Treatment Of Submacular Hemorrhage Research Articles

Multimodal imaging-based treatment recommendations for managing submacular hemorrhage.

Submacular haemorrhage (SMH) is an emergency, and the most important immediate action in the treatment of SMH is the early displacement or evacuation of subretinal heme from below the fovea, followed by simultaneous or sequential treatment of the underlying cause. Photoreceptor damage can occur immediately after the onset of SMH for a variety of reasons, including toxins released from the blood, the diffusion barrier created by the blood for oxygen delivery and nutrition to the outer retinal layers, and shearing forces on the outer retinal layers, resulting in permanent visual deterioration. A clinician's decision to treat SMH is influenced by a number of factors, including presenting visual acuity, duration of visual symptoms, SMH aetiology and characteristics, availability of intraocular gases and tissue plasminogen activator, and pars plana vitrectomy facilities. For many clinicians, the duration of visual symptoms is the most important and first consideration when planning SMH treatment. Very little emphasis is given to the SMH's imaging characteristics. Currently, there are several treatment options for SMH removal. There is a need to develop a simplified treatment algorithm for SMH that is less reliant on the patient's visual complaints, considers heme characteristics on basic retinal imaging, and has the potential to achieve uniform and predictable treatment outcomes in real-world situations. In this short article, we discuss the various factors that can assist clinicians in the management of SMH and present a simplified treatment algorithm based on the SMH's retinal imaging characteristics.

Способ малоинвазивной транслокации организовавшегося субфовеального кровоизлияния

Purpose. To present a method of minimally invasive surgery, including two-port 27G surgery with controlled administration of a solution of recombinant prourokinase in a patient with organized submacular hemorrhage (SMH). Material and methods. A patient with SMH lasting for 30 days underwent a procedure developed on the basis of the N.I. Pirogov National Medical Surgical Center. It's a minimally invasive technique that includes a two-port 27G access without vitrectomy with controlled administration of a solution of recombinant prourokinase 500 ME through a 38G cannula subretinally, followed by tamponade of the vitreal cavity with a 20 % gasair mixture of hexafluoroethane C2F6. A standard ophthalmological examination was performed before the start of treatment, on the 1st day, 2 weeks later, 6 months after vitreoretinal intervention. Results. Visual acuity was 0.1 at the initial examination and 0.05 upon admission to the surgical hospital. Follow-up showed an increase in visual function to 0.3 at 1 month and to 0.5 at 6 months with antivasoproliferative therapy. According to optical coherence tomography at the initial examination, the central retinal thickness (CRT) was 642 µm, followed by a depression of up to 451 µm by the time of hospitalization. On the 14th day, the decrease in CRT reached 267 µm with complete translocation of the hemorrhage and 243 µm after 6 months. The height of detachment of the retinal pigment epithelium at the initial examination showed a value of 167 µm, and at subsequent observation it was 45 µm, 38 µm and 12 µm on the 1st, 14th day and after 6 months, respectively. Against the background of anatomical results, there was a decrease in the zone of absolute scotoma from 25 loci at the time of admission to 3 loci after 6 months, and an increase in total photosensitivity from 4.5 dB to 15.6 dB, respectively. Conclusion. The use of a minimally invasive method for the treatment of SMH, including subretinal administration of tissue plasminogen activator without vitrectomy with gas-air tamponade, improves morphological and functional prognosis. However, further study of the proposed technique on long-term hemorrhages is required. Keywords: submacular hemorrhage, tissue plasminogen activator, pneumodislocation

Малоинвазивное хирургическое лечение организовавшегося субмакулярного кровоизлияния

