Thick Submacular Hemorrhage Research Articles

Early surgical displacement of submacular hemorrhage without tissue plasminogen activator use: one-year outcomes

ObjectifLa présente étude se penchait sur l’évolution de la meilleure acuité visuelle (AV) corrigée et la résolution de l'hémorragie sous-maculaire (HSM) à la suite d'un seul déplacement pneumatique de l'hémorragie sous-rétinienne réalisé rapidement qui comprenait l'administration sous-rétinienne d'une solution saline équilibrée et d'air stérile sans recours à un activateur tissulaire du plasminogène (tPA, pour tissue plasminogen activator). NatureAnalyse d'intervention comparative rétrospective. ParticipantsAinsi, 26 yeux présentant une HSM abondante qui ont subi une vitrectomie par la pars plana et un déplacement pneumatique de l'hémorragie sous-rétinienne sans administration de tPA entre 2015 et 2021 et pour lesquels on disposait d'un suivi d'au moins 1 an. MéthodesL'intervention chirurgicale reposait sur la vitrectomie par la pars plana standard réalisée à l'aide d'une aiguille de petit calibre s'accompagnant d'un déplacement pneumatique sous-rétinien obtenu par l'injection sous-rétinienne d'une solution saline équilibrée et d'air stérile suivie d'un échange liquide-gaz/air partiel. Au nombre des principaux paramètres de mesure, mentionnons le degré de déplacement de l'HSM sous-fovéale, les meilleures AV et les AV postopératoires finales de même que les effets indésirables. L'AV mesurée sur l’échelle de Snellen a été convertie en logMAR en vue de l'analyse statistique. RésultatsL’étiologie la plus fréquente de l'HSM abondante (92,3 %) était la dégénérescence maculaire liée à l'âge de type néovasculaire. Ainsi, 1 mois après la chirurgie, on a noté un déplacement complet de l'hémorragie sous-fovéale chez 21 patients (80,8 %). La plupart des interventions visant à déplacer l'HSM ont eu lieu dans la semaine suivant l'apparition des symptômes. La durée moyenne de l'HSM avant l'intervention était de 3,60 ± 2,78 jours (fourchette : 1–12 jours). La meilleure AV corrigée en logMAR est passée de 1,63 ± 0,58 (équivalent de 20/800 sur l’échelle de Snellen au départ) à 0,90 ± 0,42 lettre (équivalent de 20/160 sur l’échelle de Snellen) lors du dernier suivi (p = 0,001). L'amélioration de l'AV enregistrée dans le cadre de la présente étude est comparable à celle d’études antérieures qui incluaient l'administration de tPA. Les complications postopératoires hâtives comprenaient 1 cas de décollement de rétine, 1 cas d'hémorragie du vitré et 1 cas de trou maculaire. ConclusionL'intervention rapide reposant sur l'injection sous-rétinienne d'une solution saline équilibrée et d'air stérile sans administration de tPA permet le déplacement efficace d'une HSM abondante, le tout donnant lieu à une amélioration de la fonction rétinienne, de l'AV et de (l'orthokératologie.)

Displacement of Submacular Hemorrhage With Vitrectomy Combined With Subretinal Balanced Salt Solution and Air.

To describe a technique of displacement of submacular hemorrhage (SMH) using subretinal injection of balanced salt solution and filtered air. Patients presenting within 2 weeks of massive SMH (>4 disk diameter) were prospectively included. All patients underwent 25-gauge pars plana vitrectomy, posterior vitreous detachment, injection of subretinal balanced salt solution and filtered air followed by partial fluid air exchange, 20% sulfur hexafluoride tamponade, and heads-up positioning postoperatively. Degree of displacement of SMH was assessed at 1 month and change in best-corrected visual acuity was assessed at 3 months. Ten patients with massive SMH who underwent the aforementioned procedure were included. Complete displacement of bleed from the macula was achieved in nine (90%) of 10 eyes at 1 month. There was significant improvement in best-corrected visual acuity from baseline at 1 month ( P = 0.015) and 3 months ( P = 0.043). Pars plana vitrectomy with injection of subretinal balanced salt solution and filtered air was well-tolerated and efficacious in displacing large and thick SMH in patients operated within 2 weeks of onset of symptoms.

