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Editor,— Subhyaloid haemorrhage can be caused by a variety of retinal disorders, such as age related macular degeneration, proliferative diabetic retinopathy, Valsalva retinopathy, macroaneurysm, and trauma. Nd:YAG laser membranotomy has been used for the rapid clearing of premacular haemorrhage, but complications such as retinal or choroidal haemorrhage and retinal hole formation were reported with the use of Nd:YAG laser. If the patient has cataract or media opacity, effective and precise laser delivery would be difficult.1
Hassan et al reported that intravitreous tissue plasminogen activator (tPA) and C3F8 injection effectively displaced the subretinal haemorrhage.2Furthermore, it has been recently reported that intravitreal tPA and SF6 promote the clearing of premacular subhyaloid haemorrhages in shaken and battered baby syndrome.3
We treated a patient with subhyaloid haemorrhage by intravitreal tPA and C3F8 injection without any complications. YAG laser membranotomy failed because the patient's pterygium and cataract hindered proper contact lens application and caused laser beam scattering.
A 75 year old female patient visited our clinic because of sudden visual loss in her right eye 45 days earlier. Visual acuity was counting fingers at 20 cm in the right eye and 20/100 in the left. There were pterygia in both eyes, and her lenses showed cortical opacity. On fundus examination, a round dark red haemorrhage with a convex surface covering the right macula was noted (Fig 1). There was a fluid level in the upper part of haemorrhage and its preretinal location was confirmed by fluorescein angiography. There was neither posterior vitreous detachment nor a hole in the posterior hyaloid. Indocyanine angiography showed an arterial macroaneurysm in the superotemporal vascular arcade in the right eye.
Since the subhyaloid haemorrhage was thick, we first tried Nd:YAG laser membranotomy. However, this failed because her pterygium hindered proper contact lens application, and YAG laser was not able to be precisely focused on the anterior surface of the subhyaloid membrane owing to the poorly applied contact lens and cataract. Therefore, we decided to perform intravitreal tPA and C3F8injection under topical anaesthesia. Twenty minutes after injecting intravitreal 0.1 ml of 25 μg/0.1 ml tPA (total dose of 25 μg), 0.5 ml of 100% C3F8 was injected into the vitreous cavity. A paracentesis was done to decrease the intraocular pressure. The patient was told to maintain the face down position for 2 weeks. Three days after the injection, the subhyaloid haemorrhage was displaced by the gas bubble out of the macular region. The haemorrhage slowly decreased in size over 2 weeks, and then markedly decreased. After 2 months, the subhyaloid haemorrhage had completely cleared (Fig2). Her vision in the right eye increased to 20/70 on her last visit.
Although the subhyaloid haemorrhage was somewhat old and very thick, it was rapidly displaced out of the macular region within 3 days. We suggest that tPA worked to lyse the blood clot. The vision of 20/70 may be attributed to cataract and retinal damage caused by the subhyaloid haemorrhage.
Tissue plasminogen activator and C3F8 injection seems to be an alternative way to clear the subhyaloid haemorrhage especially when the patient has media opacity or when there is a problem with contact lens application for laser.4 5