Quantitative effect of intravitreally injected tissue plasminogen activator and gas on subretinal hemorrhage

Displacement of submacular hemorrhage with intravitreal tissue plasminogen activator following 27 gauge transvitreal fine needle aspiration biopsy for choroidal melanoma

Purpose

To describe the management of submacular hemorrhage (SMH), a vision threatening complication following transvitreal choroidal biopsy, with intravitreal tissue plasminogen activator (tPA) and pure perfluoropropane (C₃F₈) gas bubble injection.

Observations

A 53 year old female with choroidal melanoma of the left eye underwent iodine-125 plaque brachytherapy placement and 27 gauge transvitreal fine needle aspiration choroidal biopsy for gene expression profiling. On postoperative day 2, large SMH was identified on dilated fundus examination. At the time of plaque brachytherapy removal, intravitreal tPA and pure C₃F₈ gas bubble injection with post operative positioning was also performed to attempt displacement of SMH. At postoperative month 1 following tPA and gas bubble displacement, the SMH was completely displaced inferotemporally outside of the macula and visual acuity improved from 20/70 at postoperative week 1 to 20/25 at postoperative month 1.

Conclusions and importance

Subretinal hemorrhage can be a complication of transvitreal choroidal tumor biopsy but early detection and prompt treatment can result in good visual outcomes.

An Innovatory Surgical Technique for Submacular Hemorrhage Displacement by Means of a Bioengineering Perspective

The purpose of this case report is to present a new surgical technique for the treatment of large Subretinal Hemorrhage (SRH) secondary to Age-related Macular Degeneration (AMD). Considering the biomechanics of foam evolution theory, bubble coarsening effect, and gas-liquid biphasic absorption, an SRH due to an AMD case was treated with vitrectomy. The treatment was implemented by subretinal injection of air bubbles combined with rtPA followed by air fluid exchange. The air bubbles helped mess up and remove the blood from the macula area, and no complications occurred. Two weeks postoperatively, there was no sign of hemorrhage and the Central Macular Thickness (CMT) was sharply decreased from 443 μm to 317 μm. At the five-month follow-up, the CMT remained at 267 μm and the patient's visual acuity improved from light perception to 20/70 according to the Snellen chart. The combination of injecting multiple air bubbles and submacular rtPA, followed by air fluid exchange, was able to displace more than (90%) of the subretinal blood just two weeks postoperatively. Our technique is a promising alternative surgical approach for the displacement of SMH due to AMD, with a clear visual and anatomical benefit seen in the early follow-up period.

[Management of submacular hemorrhage : What, when, how?]

BACKGROUND

Subretinal hemorrhage involving the macula is a typical complication in a variety of retinal diseases, whereby age-related macular degeneration (AMD) is by far the leading cause.

METHOD

A literature search was carried out in PubMed.

RESULTS

Numerous studies have demonstrated the effectiveness of various approaches to the management of submacular hemorrhage, including intravitreal anti-VEGF treatment, pneumatic displacement supported by fibrinolytic agents or surgical drainage.

DISCUSSION

There is currently no consensus regarding evidence-based standard treatment for macular hemorrhage, although there is a trend towards minimally invasive approaches. Regardless of the choice of the primary treatment approach, the time to treatment and an accompanying intravitreal treatment with VEGF inhibitors are decisive for the functional outcome.

Combined Administration of Preoperative Intravitreal and Intraoperative Subretinal Recombinant Tissue Plasminogen Activator in Acute Hemorrhagic Age-related Macular Degeneration

Purpose

To evaluate the efficacy of combining pre-operative intravitreal administration of recombinant tissue plasminogen activator (rTPA) followed by 23G pars plana vitrectomy with the subretinal administration of rTPA in the management of acute submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD).

Methods

This is a single-center case series report that included 14 patients with SMH secondary to neovascular AMD. All of them received preoperative intravitreal injection of 0.05 ml (50 µg) rTPA, followed on the next day by 23G pars plana vitrectomy with subretinal 0.1 ml (10 µg) rTPA administration and air tamponade.

Results

There was a significant (p=0.01) overall improvement in the visual acuity post-treatment (from 1.4±0.5 log MAR to 0.9±0.4). The mean overall change in the visual acuity post-treatment was 0.5±0.3 log MAR (mean % change=31.7±15.1). There was a significant (p=0.03) overall reduction in the central macular thickness post-treatment (896±608.1 µm to 497.2±196.0 µm). The mean overall change in the central macular thickness post-treatment was 398.8±458.1 µm (mean % change=38.1±18.1).

Conclusion

Combined treatment of 24 hours of preoperative administration of intravitreal rTPA followed the next day by vitrectomy and the administration of subretinal rTPA with air tamponade appeared to be effective as a prompt intervention in managing acute SMH secondary to neovascular AMD. However, similar studies with larger sample size and a control comparative group are warranted to further confirm these findings.

