title: Long-term outcome of subretinal coapplication of rtPA and bevacizumab followed by repeated intravitreal anti-VEGF injections for neovascular AMD with submacular haemorrhage.
abstract: OBJECTIVE
  To evaluate short-term and long-term outcomes of subretinal coapplication of recombinant tissue plasminogen activator (rtPA) and bevacizumab followed by intravitreal injections of bevacizumab or ranibizumab for neovascular age-related macular degeneration with submacular haemorrhage (SMH).
  
  
  METHODS
  Retrospective, consecutive, interventional case series of 41 eyes of 40 patients. All patients underwent pars plana vitrectomy with subretinal coapplication of rtPA and bevacizumab and intravitreal gas tamponade. Postoperatively, repeated intravitreal injections of bevacizumab or ranibizumab were applied following a flexible, predominantly visual acuity-driven re-treatment regimen.
  
  
  RESULTS
  Mean diameter of SMH was 4.5 disc diameters (range 1.5-12). Complete displacement of SMH was achieved in 35 of 41 eyes. Large and prominent SMH extending beyond the vascular arcades were completely displaced in six of eight eyes. SMH recurred in eight eyes after a mean of 9.1 months (2-19). A mean of 4.5 (2-9) intravitreal anti-vascular endothelial growth factor injections were applied during 12 months postoperatively. Short-term (3 months, n=41), mean best corrected logMAR visual acuity (BCVA) improved significantly from the preoperative value 1.7 (3.0-0.5) to 0.8 (1.6-0.2). 12 eyes had reading ability (≤logMAR 0.4) and 29 eyes had gained ambulatory visual acuity (≤logMAR 1.6). Long-term (mean 17 months (12-32), n=26) BCVA was 0.9 (1.6-0.1). Compared with short-term, BCVA had decreased in 12 of 26 eyes.
  
  
  CONCLUSIONS
  The operation effectively displaces small and large SMHs. In the long-term, a predominantly visual acuity-driven re-treatment regimen puts the initial functional improvement at risk. More sensitive re-treatment parameters may help to improve long-term functional outcome.
authors.affiliation: Department of Ophthalmology, University Medical Center Schleswig-Holstein, Arnold-Heller Str. 3, Haus 25, D-24105 Kiel, Germany. ftreumer@auge.uni-kiel.de
authors.forename: Felix
authors.initials: F
authors.lastname: Treumer
authors.forename: Johann
authors.initials: J
authors.lastname: Roider
authors.forename: Jost
authors.initials: J
authors.lastname: Hillenkamp
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000008:administration & dosage*; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage*; D000068258:Bevacizumab; D004359:Drug Therapy, Combination; D058450:Endotamponade; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005451:Fluorescein Angiography; D005500:Follow-Up Studies; D006801:Humans; D058449:Intravitreal Injections; D008297:Male; D008875:Middle Aged; D000069579:Ranibizumab; D011994:Recombinant Proteins; D012166:Retinal Hemorrhage / Q000188:drug therapy* / Q000503:physiopathology; D019233:Retreatment; D012189:Retrospective Studies; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors; D014792:Visual Acuity / Q000502:physiology; D014821:Vitrectomy; D057135:Wet Macular Degeneration / Q000188:drug therapy* / Q000503:physiopathology
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; C467484:VEGFA protein, human; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab; D010959:Tissue Plasminogen Activator; D000069579:Ranibizumab