INTRAVITREAL VERSUS SUBRETINAL ADMINISTRATION OF RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR COMBINED WITH GAS FOR ACUTE SUBMACULAR HEMORRHAGES DUE TO AGE-RELATED MACULAR DEGENERATION: An Exploratory Prospective Study

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

OBJECTIVE

This study evaluated changes in best-corrected visual acuity and submacular hemorrhage (SMH) resolution in eyes after a single rapid subretinal displacement surgery using subretinal balanced saline solution and sterile air without tissue plasminogen activator (tPA).

DESIGN

A retrospective comparative interventional analysis.

PARTICIPANTS

Twenty-six eyes with thick SMH who underwent pars plana vitrectomy and subretinal fluid displacement without tPA from 2015 and 2021 and at least 1-year of follow-up.

METHODS

Surgical intervention included a standard small-gauge pars plana vitrectomy with subretinal displacement using balanced saline solution with subretinal sterile air and partial gas-air fluid exchange. Main outcome measures included degree of subfoveal SMH displacement, best and final postoperative visual acuities, and adverse events. Snellen acuity was converted to logMARs for statistical analysis.

RESULTS

The most common etiology associated with thick SMH (92.3%) was neovascular age-related macular degeneration. Within 1 month postoperatively, 21 patients (80.8%) saw complete subfoveal blood displacement. Most of the SMH surgical displacements were done within 1 week of presenting symptoms. Average preoperative duration of SMH was 3.60 ± 2.78 days (range, 1-12 days). Mean logMAR best-corrected visual acuity improved from 1.63 ± 0.58 (Snellen 20/800 baseline) to 0.90 ± 0.42 letters (Snellen 20/160) at last follow-up (p = 0.001). This study's visual acuity improvement is comparable with that of prior studies using tPA. Early postoperative complications included 1 retinal detachment, 1 vitreous hemorrhage, and 1 macular hole.

CONCLUSION

Rapid surgery with subretinal balanced saline solution-sterile air injection without tPA was found to be effective for displacement of thick SMH with retinal function, visual acuity, and corneal refractive therapy improvement.

Combined treatment of submacular hemorrhage with low-dose subretinal recombinant tissue plasminogen activator and intravitreal conbercept

BACKGROUND

Pars Plana Vitrectomy (PPV) combined with subretinal injection of low-dose recombinant tissue plasminogen activator (rt-PA) and intravitreal injection of Conbercept as a novel therapy for submacular hemorrhage (SMH) requires evaluation.

METHODS

In a retrospective interventional clinical study, 14 eyes of 14 patients with SMH underwent PPV along with rt-PA (subretinal) and Conbercept (intravitreal) injections. The main outcomes included best-corrected visual acuities (BCVAs), degrees of blood displacement, and adverse events. All patients completed at least 6-month follow-up visits.

RESULTS

Mean BCVAs significantly improved at 7 days (22.29 ± 15.35), 1 month (30.71 ± 16.42), 3 months (38.29 ± 13.72), 4 months (38.86 ± 14.15), and 6 months (41.21 ± 14.91) post-treatment compared to baseline (16.36 ± 13.97) (F = 12.89, P = 0.004). The peak improvement in BCVAs occurred at 6 months postoperatively. The procedure effectively eliminated subfoveal hemorrhages in all eyes, with clots removal and absorption occurring within one month and complete regression by 3-month follow-up visits. Postoperatively, two cases of AMD resulted in discoid scars on the fundus. No instances of rt-PA-related retinal toxicity were observed during the follow-up period.

CONCLUSION

The combined approach of PPV with low-dose rt-PA and anti-VEGF shows promise in enhancing both vision and anatomical structure in SMH therapy. Individualized treatment plans tailored to the primary disease should be developed to optimize visual prognoses.

TRIAL REGISTRATION

Retrospectively registered No.ChiCTR2100053034. Registration date: 10/11/2021.

VITRECTOMY WITH SUBRETINAL INJECTION OF RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR FOR SUBMACULAR HEMORRHAGE WITH OR WITHOUT VITREOUS HEMORRHAGE

PURPOSE

To evaluate the outcomes and prognostic factors of pars plana vitrectomy combined with subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage (SMH) patients with or without vitreous hemorrhage (VH).

METHODS

Sixty-four eyes of 64 patients with SMH underwent pars plana vitrectomy with subretinal injection of recombinant tissue plasminogen activator. Best-corrected visual acuity, SMH displacement, and postoperative complications were analyzed. Predictive factors of the final best-corrected visual acuity were determined using multivariant linear regression.

RESULTS

There were 26 eyes with VH and 38 eyes without VH best-corrected visual acuity significantly improved in both VH group (from 2.27 ± 0.40 to 1.25 ± 0.70 logarithm of the minimum angle of resolution) and non-VH group (from 1.76 ± 0.55 to 0.85 ± 0.65 logarithm of the minimum angle of resolution). Complete displacement of SMHs was observed in 47 (73.43%) eyes. Postoperative complications included recurrent SMH (4.69%), recurrent VH (10.94%), rhegmatogenous retinal detachment (3.13%), and epiretinal membrane (4.68%). Treatment-naive condition, early surgery, and younger age were significantly associated with better final best-corrected visual acuity ( B = 0.502, 0.303, and 0.021, respectively, with all P < 0.05).

CONCLUSION

Pars plana vitrectomy combined with subretinal recombinant tissue plasminogen activator injection is an effective treatment for SMH patients with and without VH.

Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration

PURPOSE

To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration.

METHODS

This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200.

RESULTS

Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement.

CONCLUSION

Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.

Outcomes in the Treatment of Subretinal Macular Hemorrhage Secondary to Age-Related Macular Degeneration: A Systematic Review

Background: Subretinal macular hemorrhage (SRMH) secondary to age-related macular degeneration (AMD) is a relatively rare condition in ophthalmology characterized by blood collection between the neurosensory retina and the retinal pigment epithelium (RPE). Without prompt treatment, visual prognosis is poor. A plethora of treatment approaches have been tried over the past years ranging from intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy to direct subretinal surgery, with no conclusive superiority of one over the other. Materials and Methods: We conducted a systematic review of the outcomes and treatment modalities of SRMH from inception to 14 June 2022, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). The level of evidence was assessed for all included articles according to the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: A total of 2745 articles were initially extracted, out of which 1654 articles were obtained after duplicates were removed and their abstracts screened. A total of 155 articles were included for full-text review. Finally, 81 articles remained that fulfilled the inclusion criteria. Conclusions: Even though there are solid results supporting a variety of treatments for SRMH, the best treatment modality has still not been conclusively demonstrated and further research is needed.

Three-dimensional heads-up system assisted pars plana vitrectomy and subretinal recombinant tissue plasminogen activator injection for submacular hemorrhage

BACKGROUND

To evaluate the outcomes of three-dimensional (3D) heads-up system assisted pars plana vitrectomy (PPV) and subretinal injection of recombinant tissue plasminogen activator (rt-PA) for submacular hemorrhage (SMH).

METHODS

Medical records of SMH patients who underwent 3D heads-up system assisted-PPV and subretinal injection of rt-PA from June 2021 to January 2022 were reviewed. The main outcomes included best-corrected visual acuity (BCVA), SMH absorption, and perioperative complications.

RESULTS

We finally included 18 SMH eyes, most of which happened secondary to polypoidal choroidal vasculopathy (PCV) (10, 55.56%), followed by retinal arterial microaneurysm (RAM) (5, 27.78%), traumatic retinopathy (2, 11.11%) and neovascular age-related macular degeneration (nAMD) (1, 5.56%). The greatest linear dimension (GLD) and height of SMH were 6538.17 ± 2533.11 μm and 937.36 ± 420.21 μm, respectively. After an average postoperative follow-up period of 131.06 ± 38.96 days, patients' BCVA improved significantly from 1.85 ± 0.62 to 1.14 ± 0.82 logMAR (P < 0.05). SMH was completely and partially absorbed in 9 (50.00%) and 6 (33.33%) eyes, with no occurrence of iatrogenic retinal break. However, 4 additional PPVs were performed to manage the postoperative SMH and/or vitreous hemorrhage (VH) recurrence (2, 11.11%) and retinal detachment (RD) occurrence (2, 11.11%). Preoperative BCVA was significantly correlated with postoperative BCVA in multiple linear regression analysis (P < 0.05), and hemorrhagic pigment epithelial detachment (PED) was significantly correlated with SMH and VH recurrence in univariate binary logistic regression analysis (P < 0.05).

CONCLUSIONS

The 3D heads-up system assisted-PPV and subretinal injection of rt-PA were efficacious in eliminating SMH and improving visual prognosis with satisfactory safety profile, while caution should be taken for PCV patients with hemorrhagic PED and massive SMH.

Comparison of treatment methods for submacular hemorrhage in neovascular age-related macular degeneration: conservative versus active surgical strategy

The optimal treatment of submacular hemorrhage (SMH) following neovascular age-related macular degeneration (nAMD) is controversial. This study aimed to compare visual outcomes of conservative versus active surgical treatment. Two hundred thirty-six eyes of 236 patients with SMH (≥ 1 disc diameter) were stratified into four groups: observation (n = 21); anti-vascular endothelial growth factor (VEGF) monotherapy (n = 161); non-surgical gas tamponade (n = 31); and subretinal surgery (n = 23). The primary outcome was best-corrected visual acuity (BCVA) at 12 months. The baseline BCVAs of the observation, anti-VEGF monotherapy, non-surgical gas tamponade, and subretinal surgery groups were 1.50 ± 0.70, 1.09 ± 0.70, 1.31 ± 0.83, and 1.62 ± 0.77 logarithm of minimal angle resolution (LogMAR), respectively. The mean BCVAs at 12 months were 1.39 ± 0.84, 0.90 ± 0.83, 1.35 ± 0.88, and 1.44 ± 0.91 LogMAR, respectively. After adjusting for age, baseline BCVA, SMH size, and the number of intravitreal anti-VEGF injections before SMH, the mean BCVA showed no significant difference among treatments at 12 months (P = 0.204). The anti-VEGF monotherapy group showed better mean BCVA significantly at 3 months (P < 0.001). Only baseline BCVA was associated with VA gain at 12 months (Odds ratio = 3.53, P < 0.001). This study demonstrated that there was no difference in 12 month visual outcomes among treatments and a better early visual outcome can be expected with anti-VEGF monotherapy.

