title: The role of pigment epithelial detachment in AMD with submacular hemorrhage treated with vitrectomy and subretinal co-application of rtPA and anti-VEGF.
abstract: OBJECTIVE
  To assess the incidence of pigment epithelial detachment (PED) in age-related macular degeneration (AMD) with submacular hemorrhage (SMH) and its response to treatment with pars plana vitrectomy (ppV), subretinal co-application of recombinant tissue plasminogen activator (rtPA) and anti-VEGF, and an intravitreal gas tamponade.
  
  
  METHODS
  Consecutive interventional case series of 132 eyes of 129 patients with neovascular AMD with SMH. All eyes underwent ppV with subretinal co-application of rtPA and bevacizumab followed by a gas tamponade. Postoperatively, two additional intravitreal anti-VEGF injections were applied monthly, followed by intravitreal anti-VEGF injections applied PRN thereafter. PEDs and SMHs were evaluated with SD-OCT pre- and postoperatively.
  
  
  RESULTS
  Preoperatively, 88 of 132 (67%) eyes were examined by OCT, and in 81 of these eyes the RPE could be visualised. A PED was found in 74 (91%) eyes, and no PED was found in five (6%) eyes. Median height of preoperative PED was 503 μm (range 150-1242, n = 65) and reduced to 344 (n = 62) and 306 μm (n = 27) after 3 and 12 months respectively. Two eyes showed a pre-existing rip of the RPE. Postoperatively, a rip was documented in 12 of 128 (9%) eyes. Median height of SMH was 762 μm (range 217-1840), median diameter was 4.3 (1.5-15) disc diameter. A complete displacement of the SMH from the fovea was achieved in 112 of 129 (87%) eyes. Overall, median best-corrected logMAR visual acuity (BCVA) improved significantly from preoperative 1.6 (0.5-2.0, n = 132) to 1.0 (0.2-2.0) 3 (n = 132) and 12 months (n = 74) postoperatively. Excluding eyes with pre-existing macular scars (n = 22), BCVA 3 months postoperatively was 0.8. Height of PED or SMH did not correlate with postoperatively BCVA, while size of SMH showed a mild correlation (rho = 0.25, p = 0.005).
  
  
  CONCLUSIONS
  PpV with subretinal co-application of rtPA and bevacizumab and an intravitreal gas tamponade effectively displaces SMH and improves BCVA. Preoperatively, PED is found in the majority of eyes. Height of PED or SMH did not correlate with postoperatively BCVA. Tears of the RPE occur as frequently as in exudative AMD without SMH.
authors.affiliation: Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany. felix.treumer@uksh.de.
authors.forename: F
authors.identifier: http://orcid.org/0000-0003-2664-7040
authors.initials: F
authors.lastname: Treumer
authors.affiliation: Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Wienand
authors.affiliation: Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Purtskhvanidze
authors.affiliation: Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Roider
authors.affiliation: Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.|Department of Ophthalmology, University Medical Center Würzburg, Josef-Schneider Str. 11, 97080, Würzburg, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Hillenkamp
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000008:administration & dosage; D000068258:Bevacizumab / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D058450:Endotamponade / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D005451:Fluorescein Angiography; D005500:Follow-Up Studies; D005654:Fundus Oculi; D006801:Humans; D058449:Intravitreal Injections; D008268:Macular Degeneration / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011994:Recombinant Proteins; D012163:Retinal Detachment / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D012166:Retinal Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D055213:Retinal Pigment Epithelium / Q000473:pathology*; D012189:Retrospective Studies; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D041623:Tomography, Optical Coherence; D016896:Treatment Outcome; D014792:Visual Acuity; D014821:Vitrectomy / Q000379:methods*
chemical_list: D020533:Angiogenesis Inhibitors; D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D000068258:Bevacizumab; D010959:Tissue Plasminogen Activator
keywords: Age-related macular degeneration; Bevacizumab; Pigment epithelial detachment; Submacular hemorrhage; rtPA