Purpose. To present a method of minimally invasive surgery, including two-port 27G surgery with controlled administration of a solution of recombinant prourokinase in a patient with organized submacular hemorrhage (SMH). Material and methods. A patient with SMC lasting 30 days underwent a procedure developed on the basis of the Center for Ophthalmology «N.M. N.I. Pirogov» is a minimally invasive technique that includes a two-port 27G access without vitreectomy with controlled administration of a solution of recombinant prourokinase 500 ME through a 38G cannula subretinally, followed by tamponade of the vitreal cavity with a 20% gas-air mixture of hexafluoroethane C2F6. A standard ophthalmological examination was performed before the start of treatment, on the 1st day, 2 weeks later, 6 months after vitreoretinal intervention. Results. Visual acuity was 0.1 at the initial examination and 0.05 upon admission to the surgical hospital. Follow-up showed an increase in visual function to 0.3 at 1 month and to 0.5 at 6 months with antivasoproliferative therapy. According to optical coherence tomography at the initial examination, the central retinal thickness (CRT) was 642 µm, followed by a depression of up to 451 µm by the time of hospitalization. On the 14th day, the decrease in CRT reached 267 µm with complete translocation of the hemorrhage and 243 µm after 6 months. The height of detachment of the retinal pigment epithelium at the initial examination showed a value of 167 µm, and at subsequent observation it was 45 µm, 38 µm and 12 µm on the 1st, 14th day and after 6 months, respectively. Against the background of anatomical results, there was a decrease in the zone of absolute scotoma from 25 loci at the time of admission to 3 loci after 6 months, and an increase in total photosensitivity from 4.5 dB to 15.6 dB, respectively. Conclusion. The use of a minimally invasive method for the treatment of SMH, including subretinal administration of tissue plasminogen activator without vitreectomy with gas-air tamponade, improves morphological and functional prognosis. However, further study of the proposed technique on long-term hemorrhages is required. Key words: submacular hemorrhage, tissue plasminogen activator, pneumodislocation

Оценка отдаленных результатов хирургии субмакулярных кровоизлияний на фоне влажной формы возрастной макулярной дегенерации

Purpose. To evaluate the long-term outcomes of surgery of submacular hemorrhage (SMH) in patients with exudative age-related macular degeneration. Material and methods. A dynamic follow-up of 32 patients with SMH (32 eyes) was carried out, who underwent 25G endovitreal intervention with subretinal injection of 1000 to 3000 IU of the Gemaza drug. The area of the SMH in all cases was extensive with the capture of the fovea. The follow-up period ranged from 24 to 30 months. Results. There was displacement of almost the entire volume of SMH from the macular area to the low periphery in all operated eyes by the next day after the operation. There were complete elimination of SMH and the formation of a normal configuration of the macular profile in 7 days after surgery in all eyes. All patients were satisfied with the results of the surgery according to significant increase of visual acuity and disappearance of a spot in the central visual field. Postoperative complications appeared in four eyes at different times of follow up period, but they were eliminated after reoperation. Conclusion. Subretinal administration of the drug Gemaza and pneumodislocation of the blood clot is an effective method for the treatment of SMH with a limitation period of up to 2 weeks. In the vast majority of cases (88%), it was possible to achieve complete elimination of the SMH and a significant improvement in central vision. Key words: submacular hemorrhage, Gemaza, recombinant prourokinase, age-related macular degeneration, subretinal neovascular membrane

Visual prognosis of submacular hemorrhage secondary to age-related macular degeneration: A retrospective multicenter survey.

PurposeTo investigate the clinical features, treatment options, and visual outcomes of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).DesignA retrospective, observational case series.MethodsSetting: Multicenter institutional setting. Patient Population: A total of 127 patients (127 eyes; 88 men, 39 women; (mean age, 74.2 years)) diagnosed with AMD-associated SMHs exceeding 2 disc diameters involving the fovea. Observation: The AMD types, previous treatments, treatment options, anatomic findings, and best-corrected visual acuity (BCVA) were assessed. Main Outcome Measures: Clinical features, treatment options, and visual outcomes of SMHs secondary to nAMD.ResultsThirty-two eyes had typical AMD, 94 eyes polypoidal choroidal vasculopathy (PCV), and one eye retinal angiomatous proliferation. Eighty-five eyes were treatment-naïve; 42 eyes were treated previously: anti-vascular endothelial growth factor (VEGF) therapy (n = 26), photodynamic therapy (n = 3), and combined therapy (n = 13). Treatment of SMHs included vitrectomy (36 eyes), pneumatic displacement (49 eyes), and anti-VEGF monotherapy (42 eyes). The final BCVA improved significantly in treatment-naïve cases from 0.86 to 0.62 logarithm of the minimal angle of resolution (logMAR) unit (Snellen equivalent from 20/145 to 20/83) and from 0.80 to 0.56 (Snellen equivalent from 20/126 to 20/73) in PCV cases. Meanwhile, the BCVA logMAR values improved from 1.15 to 0.75 (Snellen equivalent from 20/283 to 20/112) and from 0.87 to 0.63 (Snellen equivalent from 20/148 to 20/85) in eyes that underwent vitrectomy or pneumatic displacement, respectively. In eyes with BCVAs between 20/133 to 20/40 at SMH onset, the final VA in the pneumatic displacement group was better than in the anti-VEGF monotherapy group. One eye had a retinal detachment and 1 eye had a macular hole in the vitrectomy group, and 5 eyes had a vitreous hemorrhage in the pneumatic displacement group.ConclusionsThe recommended treatment for SMHs secondary to nAMD exceeding 2 disc area and with BCVA below 20/40 is vitrectomy or pneumatic displacement for visual improvement.