One-Year Outcome of Intravitreal Tissue Plasminogen Activator, Ranibizumab, and Gas Injections for Submacular Hemorrhage in Polypoidal Choroidal Vasculopathy

This study investigated one-year outcomes of treatment with one session of intravitreal recombinant tissue plasminogen activator, ranibizumab, and gas injections for submacular hemorrhage secondary to polypoidal choroidal vasculopathy (PCV). An extended study of a previous prospective trial of this treatment modality in PCV patients was conducted in 64 patients (64 eyes). Early Treatment Diabetic Retinopathy Study (ETDRS) score, central retinal thickness (CRT), and central pigment epithelial detachment thickness (CPEDT) before and 1, 3, and 12 months after treatment were analyzed. Mean ETDRS score increased from 58 at baseline to 64 letters (p = 0.0122), CRT decreased from 543 to 192 μm (p < 0.0001), and CPEDT decreased from 161 to 103 μm (p = 0.0668) at 3 months and were maintained until 12 months. Complications requiring reoperation occurred within one month in four eyes. Recurrence was observed in 46 eyes (72%), and 1.6 ± 1.5 (0−7) intravitreal aflibercept injections were given pro re nata. Univariate and multivariate analyses identified CPEDT as the pre- and post-treatment factor affecting 12-month ETDRS score (p < 0.0001). Improved visual acuity stabilized 3 months after treatment. Although 72% of patients experienced recurrence, an average of 1.6 aflibercept injections/patient maintained visual acuity up to 12 months. CPEDT was the most important factor associated with visual outcome.

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

Background

Neovascular (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.

Methods

TIGER 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.

Discussion

The best management of SMH is unknown. TIGER aims to establish if the benefits of SMH surgery outweigh the risks, relative to aflibercept monotherapy.

Trial registration

ClinicalTrials.govNCT04663750; EudraCT: 2020-004917-10.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05966-3.

Visual Outcome after Vitrectomy with Subretinal tPA Injection to Treat Submacular Hemorrhage Secondary to Age-Related Macular Degeneration or Macroaneurysm

Purpose

To determine the efficacy and safety of 23G transconjunctival sutureless vitrectomy, subretinal injection of tissue plasminogen activator using the EVA Surgical System, and pneumatic displacement with air to treat submacular hemorrhages.

Methods

Retrospective analysis of 93 eyes surgically treated for submacular hemorrhage caused by neovascular AMD or retinal macroaneurysms. Main Outcome Measures. Postoperative visual acuity and surgical complications.

Results

After surgery, visual acuity improved after 6 weeks but decreased again at the final postoperative visit at 8 months due to progression of the underlying disease. Complications consisted of 2 cases of retinal pigment epithelial tear, 7 vitreous hemorrhages, 4 hyphema, 6 cases of retinal detachment, and 2 subchoroidal hemorrhages during the follow-up period.

Conclusions

This study suggests that a surgical approach with 23G vitrectomy, subretinal tPA injection, and pneumatic displacement using air may be an effective procedure for submacular hemorrhage displacement in patients with AMD and retinal macroaneurysms. However, visual outcome is limited by the underlying macular pathology. Larger multicenter randomized controlled studies are warranted to determine the therapeutic effect of this surgical approach.

Macular Hemorrhage Due to Age-Related Macular Degeneration or Retinal Arterial Macroaneurysm: Predictive Factors of Surgical Outcome

Objective: The study aimed to determine the outcomes and prognostic factors of vitrectomy, subretinal injection of tissue-plasminogen activator and gas tamponade in macular hemorrhage (MaH) due to age-related macular degeneration (AMD) or retinal arterial macroaneurysm (RAM). Methods: The study design utilized a multicentric retrospective case series design of consecutive patients undergoing surgery between 2014 and 2019. Results: A total of 65 eyes from 65 patients were included in the study. Surgery was performed after a mean period of 7.1 days. Displacement of MaH was achieved in 82% of the eyes. Mean best-corrected visual acuity (BCVA) improved from 20/500 to 20/125 at month(M)1 and M6 (p < 0.05). At M6, BCVA worsening was associated with an older age at diagnosis (p = 0.0002) and higher subretinal OCT elevation of MaH (p = 0.03). The use of treat and extend (TE) (OR = 16.7, p = 0.001) and small MaH fundus size (OR = 0.64 and 0.74 for horizontal and vertical fundus size, p < 0.05) were predictive of a higher likelihood of obtaining a countable BCVA at M1. Baseline BCVA was predictive of postoperative BCVA (p < 0.05). Retinal detachment and MaH recurrence occurred in 3% and 9.3% of cases at M6. Conclusion: MaH surgery stabilizes or improves BCVA in 85% of cases. Younger age at diagnosis, better baseline BCVA figures, smaller subretinal MaH height and use of TE regime were predictive of the best postoperative outcomes.

