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

Objective

To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement.

Intravitreal tissue plasminogen activator and pneumatic displacement of submacular hemorrhage secondary to retinal artery macroaneurysm.

PURPOSE: To assess the efficacy of treating submacular hemorrhages secondary to retinal arterial macroaneurysm with intravitreous tissue plasminogen activator (tPA) and gas. PATIENTS AND METHODS: Six consecutive patients (6 eyes) with submacular hemorrhage secondary to retinal arterial macroaneurysm were included in this study. Tissue plasminogen activator, at a dose of 50 microg/0.1 mL, was injected through the pars plana into the vitreous cavity. Gas (0.3-0.5 mL of perfluoropropane) instillation followed tPA injection, either immediately after injection or sometime during the next day. RESULTS: Best postoperative visual acuity improved in 5 of 6 eyes (83%) and was unchanged in 1 of 6 (17%) eyes. In 5 of 6 (83%) eyes, the procedure resulted in complete or partial displacement of submacular hemorrhage out of the foveal area. CONCLUSIONS: Intravitreous injection of tPA and gas, followed by prone positioning of the patient, is an effective and simple treatment of submacular hemorrhage secondary to retinal arterial macroaneurysm. No complication occurred in this series.     

Pneumatic displacement of submacular hemorrhage with or without tissue plasminogen activator

Purpose  

To assess the efficacy and complications of intravitreal injection of sulfur hexafluoride (SF₆) gas with/without tissue plasminogen activator (tPA) for displacing submacular hemorrhage.     

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

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

Intravitreous tissue plasminogen activator injection and pneumatic displacement in the management of submacular hemorrhage complicating scleral buckling procedures

PURPOSE: To evaluate the efficacy of recombinant tissue plasminogen activator (rTPA) and sulfur hexafluoride (SF6) in displacing submacular hemorrhage in patients who had scleral buckling procedures complicated by the development of submacular hemorrhage. Final visual acuity and complications of the procedures were evaluated. METHODS: Sequential intravitreal injections of 50 microg rTPA in 0.1 mL and 0.4 cc SF6 were performed in eight patients who showed submacular hemorrhage 1 day after a scleral buckling procedure. The fundus was checked daily for 3 days after the injection of TPA and gas, and then was followed every week for 1 month and then every 2 months. Patients were observed for at least 6 months. Visual acuity and the status of complications were evaluated. RESULTS: Submacular hemorrhage was totally or partially displaced extramacularly in all patients on the day after rTPA and SF6 injection. Vitreous hemorrhage was present in all patients. The retina was attached in all patients and no recurrent retinal detachment was noted. Visual acuity was improved at 6 months after treatment in all seven of the patients with macula-off retinal detachments compared to the preoperative visual acuity. The last patient who had a macula-sparing retinal detachment had decreased vision (20/25) at 6 months compared to preoperatively. CONCLUSIONS: Recombinant tissue plasminogen activator and SF6 injection is an easy procedure that is less complicated than and as effective as internal drainage in patients with submacular hemorrhage developing as a complication of scleral buckling procedures.     

Management of submacular hemorrhage with intravitreal injection of tissue plasminogen activator and expansile gas

PURPOSE: To evaluate the clinical outcome of intravitreal tissue plasminogen activator (tPA) and expansile gas injection as a minimally invasive treatment for submacular hemorrhage (SMH). METHODS: This study was a retrospective clinical case series examining 104 eyes that received an intravitreal injection of 30-100 mcg of tPA and expansile gas (SF6 or C3F8) for SMH. The main outcomes evaluated were visual acuities (VA), anatomic displacement of submacular blood, and surgical complications. RESULTS:: A total of 85, 77, and 81 eyes were available at 1 week, 3 months, and 12 months follow up, respectively. Postoperatively, > or = 2 Snellen lines improvement were achieved in 43/85 eyes (51%) at 1 week, 49/77 eyes (63%) at 3 months, and 52/81 eyes (64%) at 12 months. Postoperative VA improvement was significantly associated with preoperative VA, submacular blood displacement, and the underlying cause of SMH. Diagnostic postoperative angiogram and clinical examination were possible at 8.2 +/- 7.4 weeks and 9.5 +/- 7.4 weeks, respectively. The observed complications included breakthrough vitreous hemorrhage in 8 eyes (8%) and retinal detachment in 3 eyes (3%). CONCLUSIONS: In this retrospective series, intravitreal injection of tPA and expansile gas was shown to be a safe and effective technique that can improve VA in most eyes with SMH and assist in the diagnosis of the underlying cause.     