Vitrectomy for Subretinal and Submacular Hemorrhages

Submacular hemorrhage (SMH) is relatively rare in retinal practice. However, it is an important complication of many choroidal and retinal diseases, particularly neovascular age-related macular degeneration (AMD). When untreated the visual prognosis is poor, especially in patients with AMD, and SMHs cannot be effectively treated with only anti-vascular endothelial growth factor (anti-VEGF) injection. The current therapeutic approach is based upon the displacement of the subretinal hemorrhage away from the central retina as soon as possible. The use of tissue plasminogen activator (tPA) has been an important milestone in the treatment of SMHs. Current vitrectomy techniques for SMH management include subretinal tPA injection and aspiration of the blood, and subretinal tPA, and air/anti-VEGF injection with gas tamponade. Submacular surgery, which involves removal of the SMH and choroidal neovascularization (CNV) through a retinotomy, seems to be a technique reserved for selected cases where central retinal pigment epithelium appears to be undiseased/uninvolved. Among the non-surgical treatment options, pneumatic displacement with intravitreal tPA and gas injection may be preferred especially for small-medium sized and thin SMHs. However, the favored approach in real-life conditions is shaped by the physician's experience and the available treatment options. Regardless of the preferred approach, the continuity of the treatment of the underlying pathology is important. As the underlying pathology is usually a CNV, the continuation of anti-VEGF treatment is important for maintaining the visual gain of the initial treatment and reducing the risk of recurrent SMH. The breakthrough development rate of the drugs and the surgical techniques for the treatment of retinal diseases promises in terms of new and more effective treatment approaches.

Принципы терапии субретинальных кровоизлияний

Purpose. To study approaches to the treatment of submacular hemorrhage in age-related macular degeneration based on the literature data. Material and methods. The search for publications on the treatment of submacular hemorrhage (SMH) was carried out in the PubMed, SCOPUS, Umedp databases, as well as manually in journals and publications of conference materials until January 2021. Results and discussion. SMH treatment is represented by a variety of methods, from minimally invasive methods, such as intravitreal injection of drugs, gas tamponade and their combinations, to complex surgical approaches with pigment epithelium transplantation. Conclusions. The successful treatment of massive SMH is possible with minimally invasive methods. However, with significant prominating SMH, vitreoretinal surgical interventions are more appropriate. It is advisable to treat SMH as soon as possible from the moment of hemorrhage. Key words: submacular hemorrhage, age-related macular degeneration, pneumodislocation, vitrectomy, anti-VEGF inhibitors, tissue plasminogen activator.

Хирургическое лечение обширной субмакулярной геморрагии у пациента с экссудативной формой возрастной макулярной дегенерации (клинический случай)

Purpose. To evaluate the result of surgical treatment of submacular hemorrhage in patient with exudative age-related macular degeneration (AMD) by subretinal injection Gemase® and pneumatic retinopexy of blood clot. Material and methods. The article presents a clinical case of surgical treatment of submacular hemorrhage in patient with exudative AMD. The patient underwent three-port 25G vitrectomy, subretinal injection Gemase® 2000 ME by 38G needle, after which pneumatic retinopexy was performed. Results. Next day after the operation, there was displacement of subretinal blood clot from macula beyond out the lower vascular arcade. When observed after 6 months, the subretinal hemorrhage completely resolved, there was a regression of activity of subretinal neovascular membrane and macular edema, the retina was adherent in all cases. Visual acuity has improved. There was no recurrence of hemorrhage. Conclusion. This method of treatment allows you to increase and maintain the central visual acuity, as well as significantly reduce size of absolute central scotoma. Key words: submacular hemorrhage, recombinant prourokinase, Gemase®, exudative age-related macular degeneration, choroidal neovascularization, subretinal neovascular membrane.

