Management of subretinal macular haemorrhage by direct administration of tissue plasminogen activator.
OBJECTIVE
Recent studies on the treatment of acute subretinal macular haemorrhage have shown that the volume of the clot and the time to evacuation have strong prognostic factors for visual outcome. A novel technique for surgical evacuation of these lesions involves direct injection of tissue plasminogen activator (t-PA) into the haematoma using pars plana vitrectomy. The aim of this study was to evaluate the clinical outcomes of this recently described procedure.


METHODS
17 consecutive patients with subretinal macular haemorrhages caused by age related macular degeneration were enrolled. Patient demographics, acuities, and fluorescein angiograms were obtained for all evaluations. All patients underwent complete three port pars plana vitrectomy to enable direct cannulation of the subretinal space and injection of 48 mug of t-PA, partial fluid-air exchange, 1 hour face up supine positioning postoperatively, followed by upright positioning overnight.


RESULTS
88% of patients within the study had stabilisation or improvement of visual acuity. Nine patients had total clearing of the macular haemorrhage and eight patients had subtotal clearing. Two patients had recurrence of the haemorrhage after the procedure and one patient underwent repair for retinal detachment. Occult lesions demonstrated similar outcomes to classic or predominately classic lesions. Nine patients required no therapy after the study to treat subfoveal neovascularisation.


CONCLUSIONS
This study represents one of the largest case series to date showing that direct injection of subretinal t-PA with air-fluid exchange only and no intraoperative clot lysis period can have favourable results.
Vitreo-retinal Service, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
R P
RP
Singh
C
C
Patel
J E
JE
Sears
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D020256:Choroidal Neovascularization / Q000150:complications; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D006801:Humans; D015552:Injections, Intralesional; D008268:Macular Degeneration / Q000150:complications; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods; D011187:Posture; D012166:Retinal Hemorrhage / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000627:therapeutic use; D016896:Treatment Outcome; D014792:Visual Acuity / Q000187:drug effects; D014821:Vitrectomy
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator