title: Intravitreal tissue plasminogen activator, perfluoropropane (C3F8), and ranibizumab or photodynamic therapy for submacular hemorrhage secondary to wet age-related macular degeneration.
abstract: OBJECTIVE
  To report a combined intravitreal treatment for submacular hemorrhage.
  
  
  METHODS
  This retrospective, noncomparative, interventional case series included 7 patients with neovascular age-related macular degeneration and 2 with idiopathic polypoidal choroidal vasculopathy, presenting with fovea-involving submacular hemorrhage ≥ 4 disk areas in size, of <10 days of duration. All patients received a single 0.05-mL intravitreal injection of 50 μg alteplase, 0.3 mL of 100% C3F8, and facedown positioning for 1 week. Patients with newly diagnosed age-related macular degeneration received 3 consecutive monthly intravitreal injections of 0.5 mg ranibizumab, followed by monthly retreatment as needed. Those with idiopathic polypoidal choroidal vasculopathy were treated with photodynamic therapy.
  
  
  RESULTS
  Mean (± SD) logarithm of the minimum angle of resolution visual acuity improved from 0.75 ± 0.35 at presentation to 0.35 ± 0.30 at a mean final follow-up of 15.1 months (P = 0.0078). Median Snellen acuity improved from 20/200 to 20/32. Visual acuity was stable in one case and improved in eight. The average size of submacular hemorrhage was 6.8 disk areas at presentation, reducing to 2.6 within 1 month (P = 0.0039). Subfoveal hemorrhage was displaced in all cases within 9 weeks. The mean pretreatment central retinal thickness of 669 μm reduced to 528 μm (P = 0.0039). One case developed transiently elevated intraocular pressure. Two developed breakthrough vitreous hemorrhage. No adverse events were attributed to tissue plasminogen activator.
  
  
  CONCLUSIONS
  Tissue plasminogen activator and C3F8, combined with intravitreal ranibizumab or photodynamic therapy, may result in anatomical clearance of submacular hemorrhage and improved visual acuity, in a condition with an otherwise poor visual prognosis.
authors: Department of Ophthalmology, King's College Hospital, London, United Kingdom.
authors: Evangelia
authors: E
authors: Papavasileiou
authors: David H W
authors: DH
authors: Steel
authors: Efstathios
authors: E
authors: Liazos
authors: Dominic
authors: D
authors: McHugh
authors: Timothy L
authors: TL
authors: Jackson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D015862:Choroid Diseases / Q000188:drug therapy; D003131:Combined Modality Therapy; D058450:Endotamponade; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005466:Fluorocarbons / Q000008:administration & dosage*; D006801:Humans; D058449:Intravitreal Injections; D008297:Male; D008875:Middle Aged; D010778:Photochemotherapy; D011127:Polyps / Q000188:drug therapy; D016684:Prone Position; D000069579:Ranibizumab; D012166:Retinal Hemorrhage / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D012189:Retrospective Studies; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D041623:Tomography, Optical Coherence; D014792:Visual Acuity / Q000502:physiology; D057135:Wet Macular Degeneration / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D005343:Fibrinolytic Agents; D005466:Fluorocarbons; C042852:perflutren; D010959:Tissue Plasminogen Activator; D000069579:Ranibizumab