Traitement des hématomes sous-maculaires par vitrectomie, injection sous-rétinienne de rtPA et tamponnement gazeux : une étude observationnelle rétrospective monocentrique

To evaluate the functional and anatomic recovery of submacular hemorrhage (SMH), treated with vitrectomy, subretinal injection of rtPA and gas tamponade, to highlight the risk factors for their occurrence as well as the factors influencing prognosis. This is a single-center retrospective study. Thirty-two eyes of 30 patients from the Clermont-Ferrand University Hospital were included, with a submacular hemorrhage (SMH) requiring surgical evacuation. The primary endpoint was final postoperative visual recovery. Visual acuities (AV) were converted to the logarithmic minimum angle of resolution scale (logMAR) for statistical analysis. The average time from onset of symptoms to surgery was 4.8±3.3 days. The initial VA was 2.1±0.3 logMAR, with an average improvement of 0.7±0.7 logMAR (P=0.0004) at the final visit. The mean thickness of the SMH decreased by 729±352μm (P<0.0001) at the final visit. Treatment of SMH with vitrectomy, subretinal injection of rtPA and gas tamponade results in a statistically significant improvement in final VA, as well as a significant decrease in SMH thickness on OCT.

Treatment of submacular hemorrhage with tissue plasminogen activator and pneumatic displacement in age-related macular degeneration.

To evaluate visual and anatomic outcomes following pars plana vitrectomy and intravitreal or subretinal tissue plasminogen activator for submacular hemorrhage in patients with age-related macular degeneration. This was a retrospective study on patients with a minimum follow-up of 12 months undertaken at a tertiary referral center. Data collected include demographic details, visual and optical coherence tomography changes, surgical details, and complications. Surgical results were compared with patients who were age and lesion size matched and treated with anti-vascular endothelial growth factor injections alone. There were 36 patients in surgical and 18 patients in control group. Patients in surgical arm had pars plana vitrectomy, intravitreal tissue plasminogen activator with air 24 (67%), 6 (16%) with C3F8 gas, 1 (3%) with SF6 gas, 4 (11%) subretinal tissue plasminogen activator with air, and 1 (3%) with C2F6 as post-operative tamponade. Mean LogMAR in tissue plasminogen activator group at baseline was 1.56, and it was improved at all time points 1.06 at 1 month (p < 0.05), 0.91 at 6 months (p < 0.05), and 1.07 at 1 year (p < 0.05). Mean best corrected visual acuity in control group at baseline was 1.22LogMAR with no significant improvement at any time points: 1 month (1.27), 6 months (1.35), and 12 months (1.36). Complications included retinal detachment 5%, vitreous hemorrhage 7.5%, and cataract 19%. Pars plana vitrectomy with intravitreal (or subretinal) tissue plasminogen activator and pneumatic displacement can offer better outcome in comparison to anti-vascular endothelial growth factor alone in patients with submacular hemorrhage secondary to age-related macular degeneration.

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.

Retinal Penetration of Intravitreally Injected Tissue Plasminogen Activator: A Rat Model Study

Purpose: To determine whether intravitreal unconjugated tissue plasminogen activator (tPA) (alteplase) can penetrate the intact neural retina and reach the subretinal space in an experimental model. Methods: This study was performed in 24 Sprague-Dawley rats aged 12 weeks. Under general anesthesia, the right eye was injected with either 0.75 μg of 3 μL tPA (14 rats; study group) or saline (10 rats, control group) into the vitreous. Animals were euthanized at 3, 24, and 48 h. The eyes were enucleated, and cryosections were prepared for immunofluorescence staining. Goat anti-tPA antibody was used to detect tPA. Results: In the study group, staining for tPA was detected in the deep retinal layers in all eyes. The staining was deeper and more intense at 3 and 24 h than at 48 h. There was no tPA staining in the retina of eyes injected with saline. Conclusions: This experimental study shows that unconjugated tPA administered into the vitreous is capable of penetrating the deep retinal layers and the subretinal space. These findings suggest that further clinical research is warranted on the benefits of intravitreal tPA in the treatment of submacular hemorrhage.

Treatment for Submacular Hemorrhage Associated with Neovascular Age-Related Macular Degeneration

Submacular hemorrhage associated with neovascular age-related macular degeneration is a complication known to have potentially devastating effects on visual acuity. 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. This manuscript offers guidelines to the management of subretinal hemorrhage based on its size and characteristics, and highlights the need for clinical trials in this area.