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

Aim  

To compare the efficacy of pars plana vitrectomy (ppV) with intravitreal injection of recombinant tissue plasminogen activator (rtPA) and gas versus ppV with subretinal injection of rtPA and intravitreal injection of gas.     

Preoperative use of tissue plasminogen activator for large submacular hemorrhage

BACKGROUND AND OBJECTIVE: Tissue Plasminogen Activator (TPA) has been used as an adjunct in the surgical removal of submacular hemorrhage. It is usually used intraoperatively, but may not provide enough time for effective fibrinolysis, especially for a large hemorrhage. The present study was conducted to evaluate the efficiency and safety of preoperative use of TPA for large submacular hemorrhages. METHODS: Five eyes with large submacular hemorrhage secondary to age-related macular degeneration underwent subretinal injection of TPA in the office 24 hours before surgery. All hemorrhages were less than seven days old and at least 3 mm thick. RESULTS: Preoperative visual acuity ranged from counting fingers to hand motion (HM). Patient follow-up ranged from 3 months to 24 months (mean, 11 months). Final visual acuity ranged from 20/30 to HM. Four of the five eyes (80%) showed improved visual acuity after surgery and 3/5 (60%) attained visual acuity of 20/200 or better. CONCLUSION: Preoperative use of TPA for drainage of large submacular hemorrhage appears to be safe and may result in efficient clot removal. The true efficacy of TPA in the treatment of submacular hemorrhage can only be proven by a prospective randomized trial.     

Management of acute submacular hemorrhage using recombinant tissue plasminogen activator and gas

· Purpose: To assess the effects of intravitreal injection of recombinant tissue plasminogen activator (rTPA) and gas on submacular hemorrhage in age-related macular degeneration (ARMD). · Methods: Eleven consecutive patients (11 eyes) with subretinal hemorrhage due to ARMD involving the fovea with elevation of the neurosensory retina were included in this study. Subretinal hemorrhage occured 12 h to 14 days before onset of therapy. Injection of rTPA through the pars plana in a dose of 50 or 100 μg was performed. Gas instillation (0.2–0.4 ml) followed rTPA injection, either immediately after injection (7 patients) or during the following day (4 patients). · Results: After intravitreal injection of rTPA, subretinal clots were totally or partially liquefied when treatment started up to 3 days after onset of bleeding. In all patients treated with 100 μg rTPA a large exudative retinal detachment of the inferior retina resulted, which reabsorbed spontaneously within 2 weeks. After reattachment of the exudative retinal detachment hyperpigmentation of the retinal pigment epithelium was noted. Temporary opacification of the vitreous was observed between the 2nd and 7th postoperative day in 5 eyes (45.5%). Postoperative visual acuity increased in 5 patients (45.5%). · Conclusion: Intravitreal application of rTPA followed by gas injection is a sufficient and convenient technique for effective removal of freshly formed submacular hemorrhage. Removal is mediated through combined enzymatic (rTPA) and mechanical (gas) effects. This technique offers a quick recovery of vision in eyes with less severe ARMD. Received: 5 January 1998 Revised version received: 25 March 1998 Accepted: 23 June 1998     

Retinal sensitivity after displacement of submacular hemorrhage due to polypoidal choroidal vasculopathy: effectiveness and safety of subretinal tissue plasminogen activator

Purpose

To investigate the effectiveness of displacement of submacular hemorrhage (SMH) caused by polypoidal choroidal vasculopathy (PCV) by assessing retinal sensitivity using microperimetry.

Methods

We retrospectively reviewed the medical records of 11 consecutive PCV patients with SMH. All patients underwent vitrectomy, subretinal injection of tissue plasminogen activator, and fluid-air exchange, followed by antivascular endothelial growth factor therapy using a pro re nata regimen. The retinal sensitivity was measured by use of microperimetry before and after surgery.

