Management of subretinal macular haemorrhage by direct administration of tissue plasminogen activator

R P Singh; C Patel; J E Sears

doi:10.1136/bjo.2005.085001

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Management of subretinal macular haemorrhage by direct administration of tissue plasminogen activator

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Re: Management of subretinal macular haemorrhage by direct administration of tPA
H. K Kang
Published on: 16 May 2006

Published on: 16 May 2006
Re: Management of subretinal macular haemorrhage by direct administration of tPA
- H. K Kang, Vitreoretinal Fellow
- Other Contributors:
  Andrew Luff, Richard Newsom, and Chris Canning
Dear Sir,

We read with great interest the report by Singh et al,¹ describing the management of subretinal macular haemorrhage by vitrectomy, subretinal injection of tissue plasminogen activator (tPA) and pneumatic tamponade. Our experience with this techinque has also been positive, and this approa...
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Dear Sir,

We read with great interest the report by Singh et al,¹ describing the management of subretinal macular haemorrhage by vitrectomy, subretinal injection of tissue plasminogen activator (tPA) and pneumatic tamponade. Our experience with this techinque has also been positive, and this approach has replaced intravitreal tPA injection after vitrectomy and partial fluid-gas exchange, or pneumatic displacement without vitrectomy, as the preferred management of submacular haemorrhage in our unit. In most cases, the haemorrhage is sufficiently displaced by two weeks to allow angiographic studies and definitive treatment decisions to be made.

There are some notable differences between our approach and the methods described by the authors. The concentration of 12 µg per 0.1 ml is significantly lower than the concentration we have used, which is 50 µg per 0.1 ml. We are not aware of any study that showed an optimal concentration of tPA for subretinal injection, but this concentration has been shown to be safe in experimental in vivo studies.^2-4 The authors would have needed to inject 0.4 ml to reach the target dosage of 48 µg, which is a large volume for a subretinal injection. There could be an argument for a smaller injection volume to minimise distortion of the retinal architecture. We aim to inject at the edge of the haemorrhage, rather than directly into the body of the clot, in order to avoid detaching the fovea further. The injection is performed under direct vision, with the end point being an encirclement of the haemorrhage by the newly introduced subretinal fluid.

We have not found it necessary to create a separate retinotomy before the injection of tPA. We have most commonly used a 32-gauge needle (Glaser Subretinal Injector, BD Ophthalmic Systems, Warks, United Kingdom), which enables a direct injection into the subretinal space with minimal trauma. However, we have found that the needle allowed a significant amount of reflux of tPA into the vitreous cavity. More recently, we have used a 41-gauge subretinal needle (Storz Retinal Cannula 20G/41G, Bausch & Lomb, Rochester, United States) with great success, which allows a precise placement of the bleb with minimal reflux.

We prefer SF₆ 20 % tamponade as it is our impression that the haemorrhage takes at least one week to be displaced. A comparative study with air would be useful. We have used SF₆ 10 % for smaller haemorrhages.

Without treatment, the prognosis for submacular haemorrhage is poor. Pneumatic displacement offers the means for an effective displacement of submacular haemorrhage. With intravitreous tPA injection ⁵, and non-vitrectomy pneumatic displacements reporting high success rates,⁶ we agree with the authors’ conclusion that further studies will be needed to elucidate the best approach of managing this difficult problem.

References

1.   Singh RP, Patel C, Sears JE. Management of subretinal macular haemorrhage by direct administration of tissue plasminogen activator.Br J Ophthalmol 2006;90(4):429-431.
2.   Benner JD, Morse LS, Toth CA, Landers MB, 3rd, Hjelmeland LM. Evaluation of a commercial recombinant tissue-type plasminogen activator preparation in the subretinal space of the cat.Arch Ophthalmol 1991;109(12):1731-1736.
3.   Irvine WD, Johnson MW, Hernandez E, Olsen KR. Retinal toxicity of human tissue plasminogen activator in vitrectomized rabbit eyes. Arch Ophthalmol 1991;109(5):718-722.
4.   Johnson MW, Olsen KR, Hernandez E, Irvine WD, Johnson RN. Retinal toxicity of recombinant tissue plasminogen activator in the rabbit.Arch Ophthalmol 1990;108(2):259-263.
5.   Hassan AS, Johnson MW, Schneiderman TE, et al. Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement. Ophthalmology 1999;106(10):1900-6; discussion 1906-1907.
6.   Hattenbach LO, Klais C, Koch FH, Gumbel HO. Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions. Ophthalmology 2001;108(8):1485-1492.

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Conflict of Interest:
None declared.
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