Vitrectomy-Assisted Intravitreal Tissue Plasminogen Activator and SF6 Gas Injection on Submacular Hemorrhage

Purpose: To evaluate the results of vitrectomy-assisted intravitreal tissue plasminogen activator (tPA) and gas injection in the treatment of submacular hemorrhage. Methods: Thirty-one eyes of 30 consecutive patients with submacular hemorrhages undergoing vitrectomy with intravitreal tPA (50 /0.1 ml) and gas injection and completed 12 months of follow-up were evaluated. Results: The mean duration of visual symptoms was 4.1 days. Submacular blood was completely displaced in all 31 eyes after surgery. The best corrected visual acuity (logMAR) improved to 0.56 0.46 at 12 months from 1.15 0.51 at baseline (P = 0.002). The most important factors related to visual acuity at the 12-month follow-up were the underlying etiology for the submacular hemorrhage and visual acuity 3 months after surgery (P = 0.003 and P = 0.000, respectively). The 12-month visual acuity was independent of age, gender, presence of vitreous hemorrhage, sub-ILM hemorrhage, baseline visual acuity, duration of symptoms, and the diameter of the submacular hemorrhage. No retinal detachment or re-submacular hemorrhage developed during the follow-up period. Conclusions: This surgical technique can effectively displace submacular hemorrhage without complications. The 3-month visual acuity appears to predict the 12-month visual acuity. The final visual acuity was associated with the primary etiology for the submacular hemorrhage.

Retinal Toxicity of Intravitreal Tissue Plasminogen Activator on Submacular Hemorrhage

Purpose: To present the clinical feature of retinal toxicity of intravitreal tissue plasminogen activator which was used for treatment of submacular hemorrhage. Case summary: An intravitreal injection of tPA (100 ) with gas tamponade (0.2 cc) was given to treat the submacular hemorrhage in a patient with ARMD. The therapeutic effect was measured by visual acuity, slit lamp examination, indirect funduscopy and fluorescein angiogram. Three months after the operation, the hemorrhage was decreased but a pigmentary change was observed on the peripheral retina. After 8 months, the submacular hemorrhage completely reabsorbed but the peripheral pigmentary change had increased. Ten months later, the retinal pigmentary change was observed on the entire retina except the posterior pole. The fluorescein angiogram showed peripheral hyperfluorescene of the retina due to window defect from the pigmentary change but no leakage was detected. The electroretinogram showed reduced amplitude in the right eye. Conclusions: Intravitreal tPA injection of 25 to 100 with pneumatic displacement is typically used for the treatment of submacular hemorrhage. However, there is no established safety dose of tPA for use in human eyes. In the present study, 100 of tPA was used and retinal toxicity was noted. Establishing a safety dose of tPA to prevent dosage dependent complications is necessary.

Intravitreal Injection of tPA and Gas for Submacular Hemorrhage Associated with Age-related Macular Degeneration

Purpose: To study the results of intravitreal tissue plasminogen activator (tPA) and expansile gas injection for the treatment of submacular hemorrhage in age-related macular degeneration (AMD). Methods: Eleven consecutive patients (11 eyes) with submacular hemorrhage in AMD were included in this study. All patients were treated with intravitreal injections of tPA and C3F8 gas. Postoperatively, patients' follow-up period were at least 3 months. Outcome measures included early and final visual acuity, age, disc areas of hemorrhage, duration of symptoms, displacement of blood from the fovea, and final macular status. Results: The maximum diameter of the hematoma ranged from 2 to 10 disc diameters. The mean duration of submacular hemorrhage was 7.5 days. Submacular blood was completely displaced in 7 patients (64%) and partially in four (36%). Best postoperative visual acuity improved in 7 eyes; in 6 eyes (55%), the improvement was two or more lines. Final visual acuity improved in 7 eyes (64%), remained stable in 2 eyes (18%), and worsened in 2 eyes (18%). Choroidal neovascularization positioned at subfovea in 7 eyes (64%) and juxtafovea in 4 eyes (36%). No significant difference was found between postoperative visual recovery and these factors. Conclusions: Our findings suggest that intravitreal tPA and expansile gas injection are safe and of useful for displacing hemorrhages secondary to age-related macular degeneration. Final visual acuity was limited by the underlying choroidal neovascularization of AMD.