Management of submacular massive haemorrhage in age-related macular degeneration: comparison between subretinal transplant of human amniotic membrane and subretinal injection of tissue plasminogen activator

PURPOSE

Macular neovascularization (MNV) can complicate age-related macular degeneration (AMD) and lead to severe visual acuity reduction. Massive submacular haemorrhage (SMH) is a sight-threatening complication of MNV and a challenge in the management of complications related to MNV in AMD since the effects of anti-vascular endothelial growth factor treatment alone are insufficient. Here, we evaluate the different postoperative outcomes of patients affected by MNV complicated by SMH that underwent subretinal implant of human amniotic membrane (hAM) or subretinal injection of tissue plasminogen activator (tPA).

METHODS

This is a retrospective, consecutive, comparative, non-randomized interventional study. We included 44 eyes of 44 patients affected by AMD complicated by MNV and SMH. Twenty-two eyes underwent a pars plana vitrectomy (PPV), SMH and neovascular membrane removal, with a subretinal implant of hAM and silicone oil, and 22 eyes underwent PPV, subretinal injection of tPA, and 20% sulphur hexafluoride. The primary study outcome was visual acuity improvement. Secondary outcomes were postoperative complications, and MNV recurrence and optical coherence tomography (OCT)-Angiography parameters correlated with best-corrected visual acuity (BCVA).

RESULTS

Mean preoperative BCVA was 1.9 logarithm of the minimal angle of resolution (logMAR) in the amniotic membrane-group and 2 logMAR in the tPA-group. The mean final BCVA values were 1.25 and 1.4 logMAR, respectively, with a statistically significant difference. Optical coherence tomography (OCT)-Angiography scan was be used to evaluate the retinal vascularization in the treated eye.

CONCLUSION

Both techniques report similar VA improvements and postoperative complications. However, transplantation of hAM seems to have a significant benefit in inhibiting MNV recurrence.

Comparison of subretinal versus intravitreal injection of recombinant tissue plasminogen activator with gas for submacular hemorrhage secondary to wet age-related macular degeneration: treatment outcomes and brief literature review

PURPOSE

Contradictory evidence exists over the best approach for the management of submacular hemorrhage (SMH). In this study, we compared the outcomes of subretinal versus intravitreal injection of recombinant tissue plasminogen activator (r-tPA) and gas in cases of SMH secondary to age-related macular degeneration (AMD).

METHODS

Twenty five eyes with SMH were retrospectively divided in 2 groups. Group A underwent vitrectomy, subretinal r-tPA and gas (Vitrectomy group, n = 14), and group B received intravitreal r-tPA and gas (Pneumatic group, n = 11). SMH displacement and change in subfoveal hemorrhage thickness (SFHT) at 1 month post-op were assessed. Additionally, best corrected visual acuity (BCVA) and central retinal thickness (CRT) at the end of the 12 month follow-up (FU) were analyzed. Clinical and epidemiological prognostic factors were tested.

RESULTS

Mean duration of SMH prior intervention was 8.2(± 7.3) days. Baseline BCVA was 1.53 ± 0.73 LogMAR, mean extension of SMH was 4.604 ± 2079 μm and mean CRT pre-treatment was 795 ± 365 μm. SMH displacement at 1 month post-treatment was total in 9/14 versus 6/11 and partial in 4/14 versus 2/11 in Group A and Group B, respectively (Fisher's exact test p = 0.38). SFHT reduced by 404 ± 312 μm in Group A versus 376 ± 405 μm in group B (p = 0.86). BCVA improvement and reduction of CRT were highly significant at the end of FU (p = 0.002 and p < 0.001 respectively) but did not differ between the 2 groups. Only baseline BCVA and preoperative CRT proved to be significant prognostic factors for the final functional outcome (p = 0.013 and p = 0.047 respectively).

CONCLUSION

Both treatment options proved equal efficacy in displacing SMH in AMD. A multicenter trial may delineate a desirable algorithm of treatment.

Functional and structural outcome after vitrectomy combined with subretinal rtPA Injection with or without additional intravitreal Bevacizumab injection for submacular hemorrhages

Background

To analyze the functional and anatomical outcome after vitrectomy with subretinal rtPA (recombinant tissue plasminogen activator) combined with or without an intravitreal Bevacizumab injection.

Patients and methods

Retrospective, consecutive case series of 31 pseudophakic patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (AMD) treated with vitrectomy, subretinal rtPA and pneumatic air displacement with or without an additional intravitreal Bevacizumab injection. The primary endpoints were best-corrected visual acuity (BCVA), and central macular thickness (CMT) measured by SD‑OCT. The secondary endpoint was a displacement of hemorrhage from the subretinal space three months after surgery.

Results

31 eyes of 31 patients were treated with vitrectomy and subretinal rtPA. 17/31 were treated simultaneously with an intravitreal Bevacizumab injection (group +B) and 14/31 without (group -B). The mean visual acuity improved significantly in both groups (from 1.37±0.39 to 1.03±0.57 logMAR in +B and from 1.48±0.48 to 1.01±0.38 logMAR in group –B, p<0.05). The mean CMT decreased in group +B from 607±179 μm to 424±205 μm (p = 0.2) and in group –B from 722±216 μm to 460±202 μm (p<0.05). A central displacement of the hemorrhage could be achieved in 47% in group +B, whereas in group -B displacement could be achieved in 50% (p = 0.44).

Conclusions

Vitrectomy with subretinal rtPA injection and air tamponade with or without simultaneous intravitreal Bevacizumab injection displaces SMH and improves BCVA effectively. In comparison, the postoperative outcome is comparable regardless of whether or not intravitreal bevacizumab is applied simultaneously.

