 210 participants are randomised in a 1:1 ratio to pars plana vitrectomy, off-label subretinal TPA up to 25 μg in 0.25 ml, intravitreal 20% sulfahexafluoride gas and intravitreal aflibercept, or intravitreal aflibercept monotherapy. Aflibercept 2 mg is administered to both groups monthly for 3 doses, then 2-monthly to month 12. The primary efficacy outcome is the proportion of participants with best-corrected visual acuity (BCVA) gain of ≥ 10 Early Treatment Diabetic Retinopathy (ETDRS) letters in the study eye at month 12. Secondary efficacy outcomes (at 6 and 12 months unless noted otherwise) are proportion of participants with a BCVA gain of ≥ 10 ETDRS letters at 6 months, mean ETDRS BCVA, Radner maximum reading speed, National Eye Institute 25-item Visual Function Questionnaire composite score, EQ-5D-5L with vision bolt-on score, Short Warwick and Edinburgh Mental Wellbeing score, scotoma size on Humphrey field analyser, and presence/absence of subfoveal fibrosis and/or atrophy and area of fibrosis/atrophy using independent reading centre multimodal image analysis (12 months only). Key safety outcomes are adverse events, serious adverse events, and important medical events, coded using the Medical Dictionary for Regulatory Activities Preferred Terms.DiscussionThe best management of SMH is unknown. TIGER aims to establish if the benefits of SMH surgery outweigh the risks, relative to aflibercept monotherapy.Trial registrationClinicalTrials.govNCT04663750; EudraCT: 2020-004917-10.

Management of Submacular Hemorrhage

Management of Submacular Hemorrhage

Vitrectomy with subretinal t‐PA, gas tamponade and intravitreal ranibizumab for the treatment of submacular hemorrhage due to AMD

AbstractPurpose This lecture aims to summarize what is known about the effect of vitrectomy with subretinal t‐PA, gas tamponade and intravitreal anti‐VEGF in the management of submacular hemorrhage in neovascular age‐related macular degeneration.Methods Submacular hemorrhage associated with neovascular age‐related macular degeneration is a complication known to have potentially devastating effects on visual acuity. The exact incidence of submacular hemorrhage in patients with neovascular age‐related macular degeneration is unknown, and risk factors for its occurrence ill defined. It is known, however, to be a relatively common problem and important because the visual prognosis of these patients is poor.Results Multiple treatment modalities have been suggested including intravitreal anti‐vascular endothelial growth factor injections, photodynamic therapy, pneumatic displacement with or without adjuvant intravitreal tissue plasminogen activator, and pars plana vitrectomy with or without adjuvant subretinal tissue plasminogen activator. However, there remains no consensus on optimal treatment, as clinical trials for neovascular age‐related macular degeneration have excluded patients with submacular hemorrhage.Conclusion Although the final visual outcome is often limited by progression of age‐related macular degeneration, significant and stable visual recovery is possible in selected eyes. Prospective clinical trials are needed to clarify the role for vitrectomy/tPA/gas/anti‐VEGF and to provide definitive outcome comparisons with other management approaches.

Minocycline Attenuates Photoreceptor Degeneration in a Mouse Model of Subretinal Hemorrhage: Microglial Inhibition as a Potential Therapeutic Strategy

Minocycline Attenuates Photoreceptor Degeneration in a Mouse Model of Subretinal Hemorrhage: Microglial Inhibition as a Potential Therapeutic Strategy

Pneumatic displacement and intravitreal bevacizumab for management of submacular hemorrhage in choroidal neovascular membrane

Pneumatic displacement and intravitreal bevacizumab for management of submacular hemorrhage in choroidal neovascular membrane

Management of submacular hemorrhage with intravitreal versus subretinal injection of recombinant tissue plasminogen activator