Investigation of the safety of tenecteplase to the outer retina

To investigate the safety of the thrombolytic agent, tenecteplase to the outer retina in pig eyes. Tenecteplase (50 microg) was injected into the subretinal space in one eye while the fellow eye received balanced salt solution. At 24 h, 1 week and 9 weeks the eyes were examined by indirect ophthalmoscopy and photographed. Animals were killed at 9 weeks, eyes enucleated and processed for light and transmission electron microscopy. Three locations within the area of the injection bleb were analysed. Retinal pigment epithelial defects, which appeared to be iatrogenic and confined to the injection site, were seen in most of the treated and control eyes. There was no significant difference in the degree of retinal damage between the two groups of eyes at the three sites examined (P > 0.05). Fifty micrograms of tenecteplase appears to be a safe dose with no evidence of toxicity to the outer retina and may have a potential role in the treatment of submacular haemorrhage.

Results of intravitreal tissue plasminogen activator and expansile gas injection for submacular haemorrhage in Thais

To study the results of intravitreal tissue plasminogen activator (tPA) and expansile gas injection for submacular haemorrhage in Thai patients. The medical records of Thai patients who presented with submacular haemorrhage between January 1998 and December 2002 were reviewed. The inclusion criteria were acute onset of bleeding (<1 month), treatment with intravitreal injection of tPA solution (50-100 mug in 0.1 ml) and expansile gas (0.3-0.4 ml of 100% perfluoropropane or sulphur hexafluoride), and at least 6 months of follow-up. Our main outcome measures were best final postoperative visual acuity and surgical complications. A total of 19 eyes of 19 patients completed the inclusion criteria with a mean duration of 13.1 days. The causes of haemorrhage were age-related macular degeneration in 15 eyes (78.9%), idiopathic choroidal neovascularization in two eyes (10.5%), and traumatic, and valsalva retinopathy in one eye each (5.2%). After a mean follow-up of 13 months (range 6-39 months), postoperative visual acuity improved two lines or greater in 12 eyes (63.2%), stabilized in six eyes (31.6%) and worsened in one (5.2%). The final visual acuity measured 20/63 or better in 10 eyes (52.6%). The surgical complications were breakthrough vitreous haemorrhage (three eyes) and cataracts (three eyes), and two had retinal detachments. The treatment of submacular haemorrhage with intravitreal injection of tPA and expansile gas improved visual acuity in more than half of the patients. In all, 10 in 19 eyes demonstrated final visual acuity at a functional level.

Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions.

To investigate the efficacy and safety of treating submacular hemorrhages secondary to age-related macular degeneration (ARMD) with intravitreous recombinant tissue plasminogen activator (rt-PA) and gas under various conditions. Prospective, noncomparative case series. Forty-three consecutive eyes of 42 patients with recent (range, 2-28 days) subfoveal hemorrhage secondary to ARMD were included in this study. The size of subretinal hemorrhage ranged from 0.25 to 30 disc areas. All patients were treated with intravitreous injections of rt-PA (50 microg) and sulfur hexafluoride (0.5 ml). Postoperative prone positioning was maintained for 24 to 72 hours. Patient follow-up ranged from 4 to 18 months (mean, 6 months). Best and final postoperative visual acuity in relation to size and onset of hemorrhage, displacement of subretinal blood, and surgical complications. Best postoperative visual acuity compared with preoperative visual acuity was improved two or more Snellen lines in 19 eyes (44%) and stable in 24 eyes (56%). Final visual acuity was improved two or more lines in 13 eyes (30%), stable in 26 (61%), and two or more lines worse in 4 eyes (9%). Duration of hemorrhage <or=14 days was associated with a better gain of lines of vision (P = 0.0058). Best postoperative acuity was maintained for an average of 4.2 months (range, 0.5-12 months). Overall, complete displacement of blood from under the fovea was achieved in 35 eyes (81%). Nine eyes (21%) developed recurrent hemorrhage, which required repeat treatment. In three patients (7%), a mild breakthrough vitreous hemorrhage was observed. Our findings suggest that intravitreous injections of rt-PA and gas are of value for an improved and accelerated visual recovery in ARMD patients with submacular hemorrhage, although final visual outcome is often limited by the progression of the underlying ARMD. Patients with retinal hemorrhages of recent onset (<or=14 days) seem to have the most favorable results. A rapid displacement of submacular blood may reveal discrete choroidal neovascular membranes amenable to further treatment. The complication rate of this minimally invasive technique seems to be low.

Treatment of Submacular Hemorrhage with Low-Dose Intravitreal Tissue Plasminogen Activator Injection and Pneumatic Displacement

Treatment of Submacular Hemorrhage with Low-Dose Intravitreal Tissue Plasminogen Activator Injection and Pneumatic Displacement