Surgical management of submacular hemorrhage: experience at an academic Canadian centre

ObjectiveTo report the anatomical and visual outcomes of patients with thick submacular hemorrhage (SMH) treated with pars plana vitrectomy (PPV), subretinal tissue plasminogen activator (t-PA), and pneumatic displacement. DesignSingle-centre, retrospective case series. ParticipantsA total of 99 eyes of 99 consecutive patients with thick SMH secondary to any underlying etiology treated with PPV with subretinal t-PA and pneumatic displacement by 6 vitreoretinal surgeons at St. Michael’s Hospital, Toronto, between July 2004 and August 2016. MethodsAll medical records and colour fundus photographs were reviewed for data collection. Blood displacement was evaluated at follow-up visits and classified as complete, partial, or none. Main outcome measures included blood displacement at final follow-up, postoperative Snellen best-corrected visual acuities (BCVA), and complication and recurrence rates. ResultsPatients had a mean age of 77.7 ± 12.3 years and were followed up for an average of 18.4 ± 22.3 months. Wet age-related macular degeneration was the most common etiology associated with thick SMH (80.8%). Complete blood displacement was observed by final follow-up in 85.9% of the cases, partial displacement in 12.1%, and none in 2.0%. Mean logMAR BCVA improved from 2.03 ± 0.81 (Snellen 20/2143) at baseline to 1.80 ± 1.00 (Snellen 20/1262; p = 0.009) at final follow-up, and baseline BCVA was a significant predictor of final BCVA (p < 0.001). Early postoperative complications included vitreous hemorrhage in 13 eyes and rhegmatogenous retinal detachment in 8. Recurrent SMH was observed in 12 cases. ConclusionsVitrectomy with subretinal t-PA and pneumatic displacement seems to be an effective treatment for SMH in terms of blood displacement and visual outcomes.

Modified Approach in Management of Submacular Hemorrhage Secondary to Wet Age-Related Macular Degeneration.

The aim of this study was to evaluate the surgical outcomes of a modified approach in the management of thick submacular hemorrhage in patients with wet age-related macular degeneration. This was a retrospective study. A retrospective chart review was performed on 10 eyes of 10 patients with submacular hemorrhage secondary to wet age-related macular degeneration treated with 23-gauge pars plana vitrectomy, followed by submacular injection of recombinant tissue plasminogen activator (12.5 μg/0.1 mL), bevacizumab (2.5 mg/0.1 mL), and air (0.3 mL). Gas tamponade was given with 20% SF6 and postoperative propped-up positioning. Patients were evaluated for displacement of hemorrhage, preoperative and postoperative best-corrected visual acuity, occurrence of intraoperative and postoperative complications, and recurrence of hemorrhage. All patients were followed up for 6 months. Displacement of the submacular bleed was achieved in all cases. Improvement of best-corrected visual acuity was seen in 8 of 10 patients. Rebleed was seen in 2 eyes that were retreated with intravitreal injection of recombinant tissue plasminogen activator, bevacizumab, and 20% SF6 gas. This modified technique aids in the effective displacement of thick submacular hemorrhage with simultaneous treatment of the underlying choroidal neovascular membrane, which halts the disease progression resulting in significant improvement of visual acuity.

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

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.

Intravitreal anti-VEGF monotherapy for thick submacular hemorrhage of less than 1 week duration secondary to neovascular age-related macular degeneration.

Aim:To investigate the role of anti-VEGF monotherapy in patients with thick submacular hemorrhage (SMH) of ≤1 week duration secondary to neovascular age-related macular degeneration (N-AMD).Materials and Methods:A retrospective chart review of 14 eyes of 14 patients presenting with acute decrease in central vision of ≤1 week duration secondary to a thick SMH measuring ≥ 2 MPS disk areas from N-AMD was performed. Intravitreal injections of bevacizumab 1.25 mg (13 eyes) or ranibizumab 0.5 mg (1 eye) were given monthly until resolution of SMH and less frequently thereafter, based on treat-and-extend approach utilizing spectral domain optical coherence tomography (SDOCT). Patients with follow-up of ≥6 months were included.Results:Patients presented after a median of 4 (range 1-7) days from the onset of SMH. Mean lesion size was 27.9 mm2 (range 5.47-100, median 15), with blood comprising 77-98% of the lesion. Presenting visual acuity (VA) ranged from 20/60 to hand motions (median 20/200). Patients received a mean of 11.4 (range 5-20) injections over 18.4 (range 7-50) months. SMH resolved in all eyes in a mean of 4.8 (range 2-8) months. At 6 months follow-up, mean VA gain was −0.54 logMAR (range: −1.5 to +1, Snellen range 20/25-20/400, median 20/100, P = 0.0037), with 11 gaining ≥0.2 logMAR. Mean change in VA from baseline at final follow-up was −0.58 logMAR (range −1.6 to +1, Snellen range 20/30-20/400, median 20/60; P = 0.0022).Conclusion:A good anatomical and visual outcome can be accomplished in patients with thick SMH secondary to N-AMD treated with anti-VEGF monotherapy within 1 week.