Management of acute submacular hemorrhage using intravitreal injection of tissue plasminogen activator and gas: A case series

The objective of this case series is the evaluation of the efficacy and visual outcomes after displacement of subretinal hemorrhage using intravitreal injection of recombinant tissue plasminogen activator, expansile gas, and in some cases an anti-vascular endothelial growth factor agent. A case series of 28 eyes of 28 patients (16 men and 12 women with age range 67–95 years) suffering from subretinal hemorrhage (duration range 1–15 days) caused by age-related macular degeneration or retinal macroaneurysm is presented. All the patients were treated with intravitreal injection of recombinant tissue plasminogen activator and gas and some of them received an anti-vascular endothelial growth factor agent between January 2013 and December 2016. The outcomes assessed were visual acuity (preoperatively 1 week, and 1 month postoperatively) with respect to duration and dimension of hemorrhage, displacement of hemorrhage, and possible complications of the procedure. Successful displacement of hemorrhage was achieved in 25 patients (89.3%), 18 of 28 patients had significant improvement in visual acuity 1 week after the treatment, and 22 of 28 patients had significant improvement in visual acuity 1 month after the treatment. The mean improvement of all patients with anatomical displacement of the hemorrhage in visual acuity was 0.7 ± 0.5 (LogMAR) in 1 month. Two patients developed vitreous hemorrhage after the procedure and one retinal detachment. Visual outcome a month after therapy displayed week correlation with duration, diameter, and thickness of hemorrhage. The results lead to the conclusion that intravitreal treatment of recombinant tissue plasminogen activator and expansible gas with or without injection of anti-vascular endothelial growth factor agent is effective in improving visual acuity and displacing submacular hemorrhage secondary to age-related macular degeneration and retinal macroaneurysm. The best functional outcomes can be expected in patients regardless of the size and duration of the hemorrhage.

Subretinal Hemorrhage Complicating Retinal Angiomatous Proliferation in Tubercular Retinal Vasculitis

PURPOSE

To report a patient with submacular hemorrhage due to retinal angiomatous proliferation (RAP) in tubercular retinal vasculitis (TRV).

METHODS

Case report.

RESULTS

We report a 33-year-old Asian Indian patient of TRV presenting with capillary non-perfusion areas, submacular hemorrhage and venous loops. The patient presented with sudden onset decrease in vision in the right eye. Multimodal imaging revealed presence of retinal vascular anastomosis and stage 2 RAP. Systemic examination was within normal limits. Laboratory evaluation revealed positive Mantoux and interferon gamma release assay. He underwent right eye intravitreal injection of recombinant tissue plasminogen activator (12.5µg/0.1ml) with 100% sulphur hexafluoride (SF6) tamponade. The patient had successful displacement of the submacular hemorrhage with some improvement in visual acuity.

CONCLUSION

This case highlights that rare vascular alterations such as RAP can develop in subjects with ocular tuberculosis.

[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.

[Treatment of submacular hematoma by vitrectomy, subretinal injection of rtPA and gaseous tamponade: A single-center retrospective observational study]

OBJECTIVES

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

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.

To treat or not to treat: a clinical series of retinal arterial macroaneurysms: A single-center retrospective study

Retinal arterial macroaneurysms (RAMs) develop as outpouchings of the arterial wall that is weakened by arteriosclerosis. The traditional treatment of RAMs comprises observation, focal laser photocoagulation, or surgery. Recently, intravitreal injection of anti-vascular endothelial growth factor (VEGF) drugs has been announced as an effective therapy for fovea-threatening RAMs and quickly improve visual acuity and central retinal thickness (CRT).In the retrospective series, medical charts and ocular images of 24 patients diagnosed as having RAM between May 2011 and November 2018 in our facility were reviewed to delineate clinical manifestations and visual prognosis in RAM patients receiving different treatment modalities. Twenty-four patients (25 eyes; 11 men and 13 women) were enrolled, and one eye with comorbidity of branch retinal vein occlusion was excluded. The mean age of the patients was 69.00 ± 13.45 years. Fourteen patients (58.33%) had a history of hypertension, and 17 patients (70.83%) were aged > 60 years. Furthermore, patients with fovea-threatening RAMs presented with either hypertension or were aged > 60 years.Eyes with fovea involvement (n = 18) were analyzed and separated into two groups according to their treatment modalities: those receiving anti-VEGF intravitreal injections (n = 13) and observation only (n = 5). The baseline visual acuity revealed no significant difference in the two groups. In patients receiving anti-VEGF intravitreal injections, a significantly better visual acuity was detected after anti-VEGF intravitreal injections than the baseline visual acuity (logMAR, 0.78 ± 0.51 vs 1.52 ± 0.48, P < .001), and CRT significantly improved (505.50 ± 159.26 μm vs 243.60 ± 60.17 μm, P = .001). Patients receiving anti-VEGF intravitreal injections also revealed better final visual acuity than those in the observation group (logMAR, 0.78 ± 0.51 vs 1.34 ± 0.48, P = .04).A systematic work-up for hypertension and arteriosclerotic disease could be considered the recommended procedure once RAM has been diagnosed. With better final visual acuity, significant visual improvements, and fast reduction of CRT observed in patients with fovea-threatening RAMs receiving anti-VEGF intravitreal injections, intravitreal anti-VEGF was considered an effective therapy for complicated RAM. During the follow-up period, the majority of RAM eyes had good maintenance of visual function even with foveal complications.

[Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results (French translation of the article)]

PURPOSE

To evaluate anatomical and functional outcomes of surgical displacement of macular hemorrhages complicating exsudative age-related macular degeneration (AMD) after vitrectomy, subretinal rtPA (recombinant tissue plasminogen activator) injection, intravitreal bevacizumab injection and gaz tamponade.

METHODS

Retrospective case series, including 26 patients with submacular hemorrhage, who underwent a surgical displacement within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was carried out to measure the diameter of the hemorrhage and to specify the relation with retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage away from the fovea at first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit.

RESULTS

The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5,8 (±7,2) lines (P=0.0003) at 1 month postoperatively, 7,4 (±6,7) lines (P=0.0004) at 6 months and 7,4 (±7,4) lines (P=0.0002) at final postoperative visit (16,5±19,8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient P=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)).

CONCLUSION

Vitrectomy with subretinal rtPA injection was found to be effective for the displacement of AMD hemorrhage in 81 % of the patients. Mean final visual acuity improved by more than 7 lines.

Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results

INTRODUCTION

Macular subretinal hematoma is a complication of age related macular degeneration (AMD) responsible for a severe change in vision. We evaluated anatomic and functional results of surgical treatment of hematoma by vitrectomy, subretinal injection of r-tPA (recombinant tissue plasminogen activator), intravitreal bevacizumab injection and air tamponade.

METHODS

Retrospective case series including 26 patients with submacular hemorrhage who underwent vitrectomy within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was performed to measure the diameter of the hemorrhage and specify the location in relation to the retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage out of the fovea at the first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit.

RESULTS

The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5.8 (±7.2) lines (P=0.0003) at 1 month postoperatively, 7.4 (±6.7) lines (P=0.0004) at 6 months and 7.4 (±7.4) lines (P=0.0002) at the final postoperative visit (16.5±19.8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient ρ=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)).

CONCLUSION

Vitrectomy with subretinal r-tPA injection was found to be effective for the displacement of AMD hemorrhage in 81% of the patients. Mean final visual acuity improved by more than 7 lines, confirming the efficacy and functional benefit of surgical displacement.

Pharmacological Adjuncts to Vitrectomy Surgery

Pharmacological adjuncts to vitrectomy surgery are useful tools to better deal with surgery. Their introduction has enriched the therapeutic choice before, during and after operations. Although several classifications could be made to frame adjuncts to vitrectomy, we preferred to divide the pharmacological adjuncts to vitrectomy surgery for therapeutic use in the pre-operatory procedure (neo-adjuvant), for intraoperative use and for post-operatory practice (adjuvant). This type of classification allowed us to explore all the adjuncts based on the timing of their use. The actual interest in vitrectomy surgery is giving rise to considerable interest in new molecules with and without the pharmacological effect that will soon be available for the aid of vitreoretinal surgery.

Incidence of submacular haemorrhage (SMH) in Scotland: a Scottish Ophthalmic Surveillance Unit (SOSU) study

PURPOSE

Submacular haemorrhage (SMH) is a cause of severe visual loss in neovascular age-related macular degeneration (nAMD). The incidence is uncertain and furthermore there is no widely used classification system nor agreed best practice. The aim of this national surveillance study was to identify the incidence, presenting features and clinical course of new fovea-involving submacular haemorrhage associated with nAMD.

METHODS

A questionnaire was sent monthly to every ophthalmic specialist in Scotland over a 12-month period asking them to report all newly presenting patients with acute SMH secondary to nAMD of at least two disc diameters (DDs) in greatest linear diameter. A follow-up questionnaire was sent 6 months after initial presentation. Cases related to other causes were excluded.

RESULTS

Twenty-nine cases were reported giving an incidence of 5.4 per million per annum (range 2-15). The mean age was 83 years (range 66-96) and females accounted for 17/29 (59%). Fifteen of the 29 cases (52%) had a past history of AMD, of which 7 had nAMD. Nineteen of the 29 cases (66%) presented within 7 days of onset and the majority had SMH of < 11 DD (20/29, 69%). Treatment options comprised the following: observation (n = 6, 21%), anti-VEGF alone (n = 6, 21%) or vitrectomy with co-application of tissue plasminogen activator (TPA), anti-VEGF and gas (n = 17, 58%). The vitrectomy group experienced the greatest change in vision from logMAR 1.89-1.50 (p = 0.374). Four of 20 (20%) cases with 6 months follow-up suffered a re-bleed at a mean time of 96 days.

CONCLUSIONS

The incidence, clinical features and course of a consecutive national cohort of patients with SMH secondary to nAMD are presented.

[Update from France Macula Federation: Treatment of Wet AMD]

PURPOSE

To update the recommendations of the France Macula Federation for treatment of wet age-related macular degeneration (AMD).

METHODS

Analysis of literature and expert opinion.