Tissue plasminogen activator-assisted vitrectomy for submacular hemorrhage due to age-related macular degeneration

Purpose:

The purpose of this study was to evaluate the treatment efficacy of vitrectomy combined with subretinal recombinant tissue plasminogen activator (r-tPA) and factors affecting visual improvement in patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (nAMD).

Materials and Methods:

Medical records of 17 consecutive patients diagnosed with SMH secondary to nAMD were retrospectively reviewed. The initial surgical procedure involved a 23-gauge transconjunctival vitrectomy, subretinal r-tPA application through a self-sealing inferior retinotomy, and sulfur hexafluoride gas for tamponade in all patients. The duration, size, and thickness of the hemorrhage and the pre- and post-operative visual acuity (VA) using a Snellen chart were recorded. VA was converted to logMAR for statistical analysis.

Results:

The average duration and size of the SMH were 12.8 ± 18.2 days and 8.6 ± 5.3 disc areas, respectively. The mean follow-up time was 16.9 ± 4.7 months. A statistically significant visual improvement was found when comparing initial VA with postoperative best-corrected VA (BCVA) and final BCVA (Wilcoxon rank test, P ≤ 0.01). There was no significant correlation between the size of the hemorrhage and postoperative BCVA and final BCVA (Spearman's rho test). There was no statistically significant correlation between the initial VA and postoperative BCVA and final BCVA (Spearman's rho test). There was no significant correlation between the duration of hemorrhage and postoperative BCVA and final BCVA (Spearman's rho test). The preoperative thickness of hemorrhage (747.5 ± 30 μm) was not correlated with postoperative BCVA or final BCVA (Pearson's test).

Conclusions:

Vitrectomy combined with subretinal r-tPA injection and gas tamponade is an effective surgical intervention to preserve VA in selected patients with apparent SMH.

Intravitreal tPA Injection and Pneumatic Displacement for Submacular Hemorrhage in a 10-Year-Old Child

Background. Submacular hemorrhage can occur after blunt trauma to the eye. Intravitreal tissue plasminogen activator (tPA) and gas injection are often used for treatment and are effective for submacular hemorrhage caused by age-related macular degeneration. This report describes the clinical outcome in a child with submacular hemorrhage caused by traumatic choroidal rupture who underwent successful intravitreal tPA injection and pneumatic displacement. Case Presentation. A 10-year-old boy developed sudden decrease of vision and a central scotoma in his right eye after trauma. Submacular hemorrhage was found in the eye. Visual acuity was 20/70 OD. Tissue plasminogen activator (12.5 μg in 0.05 mL) and 0.3 mL of pure sulfur hexafluoride were injected into the vitreous cavity under general anesthesia. After surgery, the patient was instructed to maintain a prone position. Displacement of the submacular hemorrhage from the fovea revealed a choroidal rupture, presumed to be the cause of the hemorrhage. After 4 months of follow-up, visual acuity was restored and final visual acuity is 20/16. Conclusion. Intravitreal tPA and gas injection can be an effective treatment for children with submacular hemorrhage.

Pars plana vitrectomy with peripheral retinotomy after injection of preoperative intravitreal tissue plasminogen activator: a modified procedure to drain massive subretinal haemorrhage

AIMS

To report outcome of a modified procedure for draining massive subretinal haemorrhages (SRHs).

METHODS

The charts of eight consecutive eyes from eight patients with massive SRHs extending to the periphery and involving two or more quadrants with haemorrhagic and bullous retinal detachment were reviewed. Tissue plasminogen activator (tPA) was injected intravitreally 12-24 h preoperatively; vitrectomy was carried out with peripheral retinotomy, drainage of the SRH from the retinotomy using perfluorocarbon liquid and gas tamponade with prone positioning postoperatively.

RESULTS

The preoperative visual acuities ranged from light perception to 20/200. Most of the subretinal haematomas moved postoperatively to the vitreous cavity through the peripheral retinotomy using perfluorocarbon liquid. Residual SRHs were drained from the anterior chamber at the bedside after prone positioning overnight. SRH recurred in one eye 14 months postoperatively and was successfully retreated. No other serious complications developed. The final visual acuity improved in seven eyes (range 20/1000-20/60). Polypoidal lesions in choroidal vasculatures were present in three of seven patients.

CONCLUSIONS

The technique seems safe and effective for treating massive SRH. However, visual recovery is limited by the underlying macular pathology. Polypoidal choroidal vasculopathy, other than age-related macular degeneration, may be another cause of massive SRHs.