Subretinal tenecteplase injection in a submacular hemorrhage from polypoidal choroidal vasculopathy: a case report.

The purpose of this report was to describe a case with a thick submacular hemorrhage (SMH) resulting from polypoidal choroidal vasculopathy that was successfully treated with a subretinal tenecteplase injection. A retrospective case report. A 63-year-old man with acute SMH secondary to polypoidal choroidal vasculopathy underwent a partial posterior vitrectomy, a subretinal tenecteplase (100 μg/0.1 mL) injection with air/fluid exchange, and an intravitreal injection of bevacizumab (2.5 mg/0.1 mL). His preoperative corrected visual acuity was 20/30, but the SMH threatened the fovea. The SMH was displaced inferiorly and absorbed completely at 1 month postoperative. His visual acuity decreased to 20/40 1 week postoperative but recovered to 20/20 2 months after surgery. The electroretinogram showed no distinct elongation of implicit time and slightly decreased amplitude of a-wave and b-wave at 3 months postoperative; optical coherence tomography presented disruption of the inner segment/outer segment line at the onset of SMH but recovered completely at 3 months postoperative. Subretinal tenecteplase was found to have sufficient hemolytic function and no retinal toxicity and could represent a feasible treatment option for the management of SMH.

Pneumatic Displacement of Acute Submacular Hemorrhage with and without the use of Tissue Plasminogen Activator

To evaluate the efficacy of C(3)F(8) gas-assisted pneumatic displacement in the treatment of massive submacular hemorrhage, with and without the use of tissue plasminogen activator (tPA). Twenty-one eyes of 21 patients with recently developed (up to 10 days) dense submacular hemorrhage underwent intravitreal injection of pure C(3)F(8) gas (0.4-0.5 mL) followed by face-down positioning for pneumatic displacement. Seven of them received additional intravitreal injection of 25-50 microg tPA. The primary etiology of submacular hemorrhage was age-related macular degeneration (n=16), myopic choroidal neovascularization (n=2), retinal arterial macroaneurysm (n=2), and trauma (n=1). Visual acuity and displacement of hemorrhage were the main outcome measures. Follow-up period was 6-12 months. Effective displacement of hemorrhage was obtained in 20 of 21 patients within 7 days. Final median Snellen visual acuity (0.18) was found significantly improved compared to baseline (0.03) (p<0.001). Visual acuity improvement was similar in both groups (p=0.72). Intravitreal injection of C(3)F(8) effectively displaced thick submacular hemorrhage and improved visual acuity independently from primary cause. Additional tPA use in this study had no impact on the final outcomes.

Traitement des hématomes maculaires compliquant la DMLA par vitrectomie, injection sous-rétinienne de rt-PA et tamponnement intraoculaire par gaz

The natural prognosis of eyes with subretinal hemorrhage resulting from age-related macular degeneration is generally poor. A variety of therapeutic approaches have been developed but no consensus was found. Therefore, we evaluated a technique consisting of pars plana vitrectomy and subretinal rt-PA injection followed by evacuation of the liquid blood using sulfur hexafluoride (SF6). This study was a retrospective clinical case series examining 18 eyes of 16 patients with age-related macular degeneration and thick submacular hemorrhage treated with vitrectomy, subretinal injection of rt-PA (0.5mg), and fluid-gas exchange. The subretinal hemorrhage was displaced in all 18 cases, revealing a choroidal lesion in 17 eyes. A treatable lesion accountable for the bleeding was identified in ten eyes, which all received a secondary treatment (intravitreal injection or photodynamic therapy). After a mean follow-up of 6 months, the final visual acuity improved in ten eyes. Complications consisted of one case of retinal detachment and one case of hyphema. This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. However, further controlled and multicentric studies will be required to assess its efficacy and safety in the management of this difficult clinical problem.

Spontaneous Visual Improvement Following a Large Traumatic Submacular Hemorrhage

&lt;P&gt;&lt;B&gt;INTRODUCTION&lt;/B&gt;&lt;br&gt; A 32-year-old man presented with a 1-week history of blunt trauma to the right eye from a high-speed golf ball at the golf course. Best-corrected visual acuity was 20/400 in the right eye and 20/20 in the left eye. Examination of the right eye revealed a large, relatively thick submacular hemorrhage (Fig. 1A). A choroidal rupture temporal to the fovea was also visible, partially obscured by the submacular hemorrhage. &lt;/P&gt; &lt;H4&gt;AUTHORS&lt;/H4&gt; &lt;P&gt;From New England Retina Associates (NAC, TY, PEL), Hamden, Connecticut; and the Department of Ophthalmology (HWF), Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida.&lt;/P&gt; &lt;P&gt;Accepted for publication November 5, 2006.&lt;/P&gt; &lt;P&gt;Address correspondence to Nauman A. Chaudhry, MD, New England Retina Associates, 2200 Whitney Avenue, Hamden, CT 06518.&lt;/P&gt;