RESULTS

The FFM recommends initiating anti-VEGF therapy as soon as possible after diagnosis of exudative AMD. There has been no major change in the last several years concerning the procedure of intravitreal injection itself. However, the litigious points are discussed: simultaneous bilateral injection; antibiotic therapy; medico-legal aspects. All anti-VEGF strategies possess advantages and limitations. The strategy should be left to the ophthalmologists' preference. However, the chosen strategy should be explained to patients and strictly followed.

CONCLUSION

The treatment of wet-AMD is more precisely codified than before. However, various strategies still coexist.

Submacular hemorrhage secondary to age-related macular degeneration managed with vitrectomy, subretinal injection of tissue plasminogen activator, hemorrhage displacement with liquid perfluorocarbon, gas tamponade, and face-down positioning

Purpose

To investigate the outcomes of vitrectomy, subretinal tissue plasminogen activator (tPA) injection, hemorrhage displacement with liquid perfluorocarbon, gas tamponade, and face-down positioning, in hemorrhagic neovascular age-related macular degeneration (AMD) patients.

Methods

In this retrospective case series, we reviewed the records of patients who were diagnosed as having submacular hemorrhage (SMH) secondary to neovascular AMD between January and June 2016. The main outcome measure was the difference between preoperative and postoperative best corrected visual acuity (BCVA).

Results

In 9 eyes of 9 patients, mean preoperative and postoperative BCVA at the last follow-up were 1.65 and 1.49 LogMAR, respectively (p = 0.1), after a mean follow up time of 12.4 ± 1.0 months. The SMH was successfully displaced in 5 of the 9 patients (55.5%). Four out of 9 patients (44.4%) gained ≥3 lines. The duration of SMH was 3.6 ± 2.1 days (range 1-7) in the successfully displacement group, and was 10.0 ± 1.8 days (range 8-12) in the group in which was SMH could not be displaced (p = 0.002). The mean SMH area was smaller in the successfully displacement group than the group in which was SMH could not be displaced (p = 0.04).

Conclusion

Vitrectomy, subretinal tPA injection, hemorrhage displacement with liquid perfluorocarbon, gas tamponade and face-down positioning was associated with improved visual outcomes in patients with hemorrhagic neovascular AMD. The duration and area of the SMH seemed to be related to the success of displacement.

Visual acuity of 20/32, 13.5 years after a retinal pigment epithelium and choroid graft transplantation

Purpose

To present the 13.5-year-survival of an autologous retinal pigment epithelium (RPE) and choroid graft transplantation with good visual acuity results.

Observations

A 72-year old patient presented with a 5-weeks-old visual acuity deterioration to excentric finger counting at half a meter. Fundoscopy showed a fibrotic macular scar, a large subretinal hemorrhage, partly recent, combined with intraretinal fluid, blood, and hard exudates. RPE-choroid graft surgery was performed, and visual acuity improved to 20/32, and maintained up until 13.5 years postoperative. Microperimetry performed at the same time revealed a 3.4 dB sensitivity, with fixation on the graft. During the postoperative years glaucoma developed, an uveitis anterior was treated, and to treat a small Coats' like lesion; one bevacizumab injection was administered.

Conclusions and importance

A best corrected visual acuity of 20/32 could be achieved and maintained up to 13.5 years after an RPE-choroid graft transplantation, despite an unfavorable preoperative presentation and some early and late complications. This case is a proof of principle that an RPE-choroid graft harvested from the midperiphery can support the macular metabolism up to 13.5 after surgery in a patient with severe exudative AMD. It also represents a rationale for pursuing stem cell derived RPE replacement. Anti-vascular endothelial growth factor injections are nowadays the mainstay of therapy for choroidal neovascularization and/or small hemorrhages and offer good results. Nevertheless, selected patients that cannot benefit from this therapy may profit from an autologous RPE-choroid graft transplantation.

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

OBJECTIVE

To 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.

DESIGN

Single-centre, retrospective case series.

PARTICIPANTS

A 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.

METHODS

All 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.

RESULTS

Patients 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.

CONCLUSIONS

Vitrectomy with subretinal t-PA and pneumatic displacement seems to be an effective treatment for SMH in terms of blood displacement and visual outcomes.

OCT angiography documented reperfusion of translocated autologous full thickness RPE-choroid graft for complicated neovascular age-related macular degeneration

PurposeThe purpose of this study is to investigate the reperfusion of translocated retinal pigment epithelium (RPE)-choroid graft in the treatment of patients with neovascular age-related macular degeneration (nAMD), using OCT angiography (OCTA), a novel non-invasive, high-resolution imaging modality.Patients and methodsEighteen eyes of 18 consecutive patients suffering from complicated nAMD underwent RPE-choroid patch graft translocation surgery using a peripheral retinotomy and flap-over technique. We analyzed functional and anatomical outcome using visual acuity, Spectral Domain OCT and OCTA.ResultsWith a mean follow-up of 11 months, out of 18 patients, 15 gained vision, 1 remained stable, and 2 lost vision. Overall, the visual acuity improved with a mean of 30 letters. Perfusion of the graft tissue was confirmed in all patients. Two patients developed signs of a recurrent neovascular membrane during follow-up. No cases of proliferative vitreoretinopathy occurred in this series.ConclusionsOCTA images show signs of perfusion in all grafts. Encouraging functional results and low risk of severe complications suggest that RPE-choroid graft translocation is a valid option in patients with complicated nAMD.