Results

The mean (SD) age of the patients was 74.1 ± 9.4 years. The mean SMH diameter was 6.8 ± 5.2 disc diameters. The best-corrected visual acuity (BCVA), mean retinal sensitivity, and mean number of measure points with a sensitivity ≥10 dB before the surgery were 0.94 ± 0.49, 4.2 ± 4.5 dB, and 15.6 ± 15.1 points, respectively. These had significantly improved 6 months after surgery (0.39 ± 0.37, 15.6 ± 7.3 dB, and 50.9 ± 22.2 points, respectively; P < 0.05 for all outcome measures). The mean number of measure points with an absolute scotoma before surgery had decreased significantly 6 months after surgery (from 40.5 ± 15.0 to 9.4 ± 16.0 points; P < 0.001).

Conclusions

Displacement of SMH effectively improves retinal sensitivity as well as BCVA.

     

Recombinant tissue plasminogen activator, vitrectomy, and gas for recent submacular hemorrhage displacement due to retinal macroaneurysm

Background

The visual prognosis of submacular hemorrhages caused by a retinal arterial macroaneurysm (RAM) is poor if left untreated. The use of recombinant tissue plasminogen activator (rtPA) has frequently been reported to displace submacular hemorrhages from the foveal area in patients with age-related macular degeneration. This study aims to investigate the results of displacement of recent-onset submacular hemorrhages due to RAM.

Methods

Institutional retrospective interventional case series of 12 patients with macular hemorrhage due to RAM, who underwent pars plana vitrectomy (PPV); followed in 11 by submacular injection of rtPA and gas tamponade. The main outcome measures were displacement of the hemorrhage, complication rate, and visual acuity at 1 month after surgery and at the last follow-up visit.

Results

One month after surgery, the hemorrhage had been successfully displaced in ten out of 11 patients. In these ten patients, visual acuity (VA) increased by a mean of 1.2 logMAR at 1 month after surgery. At the last follow-up visit, the mean increase was 1.5 logMAR. Complications consisted of a vitreous hemorrhage and hyphema, retinal detachment, a new submacular hemorrhage, and vitreous hemorrhage after argon laser retinal photocoagulation of the RAM.

Conclusions

PPV with submacular rtPA and gas injection may successfully displace a recently developed submacular hemorrhage in patients with RAM, with a marked improvement in VA that is likely to be greater than if left untreated.     

Management of submacular hemorrhage by tissue plasminogen activator and SF6 gas injection

Summary The formation of platelet-fibrin clots causes degeneration of foveolar photoreceptors by subretinal hemorrhage. Patients: Twenty-two patients with submacular hemorrhages were treated by intravitreal injection of 50 μg tpa and 0.5 ml SF₆ gas within 1 h. Biomicroscopy, fundus photography and fluorescein angiography were performed pre- and postoperatively. Further multifocal electroretinograms were recorded. Results: The subfoveolar hemorrhages were dissoluted and displaced out of the macular region. The visual acuity increased in 18 cases and ranged from hand movement and 0.3 to values between 1/10 and 0.5. Conclusions: Toxic and hypoxic damage of foveolar photoreceptors by subretinal hemorrhage can be prevented by early and minimal invasive fibrinolytic therapy. After localization of choroidal neovascularizations, treatment by focal laser coagulation is possible in some cases.      

Intravitreal tissue plasminogen activator in submacular haemorrhage

Submacular haemorrhage is a major cause of sudden visual loss in age-related macular degeneration (AMD). If left untreated it often results in permanent central visual loss. We present our experience in the use of intravitreal tissue plasminogen activator (tPA) in a 65-year-old male with submacular haemorrhage.     

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

PURPOSE: To study the results of intravitreal tissue plasminogen activator (tPA) and expansile gas injection for submacular haemorrhage in Thai patients. METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Analysis of forces acting upon submacular hemorrhage in pneumatic displacement

PURPOSE: To analyze the forces affecting pneumatic displacement of submacular hemorrhage and determine an efficient postoperative positioning method for patients. METHOD: Geometric analysis of the forces that act upon submacular hemorrhage in the absence and presence of a gas bubble. RESULTS: A component of gravity force of the hemorrhage parallel to the subretinal space is responsible for pneumatic displacement. This component is largest when the patient is looking straightforward and is absent when the patient is positioned facedown. CONCLUSION: Face down positioning is not optimal for pneumatic displacement of submacular hemorrhage and should be avoided.