Subretinal recombinant tissue plasminogen activator injection and pneumatic displacement of thick submacular hemorrhage in Age-Related macular degeneration

Objective To evaluate the anatomic and visual outcomes after a surgical procedure for displacement of thick submacular hemorrhage in patients with age-related macular degeneration. Design Retrospective, noncomparative, interventional case series. Participants Twenty-nine consecutive eyes of 28 patients with thick submacular hemorrhage secondary to age-related macular degeneration. Intervention The procedure consisted of a pars plana vitrectomy with subretinal recombinant tissue plasminogen activator injection (125 mg/ml) through a translocation microcannula, followed by fluid–air exchange and postoperative prone positioning. Main outcome measures Intraoperative and postoperative surgical complications, preoperative and postoperative best-corrected visual acuities, postoperative fluorescein angiography results, and additional postoperative treatments. Results Total subfoveal blood displacement was achieved in 25 eyes, with subtotal displacement in the others. Based on fluorescein angiography results, 8 eyes were eligible for additional postoperative treatments. At 3 months, 17 eyes had gained more than 2 lines of visual acuity, whereas 3 had lost more than 2 lines. The difference between preoperative and 3-month postoperative visual acuity was statistically significant ( P = 0.0167). Complications consisted of 2 cases of vitreous hemorrhage that cleared within 4 weeks. Conclusions This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. No significant complication from the procedure was identified. However, further controlled studies will be required to assess its efficacy in the management of this difficult clinical problem.

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid–gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration

PURPOSE: To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration. METHODS: Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 μg), and fluid–gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity. RESULTS: In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity ( P = .004) but not between preoperative and final visual acuity ( P = .16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye. CONCLUSIONS: This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

Pneumatic displacement of submacular hemorrhage.

Patients with thick submacular hemorrhage complicating age-related macular degeneration and other disorders typically have a poor visual prognosis. A new outpatient procedure, consisting of intravitreal injection of tissue plasminogen activator and gas followed by brief prone positioning, is effective in displacing thick submacular blood and facilitating visual improvement in most patients. Injection of gas alone also appears to be effective in many eyes. The procedure is technically simple and the rate of serious complications appears to be acceptably low. 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 intravitreal tissue plasminogen activator and to provide definitive outcome comparisons with other management approaches.

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.

Surgical Management of Submacular Hemorrhage

The development of a thick submacular hemorrhage usually carries a poor visual prognosis. The surgical removal of submacular blood may improve the otherwise poor outlook in these cases. Forty-seven consecutive patients underwent vitrectomy with surgical removal of submacular hemorrhage. The patient population consisted of two consecutive groups. Group 1 (1989 to 1991) included 23 patients (20 with age-related macular degeneration [ARMD], one with idiopathic submacular hemorrhage, one with presumed ocular histoplasmosis syndrome [POHS], and one with angioid streaks) who underwent mechanical clot extraction. Group 2 (1991 to 1993) included 24 patients (19 with ARMD, two with POHS, two with arterial macroaneurysm, and one with angioid streaks) who underwent tissue plasminogen activator-assisted drainage of thick submacular hemorrhage. The dose of tissue plasminogen activator ranged from 10 to 40 micrograms. All patients had surgery within 72 hours of diagnosis. In group 1, the mean size of the submacular hemorrhage was 11 disc areas (range, 1 to 16 disc areas). Mean follow-up was 40 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/200. (Visual acuity improved in six eyes, was stable in seven eyes, and deteriorated in seven eyes.) All three of the eyes without ARMD had visual improvement with a mean postoperative visual acuity of 20/70. Overall, visual acuity stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%) patients. In group 2, the mean size of the submacular hemorrhage was 11 disc areas (range, 3 to 16 disc areas). Mean follow-up was 24 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/480 (visual acuity was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes). Four of five eyes without ARMD had visual improvement and one was stable, with a mean postoperative visual acuity of 20/60. Visual acuity stabilized or improved in 22 (92%) of 24 patients and decreased in two (8%). The degree of clot lysis was variable. Submacular hemorrhage secondary to ARMD has a poor visual prognosis, with or without surgical drainage. The addition of tissue plasminogen activator-assisted clot lysis does not appear to significantly improve the visual outcome following surgery. The determination of whether surgical intervention is appropriate in these cases requires a prospective, randomized clinical trial.