Retinotomy Closure Following Subretinal Stem Cell Transplant With a 30-Gauge Needle

The authors report two cases of posterior retinotomy closure following subretinal stem cell transplantation for age-related macular degeneration with a 30-gauge needle - a larger bore needle than those used in prior studies. Partial retinotomy closure was seen on optical coherence tomography within 24 hours in one patient, whereas complete closure occurred by the 5-month and 1-year follow-up visits. A trace retinal hemorrhage occurred in one case, with resolution by 12 weeks. These findings demonstrate the likelihood of uncomplicated, spontaneous retinotomy closure following subretinal stem cell transplantation with a 30-gauge needle. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:869-873.].

Progression of lamellar hole-associated epiretinal proliferation and retinal changes during long-term follow-up

Purpose

To report on progression of lamellar hole-associated epiretinal proliferation (LHEP) in eyes with lamellar macular holes (LMH) using spectral-domain optical coherence tomography (SD-OCT), and to correlate with intraretinal changes and visual function.

Methods

From a retrospectively reviewed series of 167 eyes with non-full-thickness macular holes, we exclusively included a subgroup of 34 eyes with LMH and LHEP by SD-OCT evaluation. In these eyes, area of LHEP, intraretinal changes of defect diameter, central retinal thickness, defects of the ellipsoid zone and occurrence of a contractive epiretinal membrane were analysed. Additionally, clinical data were documented.

Results

Area of LHEP significantly increased during a mean follow-up period of 40.5 months (median 52 months). Analysing intraretinal changes, a significant enlargement of minimum and maximum horizontal lamellar hole diameter was found that correlated with the area of LHEP. Defects of the ellipsoid zone were seen in 65% of the eyes at baseline and in 85% at the end of follow-up. Increase of maximum horizontal hole diameter and ellipsoid zone defects correlated with a decline of visual acuity. Fifty per cent of patients with LMH and LHEP also demonstrated extrafoveal typical contractive epiretinal membranes with retinal folds.

Conclusions

Long-term follow-up revealed an increase of the area of LHEP in eyes with LMH that correlated with the enlargement of lamellar hole diameter and ellipsoid zone defects. Our data delineate the progression of intraretinal changes in association with a decline of visual function in this subgroup of LMH eyes.

Pneumatic displacement of submacular haemorrhage

Purpose

To evaluate the outcomes of pneumatic displacement of submacular hemorrhage secondary to choroidal neovascular membrane (CNV) (n = 9) and retinal arterial macroaneurysm (RAM) (n = 3).

Methods

This is a retrospective case series study of 12 eyes from 12 patients in Aberdeen Royal Infirmary, Aberdeen, UK. The mean duration of visual loss was 10.8 ± 4.11 days. All cases received intravitreal injection of expansile gas within 24 h of presentation (C3F8 in 11 cases and SF6 in one case) and postured face down for five days. Anterior chamber paracentesis was done right after gas injection. Intravitreal anti-VEGF was injected at the same time in cases with CNV. Further anti-VEGF injections were done in CNV cases as needed afterwards. Cases were followed up for 6 months.

Results

The submacular hemorrhage was successfully displaced from underneath the fovea in all but one case. The bleeding disappeared totally in 44% of cases and was inferiorly displaced in 56%. VA improvement at 6 months was statistically significantly higher than baseline VA. All cases but 2 (one because of subfoveal fibrosis and one because of late presentation) experienced improved VA. The mean VA improved from 1.37 ± 0.18 logMAR at baseline to 0.83 ± 0.26 logMAR at 6 months. No complication related to the procedure was reported.

Conclusion

Pneumatic displacement of submacular hemorrhage appears to be a safe and effective technique to treat the condition. It is an easy procedure that can be done in outpatient setting. Further studies are needed to validate our results.

Efficacy of Vitrectomy Combined with Subretinal Recombinant Tissue Plasminogen Activator for Subretinal versus Subpigment Epithelial versus Combined Hemorrhages

BACKGROUND

The aim of this study was to compare the outcomes after subretinal recombinant tissue plasminogen activator (rtPA) treatment for subretinal hemorrhages (SRH), subpigment epithelial hemorrhages (SPH), and combined subretinal and subpigment epithelial hemorrhages (CH).

METHODS

An observational analysis of patients treated with subretinal rtPA was performed. The primary endpoint was the assessment of visual improvement (best-corrected visual acuity, BCVA) after surgery. Secondary endpoints were evaluation of the maximal hemorrhage diameter (MHD) and central macular thickness (CMT) measured by spectral domain optical coherence tomography.

RESULTS

From a total of 83 eyes included in the study, 19 eyes showed SRH, 11 eyes SPH, and 53 eyes CH. For SRH and CH, the mean BCVA, MHD, and CMT improved significantly (p < 0.05). For patients with SPH, both the mean MHD and CMT decreased significantly (p < 0.05), whereas the mean BCVA improved only slightly after surgery (p = 0.28).

CONCLUSION

Vitrectomy combined with subretinal rtPA injection and gas or air tamponade has a strong functional and anatomical effect on both SRH and CH and also seems to slightly improve the anatomical outcome in SPH.