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


METHODS
Retrospective, noncomparative case series.


METHODS
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 microg 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).


METHODS
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.
Hassan
A S
AS
W. K. Kellogg Eye Center, Department of Ophthalmology, University of Michigan School of Medicine, Ann Arbor 48105, USA.
Johnson
M W
MW
Schneiderman
T E
TE
Regillo
C D
CD
Tornambe
P E
PE
Poliner
L S
LS
Blodi
B A
BA
Elner
S G
SG
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000783:Aneurysm / Q000150:complications; D005131:Eye Injuries / Q000150:complications; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005466:Fluorocarbons / Q000627:therapeutic use*; D006801:Humans; D007267:Injections; D008266:Macula Lutea; D008268:Macular Degeneration / Q000150:complications; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D016684:Prone Position; D012166:Retinal Hemorrhage / Q000188:drug therapy* / Q000209:etiology; D012171:Retinal Vessels / Q000473:pathology; D012189:Retrospective Studies; D013459:Sulfur Hexafluoride / Q000627:therapeutic use*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome; D014792:Visual Acuity; D014822:Vitreous Body
D005343:Fibrinolytic Agents; D005466:Fluorocarbons; C042852:perflutren; D010959:Tissue Plasminogen Activator; D013459:Sulfur Hexafluoride