Surgical management of submacular hemorrhage. A series of 47 consecutive cases.
BACKGROUND
The development of a thick submacular hemorrhage usually carries a poor visual prognosis. The surgical removal of submacular blood may improve the otherwise poor outlook in these cases.


METHODS
Forty-seven consecutive patients underwent vitrectomy with surgical removal of submacular hemorrhage. The patient population consisted of two consecutive groups. Group 1 (1989 to 1991) included 23 patients (20 with age-related macular degeneration [ARMD], one with idiopathic submacular hemorrhage, one with presumed ocular histoplasmosis syndrome [POHS], and one with angioid streaks) who underwent mechanical clot extraction. Group 2 (1991 to 1993) included 24 patients (19 with ARMD, two with POHS, two with arterial macroaneurysm, and one with angioid streaks) who underwent tissue plasminogen activator-assisted drainage of thick submacular hemorrhage. The dose of tissue plasminogen activator ranged from 10 to 40 micrograms. All patients had surgery within 72 hours of diagnosis.


RESULTS
In group 1, the mean size of the submacular hemorrhage was 11 disc areas (range, 1 to 16 disc areas). Mean follow-up was 40 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/200. (Visual acuity improved in six eyes, was stable in seven eyes, and deteriorated in seven eyes.) All three of the eyes without ARMD had visual improvement with a mean postoperative visual acuity of 20/70. Overall, visual acuity stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%) patients. In group 2, the mean size of the submacular hemorrhage was 11 disc areas (range, 3 to 16 disc areas). Mean follow-up was 24 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/480 (visual acuity was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes). Four of five eyes without ARMD had visual improvement and one was stable, with a mean postoperative visual acuity of 20/60. Visual acuity stabilized or improved in 22 (92%) of 24 patients and decreased in two (8%). The degree of clot lysis was variable.


CONCLUSIONS
Submacular hemorrhage secondary to ARMD has a poor visual prognosis, with or without surgical drainage. The addition of tissue plasminogen activator-assisted clot lysis does not appear to significantly improve the visual outcome following surgery. The determination of whether surgical intervention is appropriate in these cases requires a prospective, randomized clinical trial.
Ibanez
H E
HE
Retina Consultants, Ltd, St Louis, Mo.
Williams
D F
DF
Thomas
M A
MA
Ruby
A J
AJ
Meredith
T A
TA
Boniuk
I
I
Grand
M G
MG
D000368:Aged; D000369:Aged, 80 and over; D000793:Angioid Streaks / Q000150:complications; D004322:Drainage; D015821:Eye Infections, Fungal / Q000150:complications; D005260:Female; D005654:Fundus Oculi; D006660:Histoplasmosis / Q000150:complications; D006801:Humans; D008266:Macula Lutea / Q000601:surgery*; D008268:Macular Degeneration / Q000150:complications; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012166:Retinal Hemorrhage / Q000209:etiology / Q000601:surgery*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014792:Visual Acuity; D014821:Vitrectomy
D010959:Tissue Plasminogen Activator