To compare the efficacy of pars plana vitrectomy (ppV) with intravitreal injection of recombinant tissue plasminogen activator (rtPA) and gas versus ppV with subretinal injection of rtPA and intravitreal injection of gas. Nonrandomized, retrospective, interventional, comparative consecutive series including 47 patients with submacular hemorrhage. Eighteen patients were treated with ppV, intravitreal injection of rtPA and 20% SF6 gas [group A: mean age 78 years, mean duration of symptoms 6.6 days, 15 age-related macular degeneration (AMD), three retinal arterial macroaneurysm (RAMA)]. Twenty-nine patients were treated with ppV, subretinal injection of rtPA and intravitreal injection of SF6 gas (group B: mean age 75 years, mean duration of symptoms 5.9 days, 26 AMD, two RAMA, one blunt ocular trauma). The main outcome measure was complete displacement of submacular hemorrhage from the fovea. Complete displacement of submacular hemorrhage was achieved in less patients in group A (22%) than in group B (55%) (p = 0.025). In group A, mean best-corrected visual acuity (BCVA) change was logMAR -0.14, standard deviation (SD) = 0.64, and in group B logMAR -0.32, SD = 0.68 without statistically significant difference between the two groups (p = 0.2, Mann-Whitney test). Complications (retinal detachment, vitreous hemorrhage, and recurrence of submacular hemorrhage) were more frequent in group B than in group A. ppV with subretinal injection of rtPA and intravitreal injection of gas was more effective than ppV with intravitreal injection of rtPA and gas in terms of complete displacement of submacular hemorrhage; however, it may be associated with a higher rate of postoperative complications. Functional improvement in the majority of patients suggests the absence of direct retinal toxicity of subretinally applied rtPA.

Pneumatic displacement and intravitreal bevacizumab: A new approach for management of submacular hemorrhage in choroidal neovascular membrane

Choroidal neovascular membrane (CNVM) is one of the most common causes of submacular hemorrhage (SMH). Conventional treatment involves management of the SMH with pneumatic displacement with or without tissue plasminogen activator (TPA) followed by intravitreal injection of bevacizumab in a second sitting. We decided to assess the efficacy of treating SMH secondary to CNVM with pneumatic displacement using sulphur hexafluoride (SF6) gas and intravitreal bevacizumab. Four patients with SMH secondary to CNVM were included in this study. Intravitreal bevacizumab, 0.05 ml, along with 0.5 ml of SF6 was injected through the pars plana into the vitreous cavity. Postoperative best corrected visual acuity improved in all eyes with complete or partial displacement of SMH out of the foveal area.

Can Intravitreal Tissue Plasminogen Activator and SF6 Gas Facilitate Management of Macular Degeneration with Photodynamic Therapy?

To describe the safety and efficacy of intravitreal tissue plasminogen activator (tPA) and sulfur hexafluoride (SF6) gas with sequential photodynamic therapy (PDT) in the management of submacular hemorrhage (SMH) associated with macular degeneration (MD). Consecutive case series of five patients presenting with acute SMH from neovascular MD between May 2004 and January 2006 in a UK Eye Centre. Duration of visual loss was less than 7 weeks. Treatment involved intravitreal injections of tPA, SF6 gas to achieve pneumatic displacement of SMH, and 24 hours prone posturing. Displacement of SMH was assessed by digital photography, and choroidal neovascularization (CNV) was reclassified using angiography. PDT was applied when indicated within 1 to 12 days postoperatively. Adequate displacement of SMH allowed visualization of CNV within 24 hours in three of five patients. One patient with large SMH of 7 weeks duration had partial displacement of SMH. Three patients were reclassified with classic CNV after tPA-SF6 injection, and successfully underwent PDT. Intravitreal tPA and SF6 assisted pneumatic displacement of SMH is a safe and effective intervention. This technique facilitates more accurate angiographic classification of CNV. PDT may be sequentially and rapidly applied as early as 1 day after injections. The technique may be offered to patients with neovascular MD presenting with acute SMH.

Management of submacular hemorrhage.

Submacular hemorrhage is a vision-threatening complication of choroidal and retinal disease. Visual outcome after submacular hemorrhage is dependent on the underlying disease process, amount of subretinal hemorrhage, and duration before treatment. Treatment options include observation, surgical evacuation with or without tissue plasminogen activator (tPA), or pneumatic displacement with or without tPA. The preoperative amount of subretinal hemorrhage may help dictate what treatment modality is chosen.

Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement

Objective To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. Design Retrospective, noncomparative case series. Participants From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. Methods The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25–100 μg in 0.1–0.2 ml) and expansile gas (0.3–0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). Main outcome measures Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. Results In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4–19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. Conclusions Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.