Plasminogen activators promote excitotoxicity-induced retinal damage

Increased levels of extracellular l-glutamate have been suggested to play a role in retinal damage in a number of blinding diseases such as glaucoma and diabetic retinopathy. Although glutamate can cause retinal damage in part by hyperstimulating its receptors ("excitotoxicity"), the downstream events that lead to retinal damage are poorly understood. In this study, we injected kainic acid (KA), a glutamate receptor agonist that specifically hyperstimulates non-NMDA-type receptors, into the vitreous humor of CD-1 mice and have investigated the role of plasminogen activators (PAs) [tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA)] in excitotoxicity-induced retinal damage. Injection of KA into the vitreous humor led to an up-regulation in tPA and an induction in uPA activity in the retina and this was associated with activation of zymogen plasminogen to active plasmin. Immunocytochemical analysis indicated that retinal ganglion cells (RGCs), constitutively express tPA and release it into the extracellular space upon KA injection. Immunocytochemical analysis also indicated an increase in uPA in the nerve fiber layer after KA injection that was absent in the control retinas. These events were associated with apoptotic death of cells initially in the ganglion cell layer and subsequently in the inner and outer nuclear layer, associated with loss of RGCs and amacrine cells. These phenomena were inhibited when recombinant plasminogen activator inhibitor (rPAI-1) or tPA-STOP were injected into the vitreous humor with KA, whereas a plasmin inhibitor, alpha-2-antiplasmin, failed to attenuate KA-induced retinal damage. Taken together, these results suggest that inhibition of plasminogen activators might attenuate retinal damage in blinding retinal diseases in which hyperstimulation of glutamate receptors is implicated as a causative factor to retinal damage.

Retinal toxicity of intravitreal tenecteplase in the rabbit

AIM

To investigate the retinal toxicity of intravitreal injection of a novel fibrinolytic tenecteplase in rabbit eyes.

METHODS

Tenecteplase (25-350 micro g in 0.1 ml BSS) was injected into the vitreous cavity of normal rabbit eyes. Control (fellow) eyes received 0.1 ml of BSS. One day, 1 week, and 2 months post-injection, the eyes were examined by slit lamp biomicroscopy, indirect ophthalmoscopy, and electroretinography, and then harvested for histopathological examination.

RESULTS

No evidence of retinal toxicity was seen with tenecteplase doses up to and including 50 micro g. At a dose of 150 micro g ophthalmoscopy was normal, but histology showed mild retinal damage in the inner nuclear layer and electroretinography showed a temporary reduction in B-wave amplitude. At doses of 200 micro g and above, there was evidence of retinal toxicity on electroretinography, ophthalmoscopy, and histology. Ophthalmoscopic findings included vitreal fibrosis, retinal necrosis and tractional retinal detachment and light microscopy revealed necrosis of retinal pigment epithelium and other retinal layers. Damage was centred around the injection site but was more widespread with the higher doses.

CONCLUSION

A dose of 50 micro g tenecteplase appears safe for intravitreal injection in the rabbit. Tenecteplase could have potential applications in the treatment of submacular haemorrhage and retinal vein occlusion.

Intravitreous Recombinant Tissue Plasminogen Activator and Gas to Treat Submacular Hemorrhage in Age-Related Macular Degeneration

We evaluated the safety and efficacy of intravitreous recombinant tissue plasminogen activator (rTPA) and gas for the treatment of submacular hemorrhage in age-related macular degeneration (ARMD). From January 2000 to April 2002, we enrolled 15 patients with submacular hemorrhage secondary to ARMD. All patients received 100 microg rTPA and 0.3 mL perfluoropropane intravitreously. Postoperatively, all patients were kept in a supine position for 4 hours followed by a face-down position for 4 days. Anatomic and functional results were evaluated during a follow-up period of 6 to 19 months. Submacular blood was completely displaced in 12 patients (80%) and partially in three (20%). Best postoperative visual acuity improved in all 15 eyes; in seven eyes (47%), the improvement was two or more lines. Final visual acuity improved in 12 eyes, remained stable in two eyes, and worsened in one eye. Onset of hemorrhage within 21 days was associated with better gains of lines in best postoperative (p = 0.0256) and final visual acuity (p = 0.044). Although two patients developed mild breakthrough vitreous hemorrhage within 1 day after treatment, no rTPA-related retinal toxicity was observed. Intravitreous injections of rTPA and gas are safe and effective in improving visual acuity in patients with submacular hemorrhage secondary to ARMD. Although the final visual outcome is often limited by the progression of the disease, significant and stable visual recovery over an extended follow-up period is possible using this easy and convenient technique.

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

OBJECTIVE

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.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

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.

METHODS

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).

MAIN OUTCOME MEASURES

Best and final postoperative visual acuity in relation to size and onset of hemorrhage, displacement of subretinal blood, and surgical complications.

RESULTS

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.

CONCLUSIONS

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.