Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid–gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration

doi:10.1016/S0002-9394(00)00734-0

American Journal of Ophthalmology

Volume 131, Issue 2, February 2001, Pages 208-215

https://doi.org/10.1016/S0002-9394(00)00734-0 Get rights and content

Abstract

PURPOSE: To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration.

METHODS: Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 μg), and fluid–gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity.

RESULTS: In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P = .004) but not between preoperative and final visual acuity (P = .16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye.

CONCLUSIONS: This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

Section snippets

Methods

Eleven patients (11 eyes) with age-related macular degeneration and thick subretinal hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) located beneath the foveal center were treated in the following manner: pars plana vitrectomy was performed and a posterior vitreous detachment was created if not present. Using a bent 36-gauge needle, recombinant tissue plasminogen activator (Activase, Genentech, Inc, South San Francisco, California) was injected directly

Results

Seven patients were male and four were female. The mean age was 76 years (range, 65 to 85 years). The average duration of submacular hemorrhage before surgery was 23 days (range, 1 to 90 days). Mean follow-up was 6.5 months (range, 1 to 15 months). Hemorrhage was strictly subretinal in eight cases, whereas both subretinal and sub-RPE hemorrhage were present in three cases. In all 11 eyes, retinal elevation was noted on stereo color fundus photographs.

Hemorrhage was successfully displaced from

Discussion

In this study, we evaluate a new technique for displacing thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) from the fovea in 11 patients with age-related macular degeneration. All patients underwent pars plana vitrectomy, creation of a posterior vitreous detachment if not already present, injection of tissue plasminogen activator directly into the subretinal clot, and fluid–gas exchange, followed by prone positioning. This method

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^☆: This work is supported by Core Grant P30-EYO5722 from the National Institutes of Health, Bethesda, Maryland. Dr Jaffe is a Lew R. Wasserman Merit Award recipient from Research to Prevent Blindness, New York, New York. Dr Steuer was supported by an AOS-Knapp fellowship.

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Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid–gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration☆

Abstract

Section snippets

Methods

Results

Discussion

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Am J Ophthalmol

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Am J Ophthalmol

Ophthalmology

Ophthalmology

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Ophthalmology

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Ophthalmology

Natural history of subfoveal subretinal hemorrhage in age-related macular degeneration

Retina

Natural history of macular subretinal hemorrhage in age-related macular degeneration

Ophthalmologica

The toxicity of intravitreal whole blood and hemoglobin

Graefes Arch Klin Exp Ophthalmol

Fibrin directs early retinal damage after experimental subretinal hemorrhage

Arch Ophthalmol

The retinal pigment epithelium and interphotoreceptor matrixstructure and specialized functions

Initial clinical experience with tissue plasminogen activator (tPA) assisted removal of submacular haemorrhage

Eye

Subretinal lavagea technique of continuous subretinal irrigation for removal of traumatic submacular hemorrhage

Ophthalmologica