Elsevier

Ophthalmology

Volume 106, Issue 10, 1 October 1999, Pages 1900-1907
Ophthalmology

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

Presented in part at the Association for Research in Vision and Ophthalmology annual meeting, Ft. Lauderdale, Florida, May 1998, and at the American Academy of Ophthalmology annual meeting, New Orleans, Louisiana, November 1998.
https://doi.org/10.1016/S0161-6420(99)90399-8Get rights and content

Abstract

Objective

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

Design

Retrospective, noncomparative case series.

Participants

From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each.

Methods

The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25–100 μg in 0.1–0.2 ml) and expansile gas (0.3–0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours).

Main outcome measures

Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications.

Results

In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4–19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure.

Conclusions

Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Section snippets

Patients and methods

We reviewed the medical records of 15 consecutive patients who had undergone intravitreous injection of commercial tPA solution and expansile gas for thrombolysis and displacement of submacular hemorrhage. Patients presenting at several centers to one of the authors (M.W.J., T.E.S., C.D.R., P.E.T., L.S.P., B.A.B., or S.G.E.) were accumulated retrospectively and accrued between January 1, 1997, and October 15, 1997. All patients had acute hemorrhages (<3 weeks old), thick blood under the fovea,

Results

Fifteen eyes of 15 patients (12 women) were included in the study. Patient age ranged from 13 to 91 years (median, 78 years). The mean duration of submacular hemorrhage was 5.7 days (range, 1–21 days), and the maximum diameter of the hematoma ranged from 2 to 13 disc diameters. The cause of the hemorrhage was choroidal neovascularization complicating ARMD in 13 eyes and macroaneurysm and trauma in 1 eye each (Table 1).

The procedure resulted in complete displacement of thick blood from under the

Discussion

Thick submacular hemorrhage, particularly in patients with ARMD, is generally associated with a poor visual outcome.1, 2, 3 Several mechanisms, including shearing of photoreceptors by fibrin clots, physical separation of photoreceptors from the retinal pigment epithelium, and toxic effects of iron, have been suggested as explanations for the retinal damage caused by thick subretinal blood.5, 6, 7, 20, 21 These natural history and experimental data have prompted the search for a safe and

Acknowledgements

The authors thank David C. Musch, PhD, for assistance in statistical analysis.

References (27)

  • R.L. Avery et al.

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

    Retina

    (1996)
  • C.A. Toth et al.

    Fibrin directs early retinal damage after experimental subretinal hemorrhage

    Arch Ophthalmol

    (1991)
  • M.W. Johnson et al.

    Tissue plasminogen activator treatment of experimental subretinal hemorrhage

    Retina

    (1991)
  • Cited by (0